Columbin  ^uibcrsitp  \^\5■ 
in  tijc  £itp  of  iJcb)  Oorb 
^tbool  of  IDental  anb  ®ral  ^urgerp 


Reference  Hibrarp 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/textbookofpractOOhare 


nOOKS   BY   THE  SAME  AVTllOli. 


A  TEXT-BOOK  OF  PRACTICAL  THERAPEUTICS. 

FIFTEENTH  EDITION. 
Cloth,  $4.00  net. 

DIAGNOSIS  IN  THE  OFFICE  AND  AT  THE  BED- 
SIDE. 

SEVENTH  EDITION. 
Cloth,  $4.00  net;  Leather,  $5.00  net. 


MEDICAL  COMPLICATIONS  AND  SKQUELiE  OF 
TYPHOID  FEVER  AND  THE  OTHER  EXAN- 
THEMATA. 

SECOND  EDITION. 
Cloth,  $3.25  nc(. 


MODERN  TR1-;aTMENT.  THE  ^L\XAGEMEXT  OF 
DISKA.SK  m'  MKniClXAL  AXD  XOX-MEDI- 
CINAL  RK.MEDIKS.  By  E.minent  Americ.w  and 
English  Authors.    Edited  by  Dk.  H.^re. 

2  volumes:  each.  Cloth,  $6.00  net:  Half  Jlorocco,  $7.50  net. 


A  TEXT-BOOK 


PEACTICE  OF  MEDICINE 


FOR  STUDENTS  AND  PRACTITIONERS 


HOBART  AMORY  HARE,  B.Sc,  M.D. 

,   OF  THERAPEUTICS,  MATERIA  MEDICA,  AND  DIAGNOSIS  IX  THE  JEFFERSON"  MEDICAL  COLLEGE  OF  PHIL.\DELPHIA  ; 
PHYSICIAN   TO    THE    JEFFERSON  MEDICAL  COLLEGE  HOSPITAL;    ONE   TIME    CLINICAL   PROFESSOR    OF    DISEASES    OF 
N^    IN    THE    UNIVERSITY    OF     PENNSYLVANIA;    AUTHOR     OF     "a    TEXT-BOOK    OF    PRACTICAL 
THERAPEUTICS,"     AND     "dIAGNOSI^IN    THE    OFFICE    AND    AT    THE    BEDSIDE*' 


THIRD  EDITION,  REVISED  AND  ENLARGED 


ILLUSTRATED  WITH   142    ENGRAVINGS  AND  16    PLATES  IN 
COLORS  AND  MONOCHROME 


LEA  &  FEBIGER 

PHILADELPHIA    AND    NEW   YORK 

1915 


Entered  according  to  the  Act  of  Congress,  in  the  year  1915,  by 

LEA  &  FEBIGER, 
in  the  Office  of  the  Librarian  of  Congress.     All  rights  reserved. 


PREFACE  TO  THIRD  EDITION, 


The  preparation  of  a  third  edition  of  a  book  on  the  Practice  of  Medicine 
is  a  task  almost  equal  to  the  preparation  of  the  text  of  a  first  edition,  particularly 
if  several  years  have  elapsed  since  the  second  edition  appeared.  Only  those  who 
keep  themselves  thoroughly  abreast  of  all  departments  of  medical  endeavor  can 
estimate  what  the  changes  have  been  in  our  conception  of  almost  every  disease 
as  to  etiology,  pathology,  and  symptomatology,  not  to  speak  of  treatment. 
Furthermore,  only  those  who  keep  themselves  thoroughly  well  informed  can  be  as 
optimistic  in  regard  to  our  struggle  with  disease  as  the  nature  of  the  advances 
justify.  Every  year  sees  an  increasing  army  of  investigators  in  physiology, 
pathology,  bacteriology,  protozoology,  and  therapeutics,  meeting  with  occasional 
reverses,  but  as  a  whole  moving  onward  to  clearer  ideas  concerning  some  of  the 
problems  which  but  a  short  time  ago  seemed  quite  beyond  hope  of  elucidation. 

The  text  of  the  present  edition  has  been  most  carefully  revised,  and  on  almost 
every  page  corrections  and  additions  have  been  made,  based  upon  a  careful  study 
of  the  contributions  of  others  and  the  writer's  increasing  experience  in  hospital" 
and  private  practice.  An  endeavor  has  been  made  to  place  the  necessary  facts 
in  a  concise  form  and  to  prepare  the  text  so  that  it  is  easily  read,  rather  than  to 
resort  to  short,  dogmatic  sentences,  which  do  not  hold  the  attention  because  they 
do  not  lead  the  reader  forward  step  by  step. 

My  cordial  thanks  are  due  to  Dr.  Aller  G.  Ellis,  Associate  Professor  of  Pathology, 
for  his  careful  reading  and  revision  of  the  sections  dealing  with  etiology  and 
pathology,  and  to  Dr.  G.  E.  Price,  Associate  Professor  of  Nervous  and  Mental 
Diseases  in  the  Jefferson  Medical  College,  for  similar  services  in  connection  with 
those  parts  of  the  volume  dealing  with  Diseases  of  the  Nervous  System. 

H.  A.  H. 

'Philadelphia,  1915. 


(V) 


CONTENTS. 


DISEASES  DUE  TO  A  SPECIFIC  INFECTION'. 

Typhoid  Fever 1' 

Paratyphoid  Fever 53 

Typhus  Fever 54 

Variola 60 

Vaccinia  and  Vaccination ~-i 

Varicella "~ 

Scarlet  Fever ■ "i^ 

Measles 92 

Rubella 98 

Mumps 99 

Whooping-cough 101 

Influenza 106 

Acute  Poliomyeloencephalitis Ill 

Dengue 117 

Meningococcic  Meningitis 120 

Croupous  Pneumonia 128 

Diphtheria 151 

Gonorrheal  Infection 165 

Erysipelas ■ 168 

Septicemia  and  Pyemia 1"1 

Acute  Rheumatic  Fever 1~-1 

Cholera 181 

Yellow  Fever 187 

Plague  (Bubonic  Plague) 194 

Climatic  Bubo 200 

Dysentery 200 

Epidemic  Gangrenous  Proctitis 213 

Hill  Diarrhea 214 

Malta  Fever 215 

Phlebotomous  Fever 218 

Anthrax 219 

Hydrophobia 222 

Tetanus 227 

Glanders 231 

Actinomycosis 233 

Mycetoma  (Madura  Foot,  Fungus  Foot  of  India) 234 

Frambesia  (Frambesia  Tropica,  Yaws) 235 

Tuberculosis ; 237 

Acute  Miliary  Tuberculosis 243 

Glandular  Tuberculosis 245 

Tuberculosis  of  the  Serous  Membranes 247 

Pulmonary  Tuberculosis 255 

Tuberculosis  of  the  Alimentary  Canal 278 

Tuberculosis  of  the  Liver 281 

Tuberculosis  of  the  Genito-urinary  System 281 

Tuberculosis  of  the  Fallopian  Tubes,  Ovaries  and  Uterus 285 

Tuberculosis  of  the  Heart 285 

(vii) 


Vlll 


CONTENTS 


Tuberculosis: 

Tuberculosis  of  the  Tliyioid  Gland 

Tuberculosis  of  the  Brain  and  Cord 
Hodgkin's  Disease 
Ijcprosy       ... 
Febricula 
Milk  Sickness  . 
Weil's  Disease 
Glandular  Fever 
Mountain  Fever     . 
Spottctl  t>r  Tick  Fever 
Foot-and-Mouth  Disease 

Miliary  Fever 

Verruga  (VeiTuga  Peruviana) 

Gangosa 

Syphilis 

Hereditary  Sj'philis 
Maliirial  Infection 

Latent  Malarial  Infection  and  Relapse 
Relapsing  Fever     . 
Psorosperniiasis 
Trypanosomiasis    . 

Human  Trypanosomiasis  (Trypanosoma  Fever) 

African  Lcthargj'  (Sleeping  Sickness) 

Kala-azar 

Tropical  Sore   .... 
Nematodes       .... 

Ascariasis    . 

Oxjniris  Vermicularis 

Trichina  Spiralis    . 

Uncinariasis  (Ankylostomiasis)   . 

Filariasis  (Filaria  Sanguinis  Hominis) 

Guinea-worm  Disease  (Dracontiasis) 

Strongyloides  Intestinalis 

Tricocephalus  Dispar 

Cestodes  or  Tapeworm 

Treraatodes 

Bilharzia  Disease 

Distomatosis  of  the  Lung 

Distomatosis  of  the  Liver 

Parasitic  Infusoria 

Chigger  (Sand  Flea) 

Myiasis .... 

Infection  by  Larva;  of  the  Diptern 

Intestinal  Myiasis       .... 

Dermatobia  Cyaniventris 
Tumbu-fly  Disease 


286 
286 
286 
2S9 
295 
295 
296 
296 
297 
299 
299 
299 
300 
.302 
302 
312 
316 
328 
329 
331 
331 
333 
333 
335 
336 
336 
336 
337 
337 
338 
343 
346 
348 
349 
350 
353 
353 
355 
356 
357 
357 
357 
3.57 
358 
358 
358 


DISEASES  OF  THE   RESPTIt.VroiiY   S^-STKM. 


Diseases  of  the  Nose  .... 

Acute  Coryza  .... 

Chronic  Nasal  Catarrh 

Atrophic  Nasal  Calarrli 

Hay  Fever  . 

Epistaxis 
Diseases  of  the  La^J^lx 

Acute  Catarrhal  Laryngiti? 


.S59 
359 
360 
361 
362 
364 
.■^64 
364 


CONTEXTS  IX 

Diseases  of  the  Larj'nx: 

Chronic  Catarrhal  Laryngitis 366 

Edematous  Laryngitis 366 

Spasmodic  Larjiigitis 368 

Tuberculous  Laryngitis 368 

Syphilitic  LarjTigitis 370 

Diseases  of  the  Bronchi 370 

Acute  Catarrhal  Bronchitis 370 

Chronic  Catarrhal  Bronchitis 374 

Bronchiectasis 375 

Fibrinous  Bronchitis 379 

Bronchial  Asthma 381 

Diseases  of  the  Lungs 386 

Bronchopneumonia 386 

JNIetastatic  Pneumonia 396 

Pneumonoconiosis 398 

Emphysema  of  the  Lungs 400 

Compensatory  or  Acute  Emph}-sema 404 

Small-lunged  Emphj'sema 405 

Interstitial  Emphysema 405 

Gangrene  of  the  Lung 405 

Pulmonary  Abscess 407 

Congestion  of  the  Lungs        409 

Tumors  in  the  Lungs 412 

Diseases  of  the  Pleura 413 

Plem-itis 413 

Dry  Plem-isy 414 

Pleurisy  with  Effusion 417 

Purulent  Pleural  Effusion  or  Empyema 423 

Chronic  Pleurisy 427 

Hydrothorax 428 

Pneumothorax,  Hydropneumothorax,  Pyopneumothorax 429 

;  of  the  Mediastinum 431 


DISEASES  OF  THE  CIRCULATORY  SYSTE:\I. 

;  of  the  Pericardium 435 

Pericarditis 435 

Acute  Pericarditis       .      .      . 435 

Chronic  Pericarditis 440 

Hydropericardium 442 

Hemopericardium 443 

Pneumopericardium 443 

Pj'opericardium 444 

Diseases  of  the  Heart 444 

Hypertrophy  and  Dilatation  of  the  Heart 444 

Diseases  of  the  Myocardium 448 

Degenerative  Changes 448 

Stokes-Adams  Disease 450 

Myocarditis 450 

Cardiac  Aneurj'sm 453 

Wounds  of  the  Heart 454 

Endocarditis _ 454 

Acute  Endocarditis 455 

Ulcerative  Endocarditis 458 

Chronic  Endocarditis 460 

Chronic  A^alvular  Disease  as  a  Result  of  Chronic  Endocarditis        461 

Mitral  Regurgitation  .' 464 


X  CONTEiXTS 

Diseases  of  the  Heart: 

Chronic  Valvular  Disease  as  a  Rcsull  of  Chronic  I'^ndooardilis: 

Mitral  Stenosis 469 

Aortic  Stenosis 474 

Aortic  Regurgitation 476 

Tricuspid  Regurgitation 480 

Tricuspid  Stenosis 482 

Disease  of  the  Pulmonary  Valves 482 

Disorders  of  Cardiac  Action  not  due  to  Valvular  Lesions  487 

Neuroses  of  the  Heart 487 

Palpitation 487 

Tachycardia 487 

Bradycardia 488 

Arrhythmia .488 

Angina  Pectoris 491 

Congenital  Cardiac  Defects 494 

Diseases  of  the  Arteries 495 

Aortitis 495 

Arteriosclerosis 496 

Aneurysm 500 

Aneurysm  of  Thoracic  Aorta 501 

Aneurysm  of  the  Abdominal  Aorta         507 

DISEASES  OF  THE   DIGESTIVE  TRAC^T. 

Diseases  of  the  Mouth 509 

Stomatitis 509 

Catarrhal  Stomatitis 509 

Aphthous  Stomatitis 509 

Ulcerative  Stomatitis 510 

Thrush 511 

Gangrenous  Stomatitis,  Cancrum  Oris  or  Noma    .  511 

Eczema  of  the  Tongue 512 

Leukoplakia  Buccalis 513 

Mucous  Patches 513 

Diseases  of  the  Salivary  Glands 513 

Functional  Disorders  of  the  Salivary  Glands 513 

Ptyalism 513 

Dry  Mouth 514 

Inflammation  of  the  Salivary  Glands  514 

Mickulicz's  Disease 514 

Diseases  of  the  Phaiynx 515 

Acute  Pharjmgitis 515 

Ulcerative  or  Phlegmonous  Pharyngitis 516 

Croupous  Pharyngitis 517 

Chronic  Pharyngitis    .                       517 

Follicular  Pharyngitis  517 

Epidemic  Sore  Throat                                   .            .  5 IS 

Diseases  of  the  Tonsils 518 

Acute  Tonsillitis 518 

Ludwig's  Angina 520 

Vincent's  Angina 521 

Clu-onic  Hypertrophic  Tonsillitis 521 

Diseases  of  the  Esophagus 522 

Esophagitis 522 

Organic  Stricture  of  the  Esophagus        ...  523 

Dilatation  of  the  Esophagus 523 

Spasm  of  the  Esophagus 524 

Cancer  of  the  Esophagus 525 


CONTENTS  XI 

Diseases  of  the  Stomiich ■''25 

Acute  Gastric  Catan-li -^25 

Phlegmonous  Gastritis 526 

Diphtheritic  Gastritis ''27 

Mycotic  Gastritis -^28 

Chronic  Gastritis ^28 

Gastric  Dilatation 531 

Acute  Gastrectasis 535 

Gastric  Ulcer 536 

Cancer  of  the  Stomach 545 

Hypertrophic  Stenosis  of  the  Pylorus 552 

Hour-glass  Stomach 555 

Gastric  Neuroses '  556 

Cardiospasm 556 

Pylorospasm 557 

Gastric  Hyperperistalsis 55/ 

Merycismus 557 

Nervous  Eructation 558 

Hyperesthesia 558 

Gastralgia 558 

Bulimia 559 

Anorexia  Nervosa 5o9 

Nervous  Disorders  of  Secretion 559 

Hemorrhage  from  the  Stomach 559 

Cyclic  Vomiting 560 

Diseases  of  the  Intestines 561 

Duodenal  Ulcer 561 

Diarrhea 56o 

Serous  Diarrhea ''"O . 

Catarrhal  Enteritis 566 

Ileocolitis  of  Childhood     . 566 

Cholera  Infantum 569 

Appendicitis 572 

Intestinal  Obstruction 579 

Congenital  Malformation 579 

Intussusception 579 

Internal  Strangulation 581 

Volvulus 581 

Obstruction  from  Foreign  Bodies 582 

Enteroptosis 582 

Colitis 586 

Acute  Cohtis 586 

Mucous  Colitis 586 

FoUiculus  and  Croupous  Colitis 587 

Pseudomembranous  Colitis 588 

Sprue  (Psilosis) 588 

Dilatation  of  the  Colon 591 

Membranous  Pericolitis 592 

Adhesions,  Displacements,  and  Redundancy  of  Colon 592 

DISEASES  OF  THE  PERITONEUM. 

Acute  Peritonitis 59^ 

Chronic  Peritonitis • 598 

Chronic  Adhesive  Sclerotic  Peritonitis 598 

Morbid  Growths  of  the  Peritoneum 599 

Cancer  of  the  Peritoneum 599 

Other  Growths  of  the  Peritoneum 599 

Ascites S^^ 


CONTEXTS 


DISEASES  OF  THE  LIVER. 

Inflammation  of  tlie  Liver 602 

Acute  Hepatitis  or  Hepatic  Abscess  602 

Ciiihosis  of  the  Liver 606 

Atrophic  Cii'rhosis 607 

Hypertrophic  Cirrhosis 610 

SyphiHtic  Cirrhosis 611 

Perihepatitis  (Capsular  Cirrhosis) 612 

Affections  of  the  Hepatic  Bloodvessels 612 

Amyloid  Liver 614 

Fatty  Liver 614 

Tumors  of  the  Liver 614 

Acute  Yellow  Atrophy  of  the  Liver 616 


DISEASES  OF  THE  BILIARY  TRACT. 

Acute  Catarrh  of  the  Bile-ducts,  or  Acute  Cholangitis 617 

Chronic  Catarrh  of  the  Bile-ducts 618 

Suppurative  Inflammation  of  the  Bile-ducts 619 

Occlusion  and  Constrictions  of  the  Bile-ducts 619 

Acute  Cholecystitis 620 

Cholelithiasis 621 

Malignant  Growths  of  the  Gallbladder  and  Biliary  Passages 627 

Icterus  Neonatorum 630 


DISEASES  OF  THE  PANCREAS. 

Pancreatitis 630 

Acute  Pancreatitis 630 

Chronic  Pancreatitis 634 

Pancreatic  Calculus 636 

Pancreatic  Cysts 636 

Pancreatic  Tumors 637 

Hemorrhages  into  the  Pancreas 637 


DISEASES  OF  THE  KIDNEYS. 

Malformations  of  the  Kidneys 638 

Movable  Ividney ■      ■      ■      •  ^38 

Ciiculatory  Disturbances  in  the  Ividney 640 

Acute  Hyperemia 640 

Chronic  Hyperemia 640 

Acute  Nephritis 641 

Clironic  Nephritis 643 

Chronic  Parenchymatous  Nephritis 645 

Chronic  Interstitial  Nephritis 650 

Amyloid  Disease  of  the  Kidneys 657 

L"remia 658 

Pyelonephritis  and  Pyelitis 662 

Hydronephrosis 665 

Cystic  Disease  of  the  Kidney 66 1 

Tumors  of  the  Kidney 66S 

Nephrolithiasis 669 

Perinephritic  Abscess 672 


CONTENTS  xui 

Disorders  of  Urinary  Secretion 672 

Anuria 672 

Hematuria 673 

Hemoglobinuria 674 

Hematinuria 674 

Albuminuria 6/5 

Pyuria 678 

Chyluria 678 

Phosphaturia 679 

Oxaluria 679 

Indicanuria 679 

Lithuria 680 

Melanuria 680 

Myelopathic  Albiuiiosuria 680 


DISEASES  OF  THE  DUCTLESS  GLANDS  AND  LYMPHATIC  SYSTEM. 


1  of  the  Thyroid  Gland 681 

Goitre 681 

Swelling  of  the  Thyroid 682 

Tumors  of  the  Thyi-oid  Gland     . ■ 683 

Exophthalmic  Goitre 683 

Myxedema 688 

Cretinism 689 

Diseases  of  the  Parathyroid  Gland 691 

Tetany 691 

Diseases  of  the  Thymus  Gland 693 

Status  Thymol3rmphaticus 694 

Diseases  of  the  Suprarenal  Gland 695 

Addison's  Disease 695 

Diseases  of  the  Pituitary  Body 699 

Dyspituitarism 699 

Acromegaly 699 

InfantiUsm 702 

Diseases  of  the  Spleen 702 

Splenic  Anemia 704 

Banti's  Disease 705 

Gaucher's  Disease 705 

Hemolytic  Splenomegaly 706 


DISEASES  OF  THE  BLOOD. 

Anemia 707 

Secondary  Anemia 707 

Primaiy  or  Essential  Anemias 708 

Chlorosis ■  708 

Pernicious  Anemia 710 

Aplastic  Anemia 713 

Chronic  Splenomegalic  Polycythemia  (Erythremia) .  713 

Leukemia 714 

Splenomedullary  Leukemia 715 

Lymphatic  Leukemia 716 

Chloroma 71S 

Anemia  Infantum 718 

Purpura 719 

Hemophilia 721 


CONTENTS 


DISEASES  OF  MTJilTIOX. 

Diabetes  Mellitus 723 

Bronzed  Diabetes 739 

Diabetes  Insipidus 739 

Gout 740 

Acute  Gout 745 

Chronic  Gout 746 

Irregular  Gout 746 

Arthritis  Deformans 749 

Clironic  Rheumatism 753 

Muscular  Rheumatism 754 

Rickets 755 

Scurvy ■ 759 

Obesity 762 

Adiposis  Dolorosa 764 

Osteitis  Deformans 765 

Hypertrophic  Pulmonary  Osteo-arthi'opathy 765 

Leontiasis  Ossea 765 

Scleroderma 765 

Ochronosis 766 

Ainhum 766 

Beriberi 766 


INTOXICATIONS. 

Alcoholism 771 

Acute  Alcoholism 771 

Subacute  and  Chronic  Alcoholism 772 

Morphinism 775 

Arsenical  Poisoning 777 

Lead  Poisoning,  or  Plumbism 778 

Food  Poisoning      . 7S1 

Bromatotoxismus 781 

Sitotoxismus 781 

Mytilotoxismus 781 

Ichthyotoxismus 782 

Ivreotoxismus "82 

Tyrotoxismus  and  Galactotoxismus "82 

Pellagra" "82 


DISEASES   OF  THE   NERVOUS  SYSTEM. 

DISEASES    IX    WHICH    THE    CHIEF    MANIFESTATIONS    ARE    IN    THE    BRAIN 
AND   ITS   MEMBR. 


Hemorrhage  into  the  Brain,  Cerebral  Thrombosis,  an 
Infantile  Cerebral  Paralysis  . 

Little's  Dise;ise      ... 

.Vplia.sia 

Tumors  of  the  Brain  and  its  Monibranc 
.'Vljscess  of  the  Brain   .... 
Acute  Cerebritis  or  Encephalitis 
Thrombosis  of  the  Venous  Sinuses  . 
Cerebral  Meningitis 

Pachymeningitis    .... 

Pachymeningitis  Interna 


\NES. 

mholi 


785 
795 
799 
799 
801 
809 
811 
812 
813 
813 
814 


CONTENTS  XV 

Cerebral  Meningitis: 

Leptomeningitis ^^^ 

Dementia  Paralytica ^^'' 

Disseminated  Sclerosis ^-^ 


DISEASES    IN    WHICH    THE    CHIEF    MANIFESTATIONS    ARE    IX    THE 
SPINAL   CORD. 

Locomotor  Ataxia 823 

Friedreich's  Ataxia S30 

Marie's  Cerebellar  Hereditary  Ataxia 833 

Chronic  Anterior  Poliomyelitis °^^ 

Bulbar  Paralysis 835 

Lateral  Sclerosis °3o 

Syphilitic  Spastic  Spinal  Paralysis 838 

Amyotrophic  Lateral  Sclerosis 838 

Myelitis 840 

Acute  and  Subacute  Myelitis 840 

Chi-onic  Myelitis 842 

Senile  Paraplegia   ....'' 844 

Myelomalacia 844 

Syringomj'elia  . 844 

Hemorrhage  into  the  Spinal  Cord 846 

Hemorrhage  into  the  Spinal  Membranes 847 

Compression  of  the  Spinal  Cord 848 

Spinal  Meningitis 851 

Chronic  Spinal  Meningitis 853 

Acute  Ascending  Paralj'sis  (Landry's  Paralysis) 854 

Caisson  Disease 8oo 


DISEASES   IN   WHICH   THE   CHIEF   MANIFESTATIONS   ARE   IN   THE   NERVES. 

Neuritis 857 

Special  Forms  of  Neuritis 859 

Cervicobrachial  Neuritis 859 

Obstetrical  or  Bu'th  Palsy 860 

Sciatica .  860 

Multiple  Neuritis • 860 

Diseases  of  the  Cranial  Nerves 865 

The  Olfactory  Nerve 865 

The  Optic  Nerve 865 

Optic  Atrophy 866 

Hemianopsia 867 

The  Third  or  Oculomotor  Nerve 870 

The  Fourth  or  Trochlearis  Nerve 871 

The  Fifth  or  Trifacial  Nerve 871 

Paralysis  of  the  Sixth  Abducens  Nerve 873 

Disturbances  of  Motility  in  the  Ocular  Muscles  Depending  on  the  Third, 

Fourth,  and  Sixth  Nerves 873 

Ophthalmoplegia  or  Paralysis  of  the  Internal  and  External  Muscles  of  the 

Eyeball 874 

The  Seventh  or  Facial  Nerve 875 

Facial  Spasm 878 

The  Eighth  or  Auditory  Nerve 878 

The  Ninth  or  Glossopharyngeal  Nerve 880 

The  Tenth  or  Vagus  Nerve 880 

Eleventh  or  Spinal  Accessory  Nerve 882 

Twelfth  or  Hypoglossal  Nerve 883 


CONTENTS 


DISEASES   IN   WHICH   THE   CHIEF   MANIFESTATIONS   ARK    IN     Till-;    MUSCLES. 

Muscular  Dystrophies 884 

Pseudomuscular  Hypertrophy 884 

Erb's  Juvenile  Muscular  Dystrophy 885 

Landouzy-Dejerine  Type  of  Muscular  Dystrophy  or  Facioscapulohumeral  Type  885 

Muscular  Atrophy  of  the  Peroneal  Tj^je 886 


FUNCTIONAL   NER\'OUS   DISEASES   AND   DISEASES   OF    DISPUTED 
PATHOLOGY. 

Myotonia  Congenita 886 

Paramyoclonus  Multiplex 887 

Paralysis  Agitans 888 

Chorea  Minor 890 

Other  Forms  of  Chorea 893 

Huntington's  Chorea 893 

Dubini's  Disease 894 

Hysteria 894 

Neurasthenia 899 

EpOepsy 901 

Petit  Mai,  or  Minor  Epilepsy 909 

Jacksonian  Epilepsy 909 

Eclampsia 909 

Infantile  Eclampsia 909 

Puerperal  Eclampsia 910 

Latah 911 

Amok  (Running  Amok) 911 

Astasia-abasia 912 

Traumatic  Neuroses 912 

Occupation  Neuroses 914 

Raynaud's  Disease 916 

Angioneurotic  Edema 916 

Ervihromelalgia 917 

Migraine 918 

Sunstroke 920 

Heat  E>diaustion 922 

Facial  Hemiatrophy    .      .      .    ' 922 

Periodical  Paralysis 923 


PRACTICE  OF  MEDICINE. 


DISEASES  DUE  TO  A  SPECIFIC  INFECTION. 


TYPHOID  FEVER. 

Definition. — Typhoid  or  Enteric  fever,  sometimes  called  Autumnal  or  Gastric 
fever,  is  an  acute  infectious  disease  due  to  the  entrance  into  the  body  of  a  susceptible 
individual  of  the  specific  bacillus  of  Eberth,  commonly  known  as  Bacillus  typhosus. 
The  entrance  of  tbJs  organism  into  the  system  results,  after  a  period  of  from  one 
to  three  weeks  in  some  persons,  but  not  in  all,  in  the  development  of  fever,  anorexia, 
headache,  mental  heaviness,  and  more  or  less  severe  pain  in  the  bowels,  back,  and 
limbs.  The  tongue  is  coated,  and  the  bowels  are  loose  or  constipated.  With 
these  symptoms  are  developed  enlargement  of  the  liver  and  spleen,  and  swellings 
and  ulceration  of  the  IjTnphoid  structures  of  the  small  and  large  intestines,  and  a 
rose  rash  on  the  skin. 

History. — ^Typhoid  fever  for  many  years  was  confused  with  tj-phus  fever  and 
malarial  fever,  and  its  very  name  means  "like  typhus."  In  1813  it  w-as  considered 
as  a  separate  disease,  but  this  separation  was  not  generally  known  by  the  profession 
until  Louis,  of  Paris  (1829),  first  emphasized  a  number  of  its  cardinal  points.  Not 
until  18.37  was  the  identification  complete,  when  Gerhard,  of  Philadelphia,  published 
results  achieved  under  the  guidance  of  Louis  which  proved  the  malady  to  be  a 
distinct  entity.  More  than  forty  years  later  (1880)  Eberth  isolated  the  specific 
bacillus  and  proved  it  to  be  the  sole  cause  of  the  disease.  LTp  to  that  time  various 
causes  had  been  thought  to  exist,  but  it  had  been  recognized  for  many  years  as 
a  "filth  disease,"  and,  therefore,  preventable  to  some  degree. 

Distribution. — Enteric  fever  is  one  of  the  diseases  which  may  be  said  to  be  pan- 
demic, since  it  is  found  with  some  degree  of  constancy  all  over  the  world,  its  preva- 
■  lence  depending  upon  the  introduction  into  the  body  of  the  specific  bacillus,  usually 
with  water  or  food.  It  is  estimated  that  about  150,000  cases  of  typhoid  fever 
occur  in  the  L^nited  States  each  year,  with  a  mortality  of  25,000. 

Etiology. — ^The  cause  of  this  disease,  as  just  stated,  is  the  specific  bacillus  of 
Eberth,  a  short,  thick,  actively  motile  bacillus,  with  rounded  ends  and  flagella, 
growing  readily  in  ordinary  suitable  media.  It  is  killed  by  exposure  to  60°  C. 
(140°  F.),  but  it  can  withstand  a  freezing  temperature  for  many  days.  Exposed 
to  sunlight  it  is  slowly  killed,  but  drying,  except  in  very  thin  layers,  does  not  destroy 
it.  It  remains  alive  for  months,  and  even  for  years,  in  clothing  and  in  soil,  if 
the  conditions  are  favorable.  It  is  readily  destroj^ed  by  the  stronger  germicides, 
such  as  carbolic  acid  (1:200)  and  bichloride  of  mercury  (1:2000).  The  bacillus 
of  Eberth  bears  a  close  resemblance  to  the  Bacillus  coli  covununl?,  wdiich  is  alw^ays 
present  in  the  intestine,  and  to  the  so-called  paracolon  bacillus  and  the  Bacillus 
dysenterioe. 

2  (17) 


18  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

The  second  etiological  factor  in  the  development  of  the  disease  is  the  mode 
by  which  the  bacillus  gains  access  to  the  body.  Almost  invariably  this  access 
is  through  the  mouth,  stomach,  and  intestine,  more  rarely  by  inhalation  of  the 
bacillus  in  dust  by  the  lungs.  Infection  takes  place  by  the  mouth  in  a  host  of 
ways,  as  by  infected  water,  or  milk  diluted  with  infected  water,  or  chilled  by  infected 
ice;  by  vegetables  and  oysters  and  clams,  which,  when  eaten  raw,  are  often  the 
means  of  carrying  infection.  It  has  recently  been  proved  at  Ogdensburg,  New 
York,  that  infected  ice  may  transmit  the  organism  after  it  has  been  stored  in  an 
ice-house  for  at  least  nine  months.  In  still  other  instances  persons  nursing  cases 
of  this  disease  get  the  finger-tips  infected  and  so,  on  putting  the  fingers  to  the 
mouth,  introduce  the  organism  into  the  body.  A  very  important  cause  of  enteric 
fever  is  the  so-called  "typhoid  carrier."  A  carrier  is  one  who  continues  for  many 
years  after  an  attack,  in  some  instances  as  long  as  thirty  years,  to  throw  off  the 
specific  bacillus  in  the  stools  although  in  perfect  health.  Usually  the  patient 
has  a  clear  history  of  an  attack  of  the  malady,  but  in  some  a  mild  attack  has  never 
put  the  patient  in  bed  and  no  diagnosis  of  typhoid  fever  has  even  been  thought 
of.  Klinger  traced  to  this  source  1.397  cases  of  enteric  fever.  Of  these  1272  were 
infected  by  convalescent  carriers  and  12.5  cases  by  healthy  carriers.  "Typhoid 
Mary"  in  New  York,  a  cook,  apparently  in  perfect  health,  caused  no  less  than 
seven  outbreaks  (28  cases)  of  enteric  fever  in  five  years  at  widely  separated  points. 
She  denied  that  she  had  had  typhoid  fever,  but  examination  of  her  stools  showed 
them  to  be  laden  with  typhoid  bacilli.  In  other  words,  she  was  a  chronic  typhoid 
disseminator.  Sawyer  has  reported  ninety-three  cases  of  typhoid  fever  infected 
by  one  "carrier,"  who  prepared  one  dish  at  one  meal.  More  and  more  such  cases 
are  being  reported  as  time  goes  by.  The  bacillus  of  Eberth  has  been  found  in  the 
stools  of  healthy  attendants  on  typhoid-fever  cases,  who  have  never  had  the  dis- 
ease, but  who  are,  nevertheless,  "carriers."  Again,  it  has  been  proved  beyond 
doubt  that  flies  after  lighting  upon  the  discharges  of  a  case  of  typhoid  iever  may 
carry  the  bacillus  to  otherwise  pure  food,  and  so  spread  the  infection  as  long  as 
twenty-three  days  after  feeding  on  infected  stools  (Fischer).  Stokes  describes  an 
epidemic  in  a  factory  employing  1.500  women  and  400  men.  As  many  as  200  of 
the  women  were  ill  at  one  time  with  typhoid  fever,  but  none  of  the  men  fell  ill. 
All  the  men  drank  beer  at  luncheon,  whereas  all  the  women  used  milk.  The  milk 
was  found  to  ha^•e  been  infected  by  flies  from  a  neighboring  privy.  Cockroaches 
may  also  spread  the  bacillus. 

Whipple  states  that  typhoid  fever  is  due  to  contaminated  water  in  40  jicr  cent., 
infected  milk  in  25  per  cent,  and  to  contagion  in  30  per  cent.,  including  fly  trans- 
mission. 

Every  great  epidemic  of  the  disease  has  been  due  to  contamination  of  the  water 
supply.  In  the  Maidstone  epidemic  in  England  1  person  in  every  17  in  the  town 
was  infected;  while  in  the  Plymouth  epidemic  in  Pennsylvania  1  in  every  7  was 
stricken,  for  there  were  1200  cases  in  a  population  of  SOOO.  As  only  a  part  of 
these  SOOO  persons  used  the  contaminated  water,  the  proportion  of  actual  infection 
to  exposure  was  far  higher  than  1  in  7.  The  influence  of  bad  and  good  water 
supply  is  shown  in  Figs.  1,  2  and  3. 

In  "iSSS  the  use  of  filtered  drinking-water  was  begun  in  the  French  arm%-,  as  a 
result  of  which  the  morbidity  of  typhoid  fever  was  diminished  49  per  cent,  in 
1890,  and  the  mortality  .34  per  cent. 

Prevention. — From  what  lias  just  been  said  it  is  evident  that  typhoid  fever  is 
an  entirely  preventable  disease,  provided  that  the  bacilli  as  they  escape  in  the 
feces,  the  urine,  the  sputum,  and,  perhaps,  in  the  sweat,  are  destroyed  as  soon  as 
they  pass  from  the  patient's  body.  The  destruction  of  the  discharges  and  so  of 
the  bacilli  is  therefore  absolutely  essential,  and  in  addition  careful  antisepsis  on 
the  part  of  the  attendant  as  to  personal  cleanliness  and  the  protection  of  the  dis- 


TYPHOID  FEVER 


19 


charges  from  flies  are  to  be  enforced.  As  careless  or  ignorant  persons  do  not 
disinfect  the  stools,  the  additional  measures  of  prophylaxis  are  the  boiling  of  all 
water  that  is  to  be  placed  in  the  mouth,  and  the  use  of  nothing  but  well-cooked 
foods,  which  have  not  been  exposed  to  flies  or  dust  after  cooking.  The  vessel 
which  receives  the  discharges  of  the  patient  should  contain  carbolic  acid  (1:200), 
corrosive  sublimate  (1:2000),  or  chlorinated  lime  (a  heaping  teaspoonful  to  the 
pint).  Formaldehyde  solution  (40  per  cent.)  may  also  be  used.  If  the  stool  is 
formed,  it  should  be  broken  up  by  stirring  it  with  a  rod,  so  as  to  expose  all  the  fecal 
matter  to  the  germicide. 


t-   sn    sa  O 


1 

1000 

1 

sooo 

I 

3000 

1 

iOOO 

1 

5000 

1 

6000 

1 

1 

rooo 

1 

sooo 

1 

9000 

1 

IflOOO 

\ 

1 

1 

1000 

2000 

3000 

4000 

3000 

6000 

7000 

8000 

9000 

lOWO^^^^ 

fmmF 

Fig.  1. — Mortality  in  Chicago  of  typhoid  fever.  In  1891  and  1892  the  water  was  contaminated  with 
sewage  and  the  death  rate  was  about  1  to  450  to  1  to  1500.  With  a  change  in  water  supply  the  mor- 
tality has  fallen  to  1  to  6000  or  even  1  to  9000.     (Seibert.) 

Fig.  2. — Mortality  of  typhoid  fever  in  Berlin  before  the  supply  of  drinking-water  was  filtered.  In 
the  decade  1843  to  1853  the  average  yearly  mortality  was  1  per  900  of  inhabitants. 

Fig.  3. — Mortality  of  typhoid  fever  in  Berlin  after  water  was  filtered.     (Seibert.) 


Physicians  and  nurses  are  not  careful  enough  about  the  destruction  of  the  stools, 
and  the  average  individual  is  willing  to  take  his  chances  on  the  use  of  unboiled 
water.  Another  of  the  difficulties  is  that  patients  may,  when  no  longer  kept^in 
the  house  by  the  disease,  continue  to  cast  off  bacilli  in  the  urine  or  feces  which 


20  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

arc  capable  of  infecting  water  supplies.  This  danger  is  of  great  importance,  because 
at  each  urination  or  defecation  the  convalescent  patient  may  produce  a  new  source 
of  infection.  Further,  it  is  toward  the  close  of  the  attack  and  during  convalescence 
that  the  urine  contains  these  specific  organisms  in  pure  culture  and  in  enormous 
numbers,  and  they  may  remain  persistently  present,  not  only  for  days  but  for 
months  and  even  years.  The  patient  should  be  told  of  this  danger,  should  be 
directed  to  disinfect  his  discharges,  and  should  receive  daily  doses  of  uritonc  or 
urotropin  to  destroy  the  bacilli  in  the  urine  before  they  are  passed  in  that  fluid. 
If  he  is  also  informed  that  bacilluria  is  a  danger  to  himself,  in  that  it  may  result 
in  secondary  diseases  in  his  genito-urinary  tract,  he  may  be  interested  enough  to 
aid  the  physician  in  arresting  the  spread  of  the  bacillus  by  adhering  to  a  plan  of 
careful  medication.  Purjesz  and  Perl  report  the  finding  of  typhoid  bacilli  in 
tongue-scrapings  and  upon  the  tonsils  (more  often  the  former)  of  half  the  conva- 
lescents examined.  The  examinations  were  made  at  times  between  the  fifth  and 
forty-seventh  day  after  active  symptoms  had  ceased. 

All  clothing,  instruments,  bedding,  pillows,  utensils,  bath-tubs  and  ordinary 
wash-tubs,  which  may  be  contaminated  by  the  discharges  of  a  ])atient,  should  be 
disinfected  thoroughly  as  soon  as  their  function  is  performed.  The  hands  of  the 
nurses  should  be  repeatedly  disinfected. 

Antityphoid  Vaccination. — Another  preventive  of  typhoid  fever  consists 
in  the  injection  or  inoculation  in  the  arm  or  back  of  the  individual  with  dead 
Bacillus  typhosus,  the  organisms  being  destroyed  by  heat.  Such  an  injection 
produces  no  effects,  or,  rarely,  local  swelling  and  some  pain,  a  sense  of  nausea  and 
depression,  and  some  febrile  movement,  which  symptoms  speedily  disappear, 
the  patient  at  the  end  of  twenty-four  to  thirty-six  hours  being  well  again.  Ten 
days  later  the  individual  is  injected  a  second  time  and  ten  days  later  a  third  time, 
each  dose  being  larger  than  its  predecessor.  The  dose  is  500,000,000  increased 
to  1,000,000,000  or  to  1,500,000,000.  The  dose  for  a  child  of  50  pounds  is 
considered  to  be  approximately  one-third  of  the  dose  for  an  adult  of  150  pounds. 
This  prophylactic  treatment  is  perfectly  safe  and  has  been  used  successfully  in 
so  many  hundreds  of  thousands  of  cases  as  to  be  assured  as  firm  a  place  in 
medicine  as  diphtheria  antitoxin.  The  Commission  of  the  French  Academy  of 
Medicine  advises  that  no  subject  shall  be  vaccinated  in  whom  typhoid  seems 
imminent  or  at  the  beginning  of  an  attack,  as  vaccination  may  aggravate  the 
disease.  It  should  be  practised  only  upon  perfectly  healthy  subjects,  free  from  all 
organic  or  other  defects  and  from  local  or  general  aft'ections,  no  matter  what  their 
nature,  especially  tuberculosis,  as  vaccination  may  cause  a  temporary  predisjjosi- 
tion  to  infection.  Every  person  vaccinated  against  typhoid  fever  should  take  the 
strictest  precautions  to  avoid  the  chances  of  typhoid  infection  by  a  careful  watch 
upon  the  water  that  is  drunk  and  the  food  that  is  eaten.  The  period  during  which 
such  precautions  must  be  taken  has  a  duration  of  two  or  three  weeks  at  the  most. 

The  group  of  persons  designated  as  likc]\-  to  be  ])articularly  benefited  by  anti- 
typhoid inoculation  are: 

(a)  Physicians,  medical  students,  male  and  female  nurses  in  military  and  ci\il 
hospitals. 

(6)  Members  of  families  in  which  tyj)hoid  fe\er  is  present  or  in  which  "bacillus 
carriers"  have  been  demonstrated. 

(c)  Young  persons  of  both  sexes  who  have  come  from  salubrious  regions  in  the 
country  to  cities  in  which  are  habitual  foci  of  typhoid  fex'cr. 

UJ)  The  population  of  cities  where  the  latter  flisease  is  frequent. 

(e)  Soldiers  and  sailors  (rank  and  file). 

The  immunity  induced  lasts,  so  far  as  is  known,  about  three  years.  Probably 
antibodies  do  not  exist,  but  the  body  is  ready  to  prepare  them  in  the  presence  of 
infection. 


TYPUOID  FEVER 


21 


Out  of  130,000  antityphoid  inoculations  in  the  United  States  Army,  97  per  eent. 
showed  no  disagreeable  symptoms.  In  1913  the  general  typhoid-fever  morbidity 
throughout  the  United  States  was  12.70  per  100,000.  In  the  United  States  Army  it 
was  0  per  100,000  under  inoculation. 

In  order  to  protect  not  only  from  the  typhoid  bacillus  but  also  from  both  the 
Bacillus  paratyphosus  a  and  13,  a  t>phoid-paratyphoid  vaccine  has  been  employed, 
each  injection  containing  500,000,000  typhoid 

bacilli,     250,000,000     paratyphoid     a,     and  Fig.  4 

250,000,000  paratyphoid  /3.  It  produces 
little  if  any  more  reaction  than  the  use  of  a 
single  strain,  but  its  use  is  probably  needless 
unless  there  be  present  an  epidemic  of  para- 
typhoid infection. 

Frequency. — Typhoid  fever  affects  males 
oftener  than  females,  and  occurs  most  fre- 
quently between  fifteen  and  thirty  years  of 
age.  It  may,  however,  affect  infants  or  aged 
persons.  It  occurs  more  frequently  in  August, 
September,  and  October  than  any  other  quar- 
ter of  the  year,  but  is  by  no  means  limited  to 
this  period.    (See  Fig.  5.) 

Typhoid  fever  is  becoming  less  and  less 
frequent,  and  less  severe  all  over  the  world. 
In  Munich  the  mortality  in  the  decade  from 
1851  to  1861  ranged  from  123  in  100,000 
inhabitants  to  453  in  100,000  inliabitants, 
whereas  in  the  years  from  1890  to  1897  the 
mortality  was  from  57  or  14.8  in  100,000 
people  to  10  or  2.5  per  100,000;  in  Vienna  it 
has  fallen  from  120  per  100,000  to  10  per 
100,000;  in  Dantzig,  from  100  per  100,000  to 
10.5.  In  Massachusetts  the  mortality  from 
typhoid  fever  in  33  cities  in  1901  was  only  one- 
fourth  of  what  it  was  thirty  years  before.  In 
Philadelphia  a  similar  decrease  has  occurred 
in  both  mortality  and  morbidity.  In  Mel- 
bourne, Australia,  there  has  also  been  a  de- 
crease in  the  mortality  rate  which  is  very 
noticeable,  being  over  50  per  cent.  These  de- 
creases are  due  chiefly  to  care  in  regard  to 
water  supplies. 

The  general  mortality  rate  of  the  world 
may  be  said  fifty  years  ago  to  have  been 
almost  universally  25  per  cent.,  whereas  it  is 
now  from  15  to  10  per  cent. 

With  advancing  years  of  age  the  morbidity  decreases,  but  the  mortality  greatly 
increases.     (See  Fig.  6.) 

That  typhoid  fever  is  still  the  cause  of  an  enormous  number  of  deaths  is  empha- 
sized by  Whipple's  statistics  of  the  United  States,  in  which  it  is  shown  that  in 
1910  there  were  35,379  deaths  due  to  this  disease,  a  loss  of  life  which  was  computed 
by  him  as  equivalent  to  a  pecuniary  loss  of  §212,000,000  for  that  year  alone. 

Pathology  and  Morbid  Anatomy. — In  studying  the  morbid  anatomy  of  typhoid 
fever  it  must  be  remembered  that  it  is  not,  Avhen  fwHy  developed,  a  local  infection, 
restricted  to  one  or  more  foci  from  which  the  Bacillus  typhosus  distributes  its  toxin 


ADMISSION  AND  DEATH  RATES  FOR  TYPHOID  FEVER, 
UNITED  STATES  (ENLISTED  MEN) 

ADMISSION 

RATES 

PER  1000 

Si     S 
3      IS 

ii  S  i 

=.  ^ 

U 

z 

s 

6 

In 

i 

'n' 

a 

P 

II 

II 

1 

1 

1 

1 

■ 

1 

DEATH 

RATES 

PER  TOGO 

s 

YEARS 

i'iilli'ii^ili 

ANTI-TYPHOra  VACCINATION  BEGUN  VOLUNTARILY 
IN   1909  WAS  MADE  COMPULSORY  IN  1911 

Chart  showing  (Jecreasing  morbidity  and 
mortality  from  enteric  fever  in  the  United 
States  Army  under  so-called  antityphoid 
vaccination.  (Com-tesy  of  the  Surgeon- 
General,  United  States  Army.) 


22 


DISEASES  DUE  TO  A  SPECIFIC  INFECTION 


through  the  liody.    On  the  contrary,  the  typhoid  infection  is  practically  universal, 
and  the  bacillus  may  be  found  in  varying  numbers  in  every  organ  of  the  body,  includ- 


Chart  from  the  United  States  census,  showing  the  period  of  the  year  when  the  mortality  from 
typhoid  fever  reaches  its  maximum. 

ing  the  Kpne-marrow  and  skin.    Contrary  to  general  belief,  they  may  not  be  demon- 
strable in  the  intestinal  contents  in  large  numbers  until  the  disease  is  well  advanced, 


AGE 

10 

11-1  f. 

ir,-20 

51-2.-) 

■;r.-30 

31-3,-, 

31'.- 10 

ll-ir. 

inriO 

."■,1  ■:,,:,  M-m    oi 

50- 

-|^- 

4-1- 

1 

1 

1 

"       V- 

- 

^LL 

-r~ 

.J  .L 

40- 

i 

\ 

J       - 

___    %       . 

J 

'    7 

30- 

1 

1  i  /j 

^ 

_^ 

^_ 

- 

-1-1- 

^-,-:--W- 

20- 

-- 

-- 

- 

i-T 

/  ^ 

, 

/ 

\/ 

-_ 

1 

1 

,' 

__ 

^ 

10- 

0- 

-- 

_ 

-''-' 

■-" 

^ 

'-' 

/" 

1        1 

^ 

TJ- 

-U.- 

1  1 

±L±E±: 

Showing  the  increased  mortality  of  tjT)hoid  fever  with  ago.     (Curschmann.) 

and  their  presence  in  the  stools  depends  largely  upon  the  intensity  of  the  changes 
which  take  place  in  the  intestinal  lymph  nodes.     It  is  true,  however,  that  the 


TYPHOID  FEVER  23 

agminated  follicles  (Peyer's  patches)  and  the  solitary  follicles  of  the  small  bowel 
are  the  parts  of  the  body  which  usually  are  the  seat  of  the  most  evident  and  constant 
lesions.  On  the  other  hand,  it  is  not  to  be  forgotten  that  cases  of  unfloubted  typhoid 
fever  occasionally  occur  in  which  no  ulceration  of  the  intestinal  mucosa  takes  place. 
The  alterations  from  the  normal  in  the  bowel  may  be  discussed  under  three 
heads:  (1)  a  difl'use  catarrhal  inflammation  of  the  intestinal  mucosa  of  varying 
severity,  but  usually  resulting  in  descjuamation  of  epithelium;  (2)  hyperemia, 
swelling,  endothelial  and  lymphoid  hyperplasia,  necrosis,  and  finally  ulceration 
of  the  agminated  follicles  or  Peyer's  patches;  and  (3)  a  similar  change  in  the  so- 
called  solitary  lymph  follicles  of  the  intestine,  although  the  changes  in  the  agminated 
follicles  are  distinctly  the  more  conspicuous.    These  changes  begin  in  the  very 

Fig.  7 


Ulceration  of  a  Peyer  patch  in  typhoid  fever,  with  associated  sweUing  of  solitary  glands. 

earliest  stages  of  onset,  and  do  not  wait  until  the  symptoms  of  the  disease  are  well 
developed.  If  the  patient  comes  to  autopsy  at  this  time,  the  intestinal  mucosa 
will  not  only  be  found  inflamed,  but  in  addition  the  lymphoid  structures  just  named 
will  also  be  found  swollen  and  reddened  by  hyperemia.  Their  edges  are  not  well 
defined,  and  the  entire  gland  is  hyperplastic  and  spongy.  A  little  later  in  the 
progress  of  the  disease  these  areas  become  less  red  in  hue  and  begin  to  look  some- 
what gray  in  color;  they  are  firmer  and  project  above  the  surrounding  mucous 
membrane  to  a  marked  degree,  so  that  they  extend  well  into  the  lumen  of  the  bowel. 
Sometimes  the  hyperplasia  within  the  gland  is  so  great  that  its  edges  overhang 
the  surrounding  tissue.  These  elevated,  circumscribed  masses,  made  up  of  pro- 
liferated lymphoid  and  endothelial  cells,  are  known  as  typhoid  nodu?es.     In  addition 


24  DISEASES  DUE  TO  A   SPECIFIC  INFECTION 

to  being  elevated  ahove  the  surface  of  the  intestine,  these  ceils  extend  into  the 
wall,  usually  involving  the  submucosa  and  at  times  the  muscle  coat.  Owing  to 
disturbances  in  nutrition  and  the  action  of  the  tyjjhoid  toxiiie  the  nodules  become 
necrotic,  the  dead  tissue  sloughs,  and  the  typhoid  ulcer  is  formed  (Fig.  7).  The 
most  extensive  ulceration  usually  takes  place  in  the  lower  part  of  the  ileum. 

While  ulceration  of  the  tissues  composing  Peyer's  patches  is  the  usual  result  of 
this  infection,  necrosis  does  not  always  ensue.  The  gland  may  become  red  and 
swollen  and  the  inflammatory  process  go  no  farther,  proceeding  from  this  state 
to  that  of  resolution  and  healing.  Not  infrequently  this  agminated  patch  is  not 
equally  affected  in  all  its  parts,  and  this  gives  it  an  uneven  appearance,  which  is 
emphasized  when  the  portions  which  are  most  affected  ulcerate,  so  that  small 
ulcers  are  dotted  over  the  surface  of  the  swelling,  which,  if  the  process  is  severe, 
finally  coalesce.  In  severe  types  of  the  disease  the  process  is  so  well  diffused  that 
a  huge  slough  forms  which,  when  it  drops  off,  leaves  a  swollen,  ulcerated  surface, 
the  excavation  being  usually  very  deep.  It  is  this  type  of  necrosis  that  results  in 
perforation,  the  opening  in  the  bowel  wall  being  usually  found  at  a  point  directly 
opposite  the  mesenteric  attachment.  Rarely  the  perforation  takes  place  between 
the  layers  of  the  mesentery  and  causes  a  retroperitoneal  abscess.  Ilarte  states  that 
in  140  cases  out  of  190  the  perforation  occurred  in  the  small  bowel  within  twelve 
inches  of  the  cecum. 

If  the  patient  survives  the  severer  periods  of  the  disease,  the  swelling  of  the 
glandular  tissue  gradually  diminishes,  granulations  develop,  new  connective  tissue 
largely  takes  the  place  once  occupied  by  the  gland,  and  the  ordinary  intestinal 
epithelium  covers  the  exposed  area.  While  it  is  true  that  the  solitary  glands  are 
rarely  so  markedly  affected  as  the  agminated  follicles,  they  may  suffer  much  more 
severely  and  be  found  diseased  over  a  larger  area  than  are  the  patches  of  Peyer. 

The  number  of  ulcers  in  the  bowel  in  typhoid  fever  varies  greatly.  Usually 
they  are  limited  in  number,  but  occasionally  they  are  many  and  cover  very  large 
areas.  They  may  be  more  numerous  in  the  cecum  than  elsewhere  in  the  colon. 
Out  of  577  autopsies  upon  cases  of  this  disease  in  Hamburg  and  in  Leipzig,  the 
cecum  was  ulcerated  in  510,  or  SS..39  per  cent.;  the  cecum  and  appendix  in  247, 
or  42.S1  per  cent.;  the  colon  in  184  cases,  or  31.89  per  cent.;  the  jejunum  in  41 
cases,  or  7.10  per  cent.;  the  rectum  in  12  cases,  or  2.08  per  cent.  The  percentage 
of  cecal  lesions,  in  these  statistics  of  Curschmann,  just  given,  is  much  higher  than 
is  generally  noted;  40  per  cent,  is  more  nearly  correct.  As  already  stated,  the 
lower  part  of  the  small  bowel  is  the  area  chiefly  affected. 

Next  to  the  changes  in  the  intestine  the  most  noteworthy  alterations  may  be 
said  to  take  place  in  the  lymph  nodes  of  the  mesentery,  which  lie  between  the  intestinal 
lesion  and  the  general  system.  These  tissues  go  through  a  similar  process  of 
hyperemia,  swelling,  and  endothelial  proliferation,  which  usuallj'  falls  short  of 
extensive  necrosis.  Small  necrotic  patches  are  not  infrequent.  I\Iore  rarely 
large  foci  of  softening  or  even  suppuration  may  occur  in  these  nodes,  and  as  recovery 
takes  place  small  septic  areas  are  gradually  walled  off  by  lymph,  become  encysted, 
or  are  absorbed.     Rupture  of  enlarged  mesenteric  nodes  has  been  observed. 

The  spleen,  in  addition  to  its  swelling,  which  begins  early  and  lasts  for  the  first 
three  weeks  or  more  of  the  illness,  is  full  and  tense,  and  of  a  darker  hue  than  normal. 
Later,  as  the  attack  wanes,  it  becomes  soft  and  darker  in  hue.  The  splenic  blood 
sinuses  are  distended  by  erythrocytes,  the  endothelial  cells  proliferate,  and  the 
pulp  here  and  there  becomes  the  seat  of  small  areas  of  coagulation  necrosis.  The 
splenic  lesions  may  also  consist  in  infarction  and  rupture,  but  the  latter  accident 
is  very  rare. 

Until  a  few  years  ago  the  presence  of  the  typlioid  liacilius  in  the  blnnd  was  un- 
known, but  we  now  know  that  this  organism  is  present  in  this  part  of  the  l)ody 
with  great  constancy,  probably  invariably  during  an  attack  of  typhoid  fever.    It 


TYPHOID  FEVER  25 

is  usually  present  as  early  as  the  fiftli  day  and  persists  until  the  close  of  the  third 
week,  or  even  longer  than  this.  Rosenberger  collected  535  cases  of  typhoid  fever 
in  which  the  blood  was  examined  for  the  bacillus.  It  was  found  in  SO  per  cent, 
of  these  cases.  In  a  still  more  recent  study  Coleman  and  Buxton  obtained  the 
following  results: 

Second  Week.  Of  484  examinations  made  in  the  second  week  of  the  disease, 
353  (73  per  cent.)  were  positive. 

Third  Week.  Of  268  examinations  made  in  the  third  week  of  the  disease,  178 
(60  per  cent.)  were  positive. 

Fourth  Week.  Of  103  examinations  made  in  the  fourth  week  of  the  disease,  39 
(38  per  cent.)  were  positive. 

AHer  the  Fourth  Week.  Of  58  examinations  made  after  the  fourth  week  of  the 
disease,  exclusive  of  relapses,  15  (26  per  cent.)  were  positive.  The  examination 
of  the  blood  has  therefore  become  of  great  importance  in  the  early  diagnosis  of 
the  disease.  (See  Diagnosis.)  The  bacillus  probably  gains  access  to  the  blood 
through  the  mesenteric  lymph  nodes,  and  the  destruction  of  myriads  of  the  bacilli 
by  the  blood  thereby  sets  free  their  endotoxin,  which  produces  the  symptoms  and 
many  of  the  lesions  of  the  malady. 

The  liver  is  usually  somewhat  swollen,  but  the  changes  in  its  appearance  are 
not  peculiar  to  this  disease.  The  hepatic  cells  manifest  more  or  less  cloudy  swelling, 
and  the  areas  of  coagulation  necrosis  containing  endothelial  cells  are  present.  The 
cells  lining  the  bile-ducts  may  be  swollen,  granular,  and,  in  some  cases,  undergo 
a  process  of  desquamation.  Abscess  of  the  liver  may  develop  or  gallstones  may 
by  their  presence  aid  in  the  production  of  a  cholecystitis,  but  more  commonly 
typhoid  fever  probably  induces  the  formation  of  gallstones.     (See  Complications.) 

The  heart  muscle  nearly  always  suffers  from  typhoid  infection  in  direct  proportion 
to  the  severity  of  the  toxemia  present.  The  myocardium  is  granular  and  may 
suffer  from  fatty  or  hyaline  changes.  Very  rarely  the  endocardium  becomes 
affected  and  the  specific  bacillus  has  been  obtained  from  vegetations  on  the  valves. 

The  kidneys  show  no  typical  changes.  They  usually  show  cloudy  swelling, 
and  even  an  acute  nephritis  may  be  present.  Sometimes  as  the  result  of  a  terminal 
infection  multiple  abscesses  may  form  in  the  kidneys  and  a  croupous  exudate  in 
the  pelvis  of  these  organs  may  develop. 

Reference  is  made  elsewhere  to  the  lesioiis  of  the  respiratory  tract  which  may 
complicate  the  course  of  the  malady,  such  as  laryngeal  perichondritis,  ulcerative 
laryngitis,  hypostatic  congestion,  pneumonia  in  both  its  forms,  pulmonary  infarc- 
tion, simple  pleurisy,  and  empyema.     (See  Complications.) 

An  endarteritis  (which  may  be  a  thrombo-endarteritis)  has  been  showTi  to  occur 
in  a  small  percentage  of  cases,  and  it  is  reasonable  to  assume  that  the  thrombotic 
processes  occasionally  observed  in  the  veins  depend  upon  a  similar  involvement 
of  the  lining  membrane  of  these  vessels. 

Longcope  has  shown  that  the  lesions  in  the  bone-marrow  closely  resemble  the 
changes  in  the  lymphoid  tissues  of  the  mesentery  and  of  the  bowel.  There  are 
present  many  lymphoid  cells,  large  phagocytes,  and  foci  of  necrosis. 

A  very  important  factor  to  be  recalled  in  the  study  of  the  pathology  of  typhoid 
fever  is  the  presence  of  additional  infecting  microorganisms  which  aid  the  Bacillus 
typhosus  in  producing  severe  lesions  and  often  are  equally  responsible  for  a  fatal 
termination.  This  view  is,  however,  based  on  postmortem  findings,  and  is  not 
supported  by  the  results  of  antemortem  examinations  of  the  blood,  for  of  150 
cases  of  typhoid  fever  in  which  the  blood  was  examined  during  life  Cole  found  but 
one  in  which  mixed  infection  was  present;  the  case  was  one  of  staphylococcemia, 
with  multiple  boils,  and  terminated  in  death. 

Incubation. — ^The  period  of  incubation  of  the  infection  by  typhoid  fever  is  generally 
stated  to  be  from  one  to  three  weeks.    That  the  period  of  incubation  may  be  much 


26 


DISEASES  DUE  TO  A  SPECIFIC  IXFECTIOX 


shorter  than  this  would  seem  to  be  proved  hy  tlie  case  reported  l)\-  Duflocci  and 
Voisin  of  a  girl  nineteen  years  of  age  who  dehherately  swallowed  a  virulent  culture 
of  the  typhoid  bacillus  with  the  intention  of  committing  suicide.  She  began  to 
feel  ill  on  the  third  day,  had  fever  on  the  fourth  day,  rose  si)ots  on  the  fifth  day,  and 
the  Widal  reaction  appeared  on  the  sixth  day. 

Symptoms. — Typhoid  fever  usually  begins  with  a  sense  of  wretchedness  and 
general  illness,  no  particular  symptom  being  especially  well  marked,  unless  it  be 
more  or  less  severe  frontal  headache  and  aching  in  the  back  and  limbs.  The  facial 
expression  very  early  in  typhoid  fever  usually  becomes  listless  and  later  stupid 
and  heavy,  and  the  patient  is  often  a  little  deaf  because  his  mental  state  is  Ix-numbed 
rather  than  because  there  is  any  actual  trouble  with  the  auditory  apparatus.  Not 
infrequently  there  may  be  a  considerable  amount  of  cough  without  expectoration, 
and  there  may  be  exaggeration  of  the  sounds  of  bronchial  breathing  on  auscultation. 

The  tongue  is  somewhat  coated,  and  very  early  its  edges  become  clean  and  red, 
while  the  central  coating  remains.  This  appearance  of  the  tongue  is  very  character- 
istic, even  in  mild  cases. 

Headache,  thirst,  and  sleeplessness  are  usually  prominent  symptoms  during 
the  first  week.  A  viild  fever  develops  simultaneously  and  nose-bleed  may  occur 
repeatedly.  Usually  the  liver  and  spleen  become  swollen  toward  the  end  of  the 
first  week,  and  the  belly  becomes  somewhat  tumid  and  tender. 

The  characteristic  enlargement  of  the  spleen  in  enteric  fever  may  be  undemon- 
strable  because  of  the  distention  of  the  stomach  and  intestine  with  gas;  but  while 
the  presence  of  an  enlarged  spleen  is  of  some  importance  in  reaching  a  diagnosis 
of  typhoid  fever,  inability  to  discover  any  increase  in  its  size  does  not  negative 
the  diagnosis  of  typhoid  fever  in  any  degree. 

An  undue  amount  of  gurgling  can  be  felt  and  heard  in  the  right  iliac  fossa. 

Gonstipation  is  usual  in  the  first  week,  but  diarrhea  may  be  marked,  and,  if  loose, 
the  stools  may  be  brownish,  but  later  resemble  okra-soup  or  pea-soup. 


M 

E 

M 

eIm 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

MEM 

e:m 

E 

M 

E 

M 

E 

M 

E 

M 

E 

106° 
104' 

X 

£    103° 

1     102° 

•^     101" 

100° 

00° 

= 

^y\:A/:V\y\A  A7 

... 

Z 

Z 

z 

z 

Z 

z 

\ 

£ 

E 

IL 

-- 

^ 

1 

p 

-■^Imu 

T 

^ 

E 

E 

2 

Z 

s 

= 

- 

f 

=: 

V  V  ^\i\\\ivi 

— 

- 

- 

t 

^ 

I 

; 

- 

- 

tVV 

f- 

-- 

T 

-j 

=: 

: 

= 

~ 

- 

- 

E 

-A 

^ 

4*     I'     1/  \l    \l 

/" 

_ 

_ 

_ 

— 

— 

_ 

-J 

_ 

f    V     U 

/ 

i 

_ 

- 

-J 

— 

— 

— 

- 

— 

r 

— 

r- 

^— , 

r- 

■J-, 

-L- 

— 

oisMsc 

1 

■z 

3 

i 

5 

6 

7 

8 

0 

10 

11 

12 

13 

li 

15 

16 

" 

U 

19 

m 

21| 

PULSE 

90  TO  120- DICROTIC! 

M 

'--^ 

^^ 

1 

Course  of  typhoid  fever.     (Modified  from  Musser.) 


The  temperature  in  typhoid  fever  during  the  first  week  rises  step  by  step.  Each 
morning  it  is  higher  than  on  the  previous  morning,  and  each  evening  higher  than 
on  the  night  before,  although  the  morning  temperature  is  often  lower  than  that 
of  the  preceding  evening.     (See  Fig.  8.)     Usually  by  the  end  of  this  week  it  reaches 


TYPHOID  FEVER 


27 


in  the  morning  102°  or  103°,  and  at  night  103°  to  104°,  and  remains  at  this  level 
until  the  fourteenth  or  twenty-first  day. 

The  pulse  is  more  rapid  than  normal,  ranging  from  90  to  100  beats  per  minute, 
and  it  is  usually  soft  and  compressible;  the  pulse  of  debility,  not  of  vigor.  Often 
the  pulse  is  a  little  dicrotic.  As  the  disease  progresses  the  pulse  rate  usually 
increases  to  about  110,  but  the  pulse  force  distinctly  diminishes. 

At  about  the  seventh  to  the  ninth  day  a  very  important  diagnostic  sign  first 
makes  its  appearance,  namely,  the  so-called  rose  spots,  which  usually  develop  on 
the  skin  of  the  abdomen  and  chest,  sometimes  on  the  back,  and  more  rarely  on 
the  limbs.  These  spots  are  small,  faint  macules,  usually  scanty  in  number,  which 
lose  their  color  momentarily  when  pressed  upon  or  when  the  skin  on  which  they 
exist  is  stretched  between  the  finger  and  thumb  of  the  physician.  As  a  rule  these 
spots  are  isolated,  but  very  rareh'  they  may  be  so  profuse  as  to  produce  the  appear- 
ance of  an  ordinary  rash. 

Fig.  9 


105° 

1 

— r 

— r 



— 

— 

— 

— 

— 

1 

E 

j 

5 

J 

i 

i 

£ 

; 

i 

< 

f. 

s 

= 

i 

i 

j 

j 

j 

j 

j 

j 

^ 

£ 

j 

iH 

J 

1 

_ 









— 

— 

— 

104° 
^     103° 



— 

— 

— 

— 

— 

— 

r— 

— 1 

— 

— 1 

— 

— 

— 

— 

= 

- 

- 

T 

- 

- 

- 

z 

i: 

- 

- 

- 

- 

zz 

- 

z 

X 

i    102° 

~ 

~ 

t 

c 

— 

— 

= 

\- 

■~ 

= 

- 

- 

- 

^ 

- 

- 

- 

1 

- 

i 

z: 

: 

— 

- 

zz 

- 

zz 

<    101° 
>-    100° 

^ 

I ::: 

/      - 

' 

- 

- 

^ 

a' 

~ 

^ 

- 

- 

- 

^^ 

'1 

'-M 

^ 

zz 

- 

z 

~ 

~ 

^^ 

1 W 

:|: 

r- 

= 

^ 

- 

- 

- 

- 

_ 

^ 

1 

t 

\ 

- 

- 

I 

99° 
98° 

— 

^ 

^ 

— 

zz 

- 

"T 

^ 

— 

V 

- 

- 

- 

A 

- 

- 

- 

- 

:  1 

1 

' 

7j— 

- 

z 

^ 

i 

— 

— 

— 

— 

— 

zz 

:  :| 

-1 

-: 

-~ 

= 

= 

= 

5 

± 

I 

DAY  OF 

^ 

2 

2 

r; 

s 

s 

U 

2 

5 

s 

S 

s 

s 

?5 

PULSE 

^f^ 

■9-  ^, 

^■'V 

\*'  «* 

^'''*. 

"-%* 

^'^V 

N*V 

^*^i. 

X^ 

^- 

f<0' 

^^ 

•^ 

RESP. 

^x^ 

f^ 

f,s. 

f-i' 

■i«  _  .1, 

f^ 

■''-  -l* 

f^ 

f^ 

f4 

554 

n 

5^^ 

DATE 

s  ^ 

C! 

" 

rr 

" 

= 

'- 

to 

o 

o 

n 

2 

** 

Part  of  a  chart  showing  the  period  of  steep  curves  from  the  fourteenth  to  the  twentieth  day 
of  an  attack  of  typhoid  fever. 

The  tongue  becomes  dry  and  it  may  be  fissured,  the  mental  stupor  increases, 
diarrhea  is  also  active,  and  the  moderate  tympanites  of  the  earlier  days  becomes 
more  marked.  If  the  patient  has  received  little  care,  or  if  the  case  is  essentially 
severe,  his  condition  is  manifestly  one  of  profound  toxemia,  and  by  the  end  of  the 
second  week  he  is  evidently  at  the  very  acme  of  his  infection.  Death  not  infre- 
quently takes  place  during  this  period  as  a  result  of  profound  toxemia,  hemorrhage, 
perforation,  or  pulmonary  complications. 

Because  of  the  toxemia  delirium  may  be  marked,  and  it  is  usually  of  the  low 
muttering  type,  the  patient  seems  to  be  in  a  semi-stupor,  the  teeth  are  covered 
with  sordes,  and  the  tongue  is  foul  and  dry. 

These  symptoms  gradually  carry  the  patient  into  his  third  week,  with  increasing 
diarrhea,  greater  tympanites,  deeper  stupor,  and  more  manifest  signs  of  profound 


28  DISEASES  DUE  TO  A   SPECIFIC  IXFECTIOK 

toxemia,  witli  muscular  tremors  or  true  .stihsnltiis  iendimim.  Emaciation  l)y  tliis 
time  is  marked  and  the  skin  dry  and  harsh.  The  heart  is  feeble,  its  sounds  distant 
and  muffled,  and  myocardial  degeneration  is  manifestly  advanced.  To  the  possi- 
bility of  the  appearance  of  the  fatal  complications  named  in  the  succeeding  pages 
as  appearing  at  the  end  of  the  second  week  are  added  at  this  time  still  greater 
danger  of  pulmonary  hypostatic  congestion  and  pneumonia.  The  patient  may 
be  so  profoundly  poisoned  by  the  toxic  products  of  the  disease  that  he  seems  almost 
moribund. 

If  the  pathological  process  is  not  so  severe  that  recovery  is  im])ossihlc,  the  first 
sign  of  the  ending  of  the  malady  may  develop  at  any  time  between  the  fourteenth 
and  twenty-eighth  clay,  according  to  the  severity  of  the  disease.  This  consists  in  a 
slight  modification  of  the  temperature  range  and  the  develo])ment  of  a  low  morning 
temperature  with  a  well-maintained  high  evening  temperature,  so  that  the  daily 
range  may  amount  to  from  2°  to  3°.  This  is  called  the  "period  of  steep  curves," 
and  the  appearance  of  these  steep  curves  at  this  time  in  the  course  of  the  disease 
is  usually  a  promise  of  approaching  convalescence.  An  equally  good  descrijjtion 
of  this  period  is  that  of  Murchison,  who  called  it  the  "stage  of  changing  fortunes," 
or  that  of  Wunderlich,  who  described  it  as  the  "period  of  ambiguity." 

The  last  stage  of  the  acute  febrile  period  having  been  reached,  the  temperature 
falls  to  normal  during  the  next  few  days  by  lysis,  and  then  may  be  subnormal 
until  convalescence  is  well  established,  the  patient  being  wasted  and  feeble,  but 
usually  ravenously  hungry. 

AriPiCAL  Forms. — While  the  train  of  symptoms  just  described  may  be  con- 
sidered typical  of  an  attack  of  typhoid  fever  occurring  under  conditions  favorable 
for  its  full  development,  it  is  often  so  modified  by  various  causes  that  a  large  pro- 
portion of  cases  do  not  present  many  of  the  most  prominent  and  diagnostic  symp- 
toms, but,  in  their  place,  manifestations  so  at  variance  with  those  of  ordinary 
cases  as  to  greatly  perplex  the  physician.  Thus,  very  marked  variations  in  onset 
may  occur  and  completely  mislead  the  medical  attendant  if  he  be  not  on  his  guard. 
In  some  cases  instead  of  manifesting  itself  gradually  the  disease  has  a  sudden  onset 
with  a  sharp  chill  followed,  it  may  be,  by  a  profuse  sweat  and  a  continued  fever. 
This  variation  is  perhaps  most  apt  to  occur  in  children.  Headache  may  be  so 
severe  in  the  beginning  as  to  rouse  the  suspicion  of  meningeal  inflammation,  and 
active  delirium  may  be  an  early  symptom,  being  severe  enough  to  be  maniacal 
in  type.  In  other  instances  a  pneumonia  is  the  earliest  sign  of  the  malady,  while 
in  still  others  a  severe  choleraic  diarrhea  may  begin  the  illness.  It  is  also  important 
to  recall  the  fact  that  well-developed  signs  of  appendicitis  may  appear,  due  to 
the  swelling  of  the  lymphoid  tissues  of  the  intestine  and  appendix  by  reason  of  the 
infection.  This  has  frecjuently  resulted  in  enthusiastic  surgeons  removing  the 
appendix  only  to  find  it  slightly  diseased  as  part  of  the  general  lymphatic  change, 
the  speedy  appearance  of  the  rose  rash  and  persistent  temperature  soon  showing 
the  true  character  of  the  case.  Rarely  a  severe  attack  of  vomiting  begins  the 
illness,  and  still  more  rarely  acute  renal  disease,  nephro-typhoid,  or  thefievre  typhoide 
a  forme  renale  of  the  French  observers,  develops. 

Although  diarrhea  was  correctly  considered  at  one  time  to  be  one  of  the  most 
constant  symptoms  of  enteric  fever,  it  is  now  absent  in  more  than  half  the  cases 
during  the  whole  course  of  the  disease,  and  splenic  enlargement  in  many  instances 
is  too  slight  to  be  discovered,  so  that  it  is  to  be  borne  in  mind  that  while  these  two 
symptoms  possess  a  positive  diagnostic  value  when  j)resent,  their  absence  in  no 
way  contradicts  the  diagnosis  of  typhoid  fever. 

In  other  instances  the  course  of  the  fever  greatly  varies  from  that  just  described. 
It  may  rise  very  abruptly,  and  it  may  end  equally  suddenly,  the  lysis  being  com- 
pleted in  twenty  hours.  Sometimes  the  morning  temperature  is  the  higher  of  the 
two,  although  this  is  rare.     The  regular  course  of  the  temperature  may  also  be 


TYPHOID  FEVER 


29 


greatly  altered  by  intercurrent  chills.     (See  Chills.)     Very  rarely,  strange  as  it 
may  seem,  no  febrile  movement  is  present  at  any  time  in  the  course  of  the  malady. 

The  most  important  variations  from 
what  may  be  called  the  normal  course 
of  the  temperature  in  the  second  and 
third  week  of  this  disease  are  those  pro- 
duced by  free  hemorrhage  from  an  in- 
testinal ulcer  and  by  perforation  of  the 
bowel.  A  sudden  fall  of  several  degrees 
should  always  arouse  suspicion  of  one 
of  these  accidents,  for  the  drop  in  the 
fever  may  be  noted  before  any  of  the 
other  signs  of  hemorrhage  or  perforation 
manifest  themselves. 

Marked  rises  and  falls  of  temperature 
are  also  often  seen  in  patients  who  are 
markedly  anemic  as  the  result  of  hemor- 
rhage. Abortion  also  causes  a  marked 
fall  of  the  fever. 

The  course  of  the  temperature  may 
resemble  that  of  remittent  malarial 
fever,  and  it  has  frequently  misled  phy- 
sicians into  the  belief  that  malarial  in- 
fection and  not  typhoid  infection  was 
present.  (See  Chills.)  Infectious  com- 
plications of  the  disease,  such  as  otitis 
media,  phlebitis,  furunculosis,  menin- 
gitis, and  erysipelas,  may  also  cause 
sudden  variations  in  temperature.  And 
in  cases  which  have  been  gravely  ill  it 
not  rarely  happens  that  fever  continues 
after  the  typhoid  infection  has  run  its 
course  because  of  post-typhoidal  septi- 
cemia— that  is,  a  multiple  infection  due 
to  the  presence  of  pyogenic  organisms, 
which  have  found  a  favorable  field  for 
growth  in  a  patient  whose  vitality  has 
been  impaired  by  the  specific  fever. 

As  the  stage  of  convalescence  ap- 
proaches, or  when  it  is  reached,  a  sharp 
return  of  active  febrile  movement  may 
come  on  for  a  clay  or  two,  the  temper- 
ature being  as  high  or  higher  than  ever 
before.  It  then  returns  to  its  ordinary 
level.  This  is  called  a  recrudescence, 
and  possesses  no  grave  significance.  It 
often  follows  mental  excitement  and 
the  taking  of  improper  or  too  much 
food.  When  this  rise  of  temperature 
perists,  it  usually  is  indicative  of  some 

complicating  malady,  or  of  a  relapse  called  an  "intercurrent  relapse"  if  it  takes 
place  during  the  continuance  of  the  primary  febrile  period.  (See  Fig.  10.)  After 
the  fever  has  disappeared  there  may  be  a  prolonged  continuance  of  a  slight 
evening  rise  of  temperature  as  the  result  of  nervous  irritability  and  anemia,  or  it 


31V0S     J.I3HN3aHVd 


30  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

depends  upon  the  abuse  of  strychnine,  with  the  mistaken  idea  that  it  is  a  valuable 
heart  tonic  at  this  time.  In  other  cases  a  subnormal  temperature  for  the  entire 
twenty-four  hours  may  persist  for  days.  This  is  of  no  importance  sa\e  that  it 
indicates  that  the  patient  is  feeble  and  needs  good  feedinfi;  and  fresh  air.  The 
other  variations  met  with  depend  upon  the  age  of  the  patient.  Old  persons  often 
have  an  irregular  febrile  movement,  and  children  may  have  marked  rises  and 
falls  of  temperature  which  do  not  necessarily  indicate  any  complications. 

Persistence  of  distinct  febrile  movement  after  the  fourth  week  in  any  case  of 
typhoid  fever  in  which  a  relapse  has  not  occurred  nearly  always  means  a  complicat- 
ing or  secondary  infection.  The  number  of  cases  of  rapid  tuberculosis  called 
typhoid  fever,  until  the  persistent  loss  of  flesh  and  fever  forces  the  correct  diagnosis 
upon  the  physician,  is  by  no  means  small.  The  possibility  of  ulcerative  endocar- 
ditis, cholecystitis  with  ulceration,  with  or  without  impacted  gallstones,  and  septic 
infection  due  to  suppuration  as  causes  of  fever  are  to  be  borne  in  mind  and  their 
presence  carefully  looked  for.     (See  Complications.) 

That  a  patient  witli  this  disease  may  suffer  not  only  from  the  infection  due  to 
the  bacilli  of  Eberth,  but  from  midtiple  infections  by  other  organisms  which  aid 
in  decreasing  his  vital  resistance  should  be  borne  in  mind. 

Closely  associated  with  the  study  of  the  temperature  is  that  of  chills.  They 
may  usher  in  an  acute  complicating  inflammatory  process,  or  be  entirely  without 
such  significance.  Somtimes  they  occur  in  cases  which  suffer  from  constipation, 
apparently  as  a  result  of  the  absorption  of  fecal  poisons.  (See  Fig.  11.)  In  other 
cases  they  are  due  to  a  true  coincident  malarial  infection,  but  it  is  a  noteworthy 
fact  that  during  the  course  of  typhoid  fever,  even  if  the  patient  is  also  suffering 
from  malarial  infection,  the  latter  usually  remains  in  abeyance  until  the  former 
has  about  run  its  course.  It  is  better  for  the  physician  to  regard  such  chills  as 
being  an  indication  of  some  acute  complication  than  to  consider  them  as  malarial, 
unless  he  can  prove  the  existence  of  the  last  possibility  by  finding  malarial  organisms 
in  the  blood. 

The  shin  is  sometimes  covered  by  a  jugacioiis  scarlatiniform  rash  in  the  early 
stages.  In  certain  cases  it  desquamates  in  large  flakes  or  in  fine,  branny  scales, 
the  latter  appearing  oftenest  in  those  who  have  been  actively  bathed  and  rubbed. 

Very  commonly  if  sweating  takes  place,  sudamina,  or  tiny  sweat-drops  retained 
beneath  the  superficial  epiderm,  are  found  on  the  abdomen,  chest,  or  limbs.  Herpes 
about  the  mouth  is  very  rare  in  typhoid  fever,  but  it  does  occur,  notwithstanriing 
the  denial  of  this  fact  by  some  observers. 

Under  the  name  of  tciche  blendtrc,  or  peliomata,  faint  blue  or  steel-gray  spots 
of  fairly  good  size,  are  sometimes  met  with.  They  are  not  due  to  the  disease,  but 
are  found  only  in  those  who  are  infested  with  lice.  The  so-called  tachc  ccrrhralc 
is  not  characteristic  of  this  disease,  but  is  sometimes  seen  during  its  cour.se,  and 
consists  in  a  red  line  with  white  borders  produced  by  drawing  the  finger-nail  over 
the  skin.     It  is  probably  due  to  palsy  of  the  cutaneous  vessels. 

Of  the  deeper  lesions  of  the  skin,  we  meet  with  bed-sores,  which  rarely  occur  in 
cases  seen  from  the  first  and  which  recei\'e  proper  care.  They  appear  usually 
over  the  sacrum.  Cases  of  superficial  (janqrene  of  the  skin  have  been  reported  by 
Stahl  and  the  author.  Erysipelas  occurs,  usually  of  the  face,  by  reason  of  infection 
through  fissures  in  the  buccal  or  nasal  mucous  membrane.  Sometimes  erysipelas 
migrans  develops.     In  very  malignant  cases  petechice  may  be  present. 

Patients  suft'ering  from  typhoid  fever  rarely  suffer  from  other  eruptive  diseases, 
but  instances  of  scarlet  fever,  chickenpox,  and  measles  occurring  as  complications 
are  on  record.  In  women  in  particular  the  hair  often  falls  out  freely  during  or 
after  an  attack.  Boils  are  by  no  means  rare  lesions,  and  even  carbuncles  may 
develop  as  a  result  of  multiple  infection. 

The  blood  in  typhoid  fever  suffers  from  an  increasing  degree  of  anemia  in  respect 


TYPHOID  FEVER 


31 


to  the  number  of  the  red  cells  and  of  their  richness  in  hemoglttbin.  Indeed,  the 
color-index  is  more  markedly  lowered  than  the  corpuscular  count.  When  an 
inadequate  supply  of  liquids  has  been  allowed  the  resulting  concentration  of  the 
blood  may  produce  an  apparent  corpuscular  richness  not  actually  present. 


■■.-i; 

~ 

n 

~ 

" 

~ 

" 

" 

^ 

~ 

" 

-- 

^ 

«! 

oz 

•«-To 

< 

If, 

81 

-n-vc 

\ 

K 

DO 

81 

•«"SI 

90 

81 

■B-JB 

>d 

HII 
Oil 

OS 

■I.'..  0 

- 

•■s 

. 

■KM  C 

,i 

HI 

81 

■«i;i 

% 

■n-r  r, 

mi 

or. 

■BM  0 

/ 

001 

OJ 

■B-TC 

SJ 

001 
001 

05 
7Z 

■«KS, 

k 

■U-.I  r, 

\ 

Jll 

85 

'XM  9 

K 

on 

K 

■KM  C 

H 

on 

t5 

■"7,1 

ROl 

W. 

■K-YB 

|J_,5» 

ci; 

\z 

■K-V  CI 

■t^ 

^ 

rni 

n 

■R-Y  1.. 

J,; 

oJ 

or. 

n 

■^nzi 

on 

\7. 

•it-JO 

S 

501 

05 

■"■JO 

." 

SOI 

05 

■" ,,  c 

■ 

■ 

Kil 

05 

■lint 

on 

55 

■^■Y  r, 

«. 

oOl 

05 

•W-Yll 

> 

SOI 

55 

■BYC 

1! 

811 

f5 

■>^"El 

. 

L 

_ 

- 

- 

- 

- 

001 

1-5 

■"■a  6 

^ 

^ 

^ 

KI 

Si- 

■"■,1  [1 

e 

u 

_ 

1' 

n 

1 

a 

J 

r 

001 

00 

■1,-JS 

~ 

>^ 

— 

L- 

LU 

^ 

_ 

•K-JE 

u'l.Sfi' 

II 

'^1 

" 

"~ 

^ 

s 

801 

f5 

■"51 

> 

SOI 

^5 

■"■Y  r, 

/ 

on 

t5 

■B'Yg 

^ 

on 

55 

"YC 

< 

V 

on 

05 

K"JI 

>\ 

05 

z\\ 

5C 

■"■JC 

azA 

\Z 

■"■iO 

k 

on 

85 

■it-JE 

/ 

Ell 

5C 

•"ET 

_ 

_ 

_ 

- 

- 

— 

-I 

851 

1-5 

■"■YC 

/ 

on 

t5 

•"■Y,, 

- 

— 

_ 

_ 

uLUll 

1,1 

J 

oci 

i-5 

■"■<  5 

I 

w 

i: 

. 

" 

■■ 

HI 

~ 

~ 

-■ 

-. 

.. 

1YE 

- 

Gl 

iin 

1-5 

K-5t 

^ 

o<ri 

EC 

"■J  t 

_ 

- 

-< 

i' 

-■ 

on 

EC 

■a-a  1 

/ 

r- 

" 

on 

OC 

(^■9 

> 

/ 

on 

OC 

0-0 

-• 

OEI 

OC 

■^■JO 

<. 

- 

_ 

1 

WC 

i]^\i\ 

rei 

EC 

■B^as 

h 

~'r\- 

- 

_ 

_ 

_ 

Ujg                1                 1                1                 1                 1                 1                 g                 g                SQg& 

The  bacteriolytic  power  of  the  blood  in  severe  cases  is  probably  always  dimin- 
ished. The  leukocytes  are  slightly  decreased  in  number,  the  large  mononuclear 
and  transitional  cells  are  relatively  increased,  and,  according  to  Thayer,  the  poly- 
morphonuclear cells  are  decreased.  Cabot  asserts  that  a  leukocytosis,  non-inflam- 
matory in  origin,  sometimes  occurs. 


32  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

Complications  and  Sequelae.' — Circulatory  Complications. — The  heart,  as 
already  stated,  is  weakened,  and  if  severely  affected  may  develop  enibryocardia 
or  fetal  heart-sounds.  There  are  few,  if  any,  diseases  which  do  not  have  special 
predilection  for  the  heart  muscle  or  its  valves,  which  so  greatly  interfere  with  this 
organ  as  does  typhoid  fever.  A  pulse  rate  above  125  is  ominous,  and  one  of  130 
or  140  dangerous.  The  danger  is  usually  in  direct  proportion  to  the  feebleness 
of  the  first  sound  of  the  heart.  When  the  cardiac  sounds  are  those  of  the  fcrtus 
in  utero  (enibryocardia),  the  prognosis  is  grave.  A  very  rapid  pulse  and  irritable 
cardiac  action  are  sometimes  seen  in  cases  in  which  strychnine  has  been  used  to 
excess  with  the  idea  that  it  is  a  stimulant.  A  soft  systolic  murmur  is  occasionally 
audible,  which  may  be  hemic  in  origin  or  due  to  relative  insufficiency  of  the  mitral 
valves.  Rarely  it  may  be  due  to  endocarditis  or  pericarditis,  but  pericarditis  is  a 
very  rare  complication  of  typhoid  fever.  Gaudy  and  Gourand  state  that  pericar- 
ditis arising  during  the  course  of  tj-phoid  fever  occurs  in  two  forms,  namely,  the 
fibrinous,  which  is  characterized  by  an  abundant  pseudomembranous  exudation 
with  only  slight  serous  effusion,  and  the  fibrinopurulent  form,  in  which  a  consider- 
able efl'usion  may  occur.  Pericarditis  may  exist  alone  or  may  occur  in  connection 
with  endocarditis,  myocarditis,  pleuritis,  or  pulmonary  complications.  As  a  rule, 
it  de\'elops  very  slowly  and  may  remain  latent,  so  that  only  most  careful  auscultation 
over  the  precordial  region  will  reveal  the  presence  of  friction  fremitus,  and  later 
careful  percussion  may  be  required  to  distinguish  an  effusion.  The  pathogenesis 
of  this  complication  is  obscure.  The  purulent  form  when  it  occurs  may  be  due 
to  secondary  infection,  although  the  fibrinous  variety  is  probably  due  to  a  direct 
infection  with  the  Eberth  bacillus.  Typhoid  fever  complicated  by  purulent 
pericarditis  is  always  fatal,  but  the  existence  of  the  serofibrinous  pericarditis 
influences  prognosis  slightly  if  at  all,  unless  the  eft'usion  be  profuse. 

Sudden  cardiac  failure  may  occur  as  the  result  of  myocarditis,  or  of  embolism 
or  thrombosis  of  the  coronary  arteries,  from  heart-clot,  thrombosis  of  the  cavse  and 
pulmonary  veins  or  from  pericarditis  with  effusion.  Sometimes  the  cardiac  failure 
is  gradual  when  due  to  these  causes. 

So  far  as  the  bloodvessels  are  concerned  the  most  common  lesion  is  phlebitis, 
which  usually  affects  the  veins  of  the  left  leg,  especially  the  femoral  vein.  The 
frequency  of  involvement  of  the  ^'eins  in  the  left  leg  depends  upon  the  pressure 
exercised  by  the  right  common  iliac  artery  i:pon  the  left  common  iliac  vein,  which 
tends  to  obstruct  the  flow  of  blood.  Sometimes  the  tendency  to  the  formation 
of  a  thrombus  is  greatly  increased  by  a  local  infection  of  the  endothelial  lining  of 
the  vessel,  and  it  is  not  uncommon  for  a  severe  chill  or  chills  to  mark  the  onset  of 
the  lesion.  Wright  and  Knapp  have  recently  shown  that  the  tendency  to  the 
formation  of  a  thrombus  in  typhoid  fever  is  augmented  by  the  increase  of  calciiun 
in  the  blood.  When  milk  is  the  exclusi\'e  diet  the  rise  in  the  proportion  of  calcium 
oxifle  supplied  to  the  body  is  very  noteworthy.  They  also  recommend  that  for 
the  prevention  of  this  state  the  physician  add  20  to  40  grains  of  citrate  of  soda 
to  each  pint  of  milk  taken  by  the  patient  in  order  to  decalcify  it. 

Thromboses  of  extraordinary  size  and  number  may  form  anil  extend  from  the 
femoral  vein  to  the  vena  ca\-a.  When  venous  plugging  seriously  interferes  with 
the  circulation,  the  gangrene  which  results  is  usually  moist,  but  in  the  vast  majority 
of  cases  of  phlebitis  of  the  leg  partial  recovery  takes  place,  although  varicosity 
of  the  veins  of  the  limb  may  persist  after  convalescence  is  completed.  The  rarity 
of  plugging  of  the  veins  of  the  upper  extremity  is  remarkable. 

Arterial  thrombosis  is  much  more  rare  than  is  rcnoxis  thrombosis.  This  complica- 
tion usually  develops  after  the  second  week  of  the  fever,  and  is  manifested  iiy  pain 
and  tenderness  along  the  course  of  the  vessel  affected.     Usually  the  leg  is  the 

'  See  Medical  Complications  and  Sequelaj  of  Typhoid  Fever,  by  tlie  author  and  Bcardsley,  2d  ed., 
Lea  &  Febiger. 


TYPHOID  FEVER  33 

limb  involved.  After  a  temporary  increase  in  the  force  of  pulsation  in  tlie  affected 
vessel  the  pulse  becomes  small  and  may  be  lost.  The  part  becomes  cold  and 
discolored,  and  finally  gangrene  ensues.  In  other  cases,  in  which  the  vessel  which 
is  involved  is  small,  recovery  takes  place  by  the  establishment  of  a  collateral  circula- 
tion. Even  in  the  mild  cases  the  patient  suffers  afterward  from  fatigue  in  the 
affected  limb  on  exertion,  and  intermittent  claudication  may  develop.  The  con- 
dition is  due  to  an  arteritis. 

Thayer  has  published  statistics  which  seem  to  indicate  that  typhoid  fever  is 
prone  to  produce  early  senile  changes  in  the  bloodvessels  in  after  years. 

Complications  in  the  Alimentary  Canal. — The  complications  in  the  upper 
digestive  tract  are  pharyngitis,  which  is  rarely  severe  enough  to  cause  much  dis- 
comfort, and  esophagitis,  which  is  still  more  rare,  although  several  observers  have 
recorded  idceraiion  of  the  esophagxis.  Inflammation  of  the  parotid  gland  is  a  rare 
complication  of  typhoid  fever,  and  usually  occurs  about  the  third  week  in  cases 
of  severe  infection.  This  inflammatory  state  may  be  due  to  infection  of  the  gland 
from  the  mouth  by  ordinary  pus  organisms,  or  more  rarely  be  due  to  the  specific 
bacillus.  Rarely  parotitis  occurs  in  the  first  week.  In  the  only  case  the  author 
has  seen  in  which  this  complication  developed  at  this  time  there  was  no  pain  or 
redness,  and  the  swelling  disappeared  in  about  ten  days.  It  was  also  bilateral. 
In  advanced  typhoid  fever  it  is  usually  bilateral ;  is  often  followed  by  ugly  sloughing, 
and  is  a  very  dangerous  complication. 

The  stomach  in  typhoid  fever  is  rarely  much  affected.  Digestion  in  this  viscus  is, 
as  a  rule,  feeble  because  in  all  fevers  there  is  a  lack  of  gastric  secretion,  and  this  is 
particularly  true  of  typhoid  fever.  Vomiting  may  come  on  usually  as  a  result 
of  indiscretions  in  food  and  medicine.  Sometimes,  however,  late  in  the  disease  a 
persistent,  pernicious  vomiting  develops  which  only  ends  with  exhaustion  and 
death.    A  few  cases  of  gastric  ulcer  occurring  in  typhoid  fever  are  recorded. 

When  there  are  more  than  three  or  four  stools  a  day  diarrhea  is  to  be  considered 
excessive.  When  a  far  greater  number  occur,  it  is  usually  the  result  of  improper 
feeding.  The  stools  are  thin  and  resemble  pea-soup  save  that  they  are  apt  to  be  a 
little  more  yellow.  They  are  alkaline  in  reaction,  offensive,  and  may  contain 
particles  of  undigested  food,  as  curds  of  milk,  and  also  small  shreds  of  Ijiuphoid 
tissue  from  the  sloughs  of  the  bow-el.  The  specific  bacillus  usually  is  not  to  be 
found  in  the  stools  until  about  the  seventh  or  tenth  day.  The  significance  of 
active  diarrhea  as  to  the  gravity  of  the  case  has  been  much  discussed,  some  believing 
that  it  is  a  sign  of  a  severe  infection.  The  real  significance  is  not  of  severity  of 
infection,  but  of  severity  of  intestinal  invoh'ement,  catarrhal  or  ulcerative,  although 
in  some  cases  even  the  latter  state  does  not  provoke  active  diarrhea.  General 
diffuse  pain  in  the  bowels  is  often  present  early  in  the  disease,  but  is  apt  to  disappear 
later. 

Hemorrhage  from  the  bowel  in  typhoid  fever  is  one  of  the  inevitable  complications 
in  a  certain  percentage  of  cases,  and  usually  takes  place  after  the  second  week 
of  the  disease.  Very  rarely  slight  loss  of  blood  may  occur  in  the  first  w^eek.  Proper 
treatment  of  the  patient  all  through  his  attack  may  diminish  toxemia  and  prevent 
a  fatal  terminal  infection,  but  no  form  of  treatment  so  far  devised  has  materially 
diminished  the  frequency  of  hemorrhage  or  the  mortality  from  this  cause,  although 
the  frequency  of  the  occurrence  and  mortal  effects  vary  greatly  in  different  epi- 
demics. The  general  average  of  its  occurrence  may  be  placed  at  5  per  cent.  In 
52,196  cases  of  typhoid  fever  collected  from  several  series  of  cases  reported  by 
French  and  German  physicians,  and  from  the  official  reports  of  hospitals  in  the 
United  States  and  Canada,  England  and  Ireland,  Germany,  Austria,  South  Africa, 
and  Australia,  hemorrhage  is  stated  to  have  occurred  in  2725  cases,  which  gives  a 
percentage  of  5.22.  The  mortality  in  persons  suffering  from  it  is  about  35  to  50 
per  cent.,  although  in  271  cases  of  intestinal  hemorrhage  complicating  typhoid 


34  DISEASES  DUE  TO  A  SPECIFIC  IXFECTIOX 

fever,  collected  from  the  official  reports  of  hospitals  in  the  Initcd  States,  Caiuula, 
England,  and  Germany,  71  cases  proved  fatal,  which  gives  a  percentage  of  2().2. 
Hemorrhages  usually  arise  from  ulcers  in  the  small  intestine  and  are  very  rare 
in  children.  The  symptoms  consist  of  sudden  fall  in  the  temperature  and  it  may 
be  in  the  pulse  rate,  but  this  primary  decrease  is  usually  followed  by  a  more  rapid 
pulse  than  existed  before  the  accident  occurred.  A  diagnosis  of  hemorrhage  is 
to  be  reached  not  only  by  the  observance  of  the  symptoms  just  described,  but  in 
addition  by  the  presence  of  Ijlood  in  the  stools  and  by  examining  the  blood  to 
discover  a  paucity  of  hemoglobin.  The  gravity  of  a  hemorrhage  depends  upon 
the  relation  of  the  quantity  of  blood  lost  to  the  vitality  of  the  patient  and  the 
frequency  with  which  the  bleeding  occurs.  Thus  a  fairly  profuse  hemorrhage 
in  a  strong  patient  may  be  followed  by  no  severe  symptoms,  whereas  repeated 
small  hemorrhages  may  greatly  exhaust  the  most  lusty  individual.  When  the 
patient  is  at  the  end  of  a  long  and  se\'ere  attack  of  the  fe\-er,  even  a  comparatively 
small  hemorrhage  may  be  fatal.  The  existence  of  small  losses  of  blood  not  sufficient 
in  size  to  be  manifest  to  the  eye  when  the  stools  are  examined,  may  be  discovered 
by  the  tests  for  occult  blood. 

Perforafion  of  the  bowel,  the  most  serious  of  all  the  complications  of  this  disease 
that  is  commonly  met  with,  has  no  relation  to  the  severity  of  the  general  symptoms, 
for  it  occurs  as  often  in  mild  as  in  severe  cases.  Indeed,  in  nearly  50  per  cent, 
of  recorded  cases  this  accident  occurred  in  mild  cases.  The  statistics  of  Brown 
indicate  that  25,000  deaths  occur  annually  in  the  United  States  from  this  complica- 
tion of  typhoid  fever.  It  takes  place  far  more  commonly  in  men  than  in  women, 
71  per  cent,  against  29  per  cent,  and  in  the  majority  of  cases  the  lesion  is  in  the 
ileum.  Wlien  perforation  occurs  the  symptoms  may  be  ushered  in  by  agonizing 
pain,  which  may  be  severe  enough  to  rouse  the  patient  from  a  considerable  degree 
of  stupor.  If  the  patient  is  not  too  apathetic  the  pain  is  often  described  as  being 
in  the  lower  zone  of  the  belly  near  the  median  line,  and  most  commonly  slightly 
to  the  right.  The  belly-wall  is  sensitive  to  palpation,  speedily  becomes  tense 
and  all  the  symptoms  of  a  general  diffuse  peritonitis  may  cjuickly  ensue.  The  pain 
may,  however,  be  very  slight  and  pass  away  or  become  modifieil,  as  the  peritoneal 
condition  resulting  from  the  escape  of  fecal  matter  into  its  cavity  becomes  more 
and  more  septic.  The  pulse  l)ecomes  rapid  and  running,  and  collapse  may  speedily 
assert  itself.  When  this  occurs,  death  speedily  comes  on,  the  patient  dying  in  a  few 
hours,  or,  again,  he  may  rally  and  survive  for  several  days.  Early  death  is,  however, 
the  more  common  result.  Thus  in  the  collection  of  34  cases  made  by  Fitz,  of  Boston, 
37.3  per  cent,  died  on  the  first  day,  29.5  per  cent,  on  the  second,  and  83.4  per  cent, 
in  the  fir.st  week.  During  the  second  week  9  died,  in  the  third  week  4  died,  and  2 
other  cases  lived  thirty  and  thirt>-eight  days,  respectively.  If  collajise  does 
not  ensue,  the  rally  of  the  system  results  in  a  rise  of  the  temperature  to  a  point 
higher  than  before  the  accident,  and  this  movement  is  often  accomi)anic(l  In-  chills 
and  rigors.  Usually  by  the  second  or  third  day  the  peritoneal  sym])toms  become 
more  and  more  marked,  the  condition  of  the  patient  more  and  more  asthenic  and 
depressed,  and  death  results  by  the  fourth  day  from  a  general  jx'ritonitis  with 
toxemia  from  the  absorption  of  toxic  materials.  In  other  cases  the  onset  of  the 
perforation  is  insidious;  the  l)elly  before  the  perforation  may  have  been  moderately 
tympanitic,  but  now  becomes  intensely  hard  and  rigid ;  the  pain,  which  in  some  cases 
is  so  severe,  does  not  develop,  but  the  great  fall  in  fever  followed  by  a  rise,  and 
this  again  by  rigors,  it  may  be,  give  evidence  of  the  grave  accident  which  has 
occvirred.  The  pulse  becomes  increasingly  rapid  and  running,  and  the  res])iration 
more  and  more  costal  and  less  and  less  dia])hragmatic,  until  the  patient  sinks  out 
of  life,  without  much,  if  any,  sufl'ering,  in  generally  the  same  manner  as  one  sees 
death  come  to  a  case  of  diffuse  septic  peritonitis  due  to  a  pyosalpinx  or  to  sejitic 
appendicitis.     In  such  cases  the  perforation  is  usually  very  small,  and  is  so  sur- 


TYPHOID  FEVER  35 

rounded  by  adhesions  that  the  escape  of  the  intestinal  contents  is  very  gradual 
and  insidious,  infecting  the  peritoneum  without  the  escaping  fluid  being  copious 
enough  at  any  one  time  to  produce  great  pain  or  reaction. 

In  this  connection  it  is  important  to  note  that  a  sudden  fall  in  temperature  is 
not  a  symptom  necessary  to  the  diagnosis  of  intestinal  perforation.  On  the  con- 
trary, there  are  many  cases  on  record  in  which  a  rise  of  temperature  has  followed 
this  accident. 

The  diagnosis  of  perforation  is  to  be  reached  by  the  following  signs  in  addition 
to  those  just  given:  The  hand  of  the  physician,  when  lightly  placed  upon  the 
abdominal  wall,  not  only  develops  the  fact  that  it  is  hj^persensitive,  but  that  its 
muscles  are  unduly  tense.  If  the  perforation  has  occurred,  the  abdomen,  here- 
tofore rather  swollen  and  tumid,  may  be  slightly  scaphoid.  There  is  usually  a 
sharp  increase  in  pulse  rate.  Percussion  may  indicate  the  presence  of  gas  in  the 
peritoneal  cavity,  and  the  liver  may  be  pushed  away  from  the  abdominal  wall  in 
such  a  manner  that  the  ordinary  area  of  liver  dulness  is  largely  decreased.  Percus- 
sion of  the  right  hypochondrium  is,  therefore,  an  essential  procedure  in  the  physical 
diagnosis  of  these  cases.  A  fallacy  underlying  this  test  is  the  possibility  of  a 
portion  of  the  colon,  when  greatly  distended  with  gas,  slipping  up  between  the 
liver  and  the  belly  wall,  and  thus  giving  resonance;  but  this  is  a  rare  occur- 
rence. 

In  some  cases,  however,  as  intimated,  the  symptoms  are  so  insidious  that  the 
absence  of  this  sign  does  not  negative  the  diagnosis  of  perforation.  Indeed  a 
positive  diagnosis  may  not  be  possible,  and  cases  are  sometimes  met  with  in  which 
the  perforation  has  not  been  suspected,  and  is  found  only  at  the  autopsy.  Other 
cases  have  been  operated  upon  for  perforation  and  no  opening  found. 

The  diagnosis  of  peritonitis  due  to  perforation  is  aided,  but  not  confirmed,  if 
an  examination  of  the  blood  reveals  a  leukocytosis  of  polymorphonuclear  cells, 
but  the  absence  of  leucocytes  does  not  negative  perforation. 

There  are  several  conditions  causing  pain  which  must  be  carefully  excluded 
before  the  physician  can  arrive  at  the  diagnosis  of  perforation,  even  if  the  symptoms 
and  signs  just  described  are  present.  These  are  diaphragmatic  pleurisy,  pneumonia 
of  the  bases,  appendicitis,  iliac  thrombosis,  and  intestinal  obstruction.  Further 
than  this,  peritonitis  may  develop  from  extension  of  the  inflammatory  process 
in  the  bowel  or  by  reason  of  the  migration  of  microorganisms  through  those  parts 
of  the  bowel  wall  which  have  been  impaired  by  the  ulcerative  process.  In  such 
cases  the  pain,  swelling,  and  diaphragmatic  paralysis  may  all  be  present  without 
being  due  to  perforation,  and  so  closely  may  the  symptoms  of  perforation  be  aped 
that  operation  has  been  performed,  with  the  discovery  that  no  perforation  had 
occurred;  thus  in  a  case  under  the  care  of  Herringham,  nothing  was  found  at  the 
section  and  the  patient  recovered.  Perforation  may  also  be  simulated  by  suppura- 
tion and  rupture  of  a  swollen  mesenteric  gland.  Other  causes  of  peritonitis  are 
necrosis  of  the  mesenteric  glands,  infarction  of  the  spleen,  or  the  development  of 
abscess  in  an  ovary  or  Fallopian  tube.  Very  rarely  peritonitis  arises  from  cholecys- 
titis or  cholangitis,  with  or  without  gallstones.  Liebermeister  has  recorded  two 
cases  in  which  rupture  of  the  gallbladder  with  escape  of  gallstones  into  the  abdom- 
inal cavity  took  place.  An  ulcer  in  the  appendix  may  perforate  or  an  intercurrent 
appendicitis  may  complicate  the  case. 

The  percentage  of  frequency  of  occurrence  of  perforations  is  generally  stated  to 
be  about  2.2,  but  in  30,966  cases  of  typhoid  fever  collected  by  me  from  several 
series  of  cases  reported  by  French  and  German  physicians,  and  from  the  official 
reports  of  hospitals  in  the  United  States  and  Canada,  England  and  Ireland,  Ger- 
many, Austria,  South  Africa,  and  Australia,  perforation  is  stated  to  have  occurred 
in  1144  ca.ses,  which  gives  a  percentage  of  3.69.  The  percentage  of  its  mortality, 
when  surgical  interference  is  not  resorted  to  at  the  most  favorable  time,  is  90  to 


36  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

95  per  cent.,  and  with  ojjcratix'e  interference  it  may  l)c  as  liigli  as  Si]  per  cent.  (See 
Treatment.) 

Perforation  is  very  much  more  frequently  seen  in  men  than  in  women.  Fitz 
ill  444  cases  found  71  per  cent,  in  men  and  29  per  cent,  in  women.  In  21  cases  of 
perforation  in  Basle,  15  were  men  and  6  were  women;  and  Griesinger  in  14  cases 
had  10  men  and  4  women.  Murchison  also  found  in  24  cases  Ki  men  and  S  women, 
although  the  general  mortalitj'  of  the  disease  anioiig  women  was  slightly  higher 
than  among  men.  So,  too,  Bristowe,  of  London,  met  with  this  accident  in  men 
in  II  of  15  cases,  and,  again,  Niicke  collected  100  perforation  cases,  of  which  72 
■were  in  men  and  34  were  in  women. 

Perforation  is  responsible  for  a  large  proportion  of  the  deaths  which  occur  from 
typhoid  fever.  Out  of  1721  cases  which  came  to  autopsy  the  percentage  of  deaths 
due  to  perforation  was  11.3,  according  to  Murchison.  According  to  Ilolscher,  it 
was  found  in  2000  Munich  cases  114  times  (5.7  per  cent.),  and  in  20  out  of  80  of 
his  cases  which  ended  in  death.  In  4680  cases  tabulated  by  different  writers, 
Fitz  found  the  proportion  to  be  6.58  per  cent.,  which  agrees  with  Holscher's 
statistics.  Hoffman  found  that  out  of  250  deaths  in  typhoid  fever  20  were  due  to 
perforation. 

Perforation  occurs  in  the  ileum  in  at  least  two-thirds  of  all  the  cases  of  this  acci- 
dent and  in  the  colon  or  appendix  in  about  4  per  cent.  It  takes  place  most  com- 
monly in  the  third  and  fourth  weeks  of  the  malady,  but  is  by  no  means  rare  in  the 
second  week.  It  occurs  most  commonly  in  patients  between  twenty  and  thirty 
years  of  age.  Elsberg  has  reported  a  case  of  a  child  of  three  and  a  half  years  who 
sufTered  from  this  accident,  but  whose  life  was  saved  by  abdominal  section. 

The  relation  of  typhoid  fe\'er  to  appendicitis  is  one  of  great  interest.  It  has 
been  thought  by  some  that  appendicitis  arising  in  typhoid  fever  was  a  mere  coin- 
cidence; by  others,  that  its  origin  depended  upon  a  general  infectious  process; 
and,  again,  by  others,  that  it  was  due  to  the  direct  infection  of  the  appendi.x  with 
the  bacillus  of  Eberth.  Probably  all  these  views  hold  true  in  individual  cases. 
The  richness  of  the  appendix  in  lymphoid  tissue,  and  the  fact  that  typhoid  fever 
is  particularly  prone  to  attack  such  tissues,  renders  this  organ  peculiarly  susceptible 
on  theoretical  grounds.  That  this  view  is  correct  is  proved  by  the  research  of 
Hopfenhausen,  who  collected  the  appendices  obtained  from  30  cases  of  typhoid 
fever  and  studied  them  under  Stilling  in  the  University  of  Lausanne.  She  concludes 
that  moderate  changes  in  the  appendix  may  be  found  in  nearly  all  cases  of  this 
disease,  that  it  is  most  marked  in  the  earlier  stages  of  the  malady,  and  consists 
chiefly  in  cellular  infiltration,  specific  lesions  being  rare  and  not  sufficient  to  produce 
the  more  severe  forms  of  appendicular  disease. 

True  appendicitis  complicating  typhoid  fever,  in  the  sense  of  inflammation  of 
the  appendix  severe  enough  to  produce  abscess,  is  undoubtedly  a  very  rare  affection. 
Hopfenhausen  lias  collected  statistics  of  743  cases  of  appendicitis,  of  which  5  per 
cent,  were  due  to  typhoid  fever.  This  must  be  a  very  much  larger  percentage 
than  usually  exists. 

It  is  a  noteworthy  fact  that  appendicular  symptoms  are  not  infrequent  in  early 
typhoid  fever,  and  often  disappear  under  rest  in  bed,  and  with  the  full  ilcvelopment 
of  the  infection.  Rarely  the  inflammation  goes  on  to  the  formation  of  an  appendicu- 
lar aliscess  or  perforation.  The  swelling  of  the  lymph  node  in  the  meso-appendix 
and  the  presence  of  ulcers  in  the  cecum  explain  why  it  is  that  pain  in  the  appendicu- 
lar area  is  by  no  means  rare.  (See  Plate  I.)  Sudden  pain  in  the  lower  zone  of 
the  abdomen  may  be  indicative,  not  of  appendicitis,  but  of  the  presence  of  an  iliac 
thrombosis. 

Tympanites  in  typhoid  fever  is  always  present  to  some  degree  at  some  stage  of 
the  disease.  When  very  marked,  it  is  an  evil  s\inptom  because  it  indicates  active 
fermentation  in  the  bowel,  and  the  presence  of  intestinal  atony,  and  because  the 


PLATE  I 


Showing  Typhoid  Ulcers  in  Small  Bowel  and  near  the 
Appendix.      (  Kast  and  Rumplep. ) 


TYPHOID  FEVER  37 

gas  presses  on  the  abdominal  thoracic  viscera  and  disturbs  their  functions.  By 
distending  the  intestine  it  may  also  predispose  the  patient  to  a  hemorrhage  or 
perforation  by  the  strain  on  a  severely  ulcerated  Peyer's  patch. 

Hepatic  Complications. — The  liver  and  gallbladder  rarely  show  signs  of  active 
infection  during  the  early  part  of  an  attack  of  typhoid  fever.  .Jaundice  is  one  of 
the  rarest  complications  of  this  disease.  Aside  from  some  swelling  and  tenderness 
in  the  hepatic  region,  no  symptoms  in  the  hypochondrium  are  usually  observable. 
It  is,  however,  important  to  note  that  secondary  involvement  of  the  gallbladder 
as  a  sequel  of  this  malady  is  by  no  means  rare,  a  true  cholecystitis  developing  in  a 
goodly  proportion  of  cases  as  a  result  of  infection  of  this  viscus  by  the  bacillus  of 
Eberth.  This  cholecystitis  may  be  severe  enough  to  result  in  emp>ema  of  the  gall- 
bladder and  perforation  of  itswalls,  with  symptoms  resembling  intestinal  perforation. 
A  still  more  interesting  fact  is  that  such  a  cholecystitis  due  to  this  organism  may 
develop  many  years  after  the  attack  of  typhoid  fever,  and  again  the  clumping  of 
these  organisms  in  the  gallbladder  may  give  rise  to  the  formation  of  gallstones. 

Louis,  in  his  work  on  tj^shoid  fever,  published  in  1S36,  states  that  changes  in 
the  bile  and  gallbladder  occur  more  frequently  in  typhoid  fever  than  in  other 
acute  diseases,  and  cites  3  fatal  cases  in  which  cholecystitis,  unrecognized  during 
life,  was  found  at  autopsy.  Grisolle  and  Andral  mention  similar  cases.  In  3 
instances  French  found  the  gallbladder  of  persons  who  had  died  of  typhoid  fever 
filled  with  turbid  albuminous  fluid,  and  Rokitansky  speaks  of  having  found  "fibrin- 
ous exudations"  in  the  gallbladder  of  several  patients  who  died  from  the  disease. 
Murchison  refers  to  the  cholangitis  and  cholecystitis  which  may  accompany  typhoid 
fever,  and  reports  a  case  of  rupture  of  the  gallbladder,  followed  by  general  peritoni- 
tis. In  1876  Hageimauller  reported  18  cases  of  cholecystitis  complicating  typhoid 
fever.  He  concluded  that  it  was  a  more  frequent  complication  than  had  generally 
been  supposed.  Plolscher,  in  the  2000  Munich  autopsies,  found  empyema  of  the 
gallbladder  5  times. 

In  1889  Bernlieim  suggested  that  typhoid  bacilli  might  give  rise  to  gallstones 
by  producing  alteration  or  stagnation  of  the  bile.  In  1893  Defourt  reported  19 
cases  of  cholelithiasis,  in  which  the  first  attack  of  biliary  colic  occurred  at  varying 
periods  after  typhoid  fever.  Osier  has  reported  a  case  of  hepatic  colic  occurring 
for  the  first  time  in  the  fifth  week  of  typhoid  fever.  At  operation  nothing  could 
be  found  to  account  for  perforation  of  the  gallbladder,  but  nine  months  later  a 
gallstone  was  discharged. 

Fournier  found  bacteria  in  38  out  of  100  gallstones  which  he  removed  at  autopsies. 
The  colon  bacilli  predominated,  while  the  typhoid  bacilli  were  found  to  be  second 
in  frequency.  Milian,  Chantemesse,  and  Horton  Smith  report  similar  experi- 
ences. 

Chiari  found  tj'phoid  bacilli  present  in  the  gallbladder  in  19  out  of  22  cases, 
and  obtained  pure  cultures  from  15.  In  9  out  of  10  cases  at  St.  Bartholomew's 
Hospital,  London,  Bacilli  typhosi  were  found.  Gushing  mentions  5  cases  of 
cholecystitis  complicating  tj'phoid  fever,  in  which  pure  cultures  of  colon  bacilli 
were  obtained  from  the  pus.  Marsden  reports  a  case  in  which  cultures  resembling 
Bacillus  typhosus  were  obtained.  Van  Dungern  obtained  pure  cultures  of  typhoid 
bacilli  from  pus  surrounding  the  gallbladder  fourteen  years  and  a  half  after  an 
attack  of  typhoid  fever.  Pure  cultures  have  often  been  obtained  from  six  to 
eight  months  after  the  attack  (Chantemesse,  Dupre).  This  is  a  fruitful  source  of 
infection. 

Mason  thinks  that  the  bacilli  gam  entrance  through  the  biliary  ducts.  Council- 
man believes  that  they  are  carried  through  the  blood,  and  that  areas  of  necrosis 
in  the  liver  afford  them  portals  of  entrance.  Hagenmiiller,  Mayo  Robson,  and 
Mark  Piichardson  believe  that  biliary  complications,  especially  cholecystitis,  are 
due  to  ascending  infection  of  the  ducts.     Marsden  is  of  the  opinion  that  the  most 


38  DISEASES  DUE  TO  A  SPECIFIC  IXFECTION 

important  passage  of  bacilli  into  the  gallljIaddeT  is  tliroiiuli  the  lilood,  tlic  liver, 
and  the  biliary  duets.     lie  is  undoubtedly  correct. 

Typhoid  cholecystitis  during  the  course  of  the  fe\er  is  frequently  latent.  In 
more  than  one-half  the  recorded  cases,  either  on  account  of  latency  of  symptoms 
or  typhoidal  stupor,  nothing  unusual  was  observed  during  life. 

The  two  most  constant  symptoms  are  pain  and  swelling,  the  former  being  paroxys- 
mal and  most  marked  in  the  region  of  the  gall-bladder  and  under  the  scapula. 
Maurice  Richardson  says  that  it  may  be  in  the  epigastrium  or  over  McBurney's 
point.  According  to  Mayo  Robson,  if  a  line  be  drawn  from  the  umbilicus  to  the 
ninth  rib  on  the  right  side,  there  is  almost  always  tenderness  at  the  Ijeginning  of 
the  second  third  of  this  line.  Jaundice  is  rarely  met  with,  but  there  may  be  repeated 
chills  and  sweats. 

Genito-urinary  Complications. — Albuminuria  in  typhoid  fever  is  quite  a 
constant  condition,  occurring  as  frequently  as  in  70  per  cent,  of  all  cases,  and  being 
most  marked  in  the  second  week.  Usually  its  presence  is  not  associated  with 
that  of  tube-easts  unless  the  patient  is  already  a  sufferer  from  nephritis  j^rior  to 
the  attack.  When  casts  are  present,  the  albumin  is  usually  present  in  large  amount. 
Albuminuria  without  casts  is  not  a  serious  complication.  Probably  true  nephritis 
is  present  in  almost  20  per  cent,  of  the  cases,  but  this  is  usually  not  productive  of 
renal  symptoms.  An  antecedent  nephritis  may  take  on  renewed  activity'  and  a 
true  hemorrhagic  nephritis  may  occur,  usually  in  severe  cases  only.  The  urine 
is  apt  to  be  scanty  and  of  high  specific  gravity  unless  the  physician  insists  upon 
the  patient  drinking  freely  of  water. 

Pyuria  in  slight  degree  is  common.  Blumer  says  it  occurs  in  17  per  cent.,  but 
it  is  a  noteworthy  fact  that  pyelitis  due  to  typhoid  fe\'er  is  almost  unknown.  While 
this  is  true,  it  is  also  of  interest  to  note  that  enormous  numbers  of  the  bacillus 
of  Eberth  are  to  be  found  in  the  urine  after  the  second  week  of  the  disease,  and 
often  far  into  convalescence.  Petruschky  has  estimated  that  1  c.c.  may  contain 
170,000,000  bacilli.  A  profuse  imlyuria  is  often  present  when  the  stage  of  con- 
valescence is  entered  upon. 

Orchitis  and  epididymitis  rarely  occur  as  a  result  of  a  direct  infection  with  the 
specific  bacillus.  They  differ  from  the  changes  due  to  gonorrhea  in  that  they  are 
less  painful  and  more  rapid  in  their  course  to  suppuration  or  recovery.  They  are 
usually  unilateral  and  the  testicle  is  first  affected.  Typhoidal  cystitis  due  to  the 
presence  of  the  bacillus  of  Eberth  rarely  occurs. 

Respir.\tory  Complic.a^tions. — The  respiratory  disorders  met  with  in  connection 
with  the  course  of  typhoid  fever,  aside  from  the  bronchitis  already  mentioned, 
are  quite  numerous.  In  the  later  stages  of  the  disease  we  may  meet  with  severe 
laryngeal  ulceration,  which  in  turn  may  be  complicated  by  perichondritis  or  edema 
of  the  glottis.  Hoffman  found  28  cases  of  ulcer  of  the  larynx  in  250  autopsies  in 
this  disease,  and  Griesinger  in  26  per  cent,  of  those  dying  of  the  malady,  so  that  it 
is  by  no  means  rare.  Keen  collected  146  cases  of  severe  laryngeal  disease  due  to 
this  cause,  and  found  that  necrosis  of  the  laryngeal  cartilages  when  it  occurred  was 
a  very  fatal  complication,  death  occurring  in  9.5  per  cent,  of  the  ca.ses. 

Intense  hypostatic  congestion  is  one  of  the  most  constant  pulmonary  changes 
seen  at  autopsy;  in  some  cases  the  blood  may  inundate  the  air  vesicles,  causing 
solidification.  How  often  this  change  is  agonal  cannot  be  tletermined  with  any 
degree  of  certainty,  but  as  it  depends  on  more  or  less  prolonged  maintenance  of 
one  position  aided  by  an  enfeebled  circulation  the  danger  can  be  greatly  lessened, 
if  not  avoided,  by  frequent  changes  in  posture. 

Pneumonia  develops  in  typhoid  fever  in  three  forms  and  in  different  stages  of 
the  disease:  (1)  As  an  acute  loliar  pneumonia  ushering  in  the  attack  of  enteric 
fever,  and  due  to  the  pneumococcus,  or,  it  is  thought  by  some,  to  the  infection 
of  the  lung  by  the  bacillus  of  Eberth,  the  so-called  "pneumotyphoid."      True 


rYPIIOID  FEVER  39 

croupous  pneumonia  in  the  later  stages  is  very  rare.  (2)  Bronchopneumonia, 
l)rolKit)ly  arising  from  terminal  infection  or  by  hypostatic  congestion  iluc  to  the 
profound  toxemia  and  cardiac  degeneration  and  feebleness,  is  more  common. 
(3)  Acute  tuberculous  pneiunonia  sometimes  seizes  the  typhoid-fever  patient 
when  he  seems  about  to  begin  his  convalescence. 

It  is  not  to  be  forgotten  that  infarction  of  the  lung  may  occur  as  the  result  of 
cardiac  or  venous  emboli.  Such  an  infarction  may  mislead  the  physician  into  a 
diagnosis  of  lobar  or  lobular  pneumonia  by  reason  of  the  dulness  on  percussion, 
the  rise  of  temperature,  and  blood-tinged  sputum:  An  infarction  may,  if  the 
patient  survives,  result  in  pulmonary  abscess  or  gangrene. 

Pleurisy  arises  very  rarely  as  a  primary  lesion.  It  is  usually  secondary  to 
infarction,  pneumonia,  or  gangrene.  Cases  of  empyema  due  to  the  specific  bacillus 
have,  liowever,  been  recorded. 

Nervous  Complications. — ^The  nervous  disturbances  vary  very  greatly.  In 
the  average  case  there  is  in  the  early  part  of  the  onset  no  mental  change  save  that 
of  unfitness  for  mental  occupation,  with  dreamful  sleep  which  is  apt  to  be  restless. 
Later  the  patient  continually  dozes  off,  yet  awakens  easily,  and  for  a  moment 
may  be  a  little  confused  between  the  mental  impressions  left  on  his  brain  by  the 
dream  and  the  conditions  he  finds  about  him  on  returning  to  consciousness.  Still 
later,  if  the  infection  is  severe,  he  becomes  more  apathetic  when  awake,  less  easily 
aroused  when  asleep,  and  often  delirious  in  his  sleep,  his  dreams  being  evidently 
vivid,  so  that  he  keeps  muttering  the  conversation  he  thinks  he  is  actually  having, 
or  calls  out  loudly,  as  his  dream  seems  to  lead  him  to  a  point  where  an  imperative 
call  or  sudden  action  is  needed.  Sometimes  the  delusions  in  the  delirium  amount 
to  imperative  conceptions,  and  the  patient  belie\'es  that  he  is  away  from  home 
and  must  return  there  at  once,  or  that  he  is  being  restrained  by  force,  or,  again, 
that  some  member  of  his  family  is  in  distress  and  needs  his  aid  or  is  calling  for 
him.  Often  this  form  of  mental  disturbance  is  painful  to  witness,  difficult  to 
overcome,  and  harassing  to  the  patient.  In  these  cases  the  hands  may  be  moved 
continually  in  active  motions,  as  if  to  illustrate  the  ideas  of  the  patient.  Such 
cases  are  apt  to  be  grave  if  for  no  other  reason  than  that  they  exliaust  themselves 
if  relief  is  not  given.  The  more  encouraging  type  of  delirium  is  of  the  quiet,  mutter- 
ing form,  as  if  the  patient  was  gently  "speaking  in  his  sleep"  as  in  health,  and  this 
may  be  taken  as  the  natural  form  of  delirium  in  the  disease.  Later  the  stupid 
condition  becomes  more  and  more  marked  in  some  cases,  and  absolute  mental 
stillness  is  reached,  in  which  only  rough  shaking  or  loud  calling  will  arouse  the 
patient.  In  severe  cases  with  marked  toxemia  we  find  at  times  a  state  of  mental 
confusion,  staring  eyes,  and  semi-stupor,  with  persistent  muttering — the  so-called 
coma  mgil. 

During  convalescence  viental  aherration,  depending  usually  upon  exhaustion, 
may  develop.    The  prognosis  in  such  cases  is  usually  good. 

Rarely  in  the  course  of  typhoid  fever  symptoms  of  irritation  or  inflammation 
of  the  meninges  of  the  brain  develop,  and  it  is  important  to  remember  that  these 
symptoms  may  arise  from  several  causes.  The  most  common  of  these  is  congestion 
and  engorgement  of  the  meningeal  vessels  without  any  true  inflammatory  process; 
the  next  most  common  form  is  that  due  to  the  extension  of  an  infection  from  abscess 
in  the  middle  ear;  the  third  form  is  that  in  which  there  is  infection  with  the  strepto- 
coccus or  pneumococcus,  and  very  rarely  the  meningitis  is  due  to  the  bacillus  of 
Eberth.  Cole  has  recorded  three  instances  in  which  the  typhoid  bacillus  was 
obtained  from  the  cerebrospinal  fluid  by  lumbar  puncture  in  typhoid  fever.  In 
one  the  meningitis  was  serous,  in  another  purulent;  the  character  of  the  other  is 
not  stated.  The  frequency  of  this  complication  in  the  different  periods  of  the 
disease  when  due  to  true  typhoid  infection  of  the  meninges  is  in  direct  ratio  to  the 
length  of  the  malady,  namely,  in  the  third  or  fourth  week.     In  the  great  majority 


40  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

of  instances  in  which  the  complication  lias  appeared  the  patient  was  under  thirty 
years,  and  usually  between  twenty  and  thirty  years.  That  is  the  period  in  which 
typhoid  fever  is  most  commonly  seen. 

In  every  case  of  true  typhoid  meningitis,  so  far  recorded,  death  has  occurred, 
but  this  is  a  statement  which  does  not  possess  as  great  prognostic  value  as  would 
appear  at  first  glance,  since  an  absolute  diagnosis  of  true  typhoid  meningitis  can- 
not be  made  during  life,  for  the  positive  test  is  the  bacteriological  examination  of 
the  skull  contents.  Nevertheless,  the  presence  of  marked  meningeal  symptoms 
is  of  the  gravest  import  in  all' cases. 

Sometimes,  because  of  degenerative  changes  in  the  vessels,  a  hemorrhagic  effusion 
into  the  meninges  of  the  brain  takes  place,  but  this  does  not  commonly  produce 
marked  symptoms  unless  it  is  profuse. 

Conmihions,  generalized  or  localized,  with  coma  and  delirium  may  arise  from 
thrombosis  of  the  cerebral  sinuses  or  of  the  cerebral  arteries,  but  they  are  very 
rare  from  any  cause.  Murchison  met  with  them  in  only  6  cases  out  of  2960.  If 
due  to  the  lesions  named,  they  indicate  a  fatal  termination  in  the  near  future. 
In  Osier's  case  death  followed  convulsions,  produced  by  thrombosis  of  the  branches 
of  the  left  middle  cerebral  artery,  in  twelve  hours.  If  they  occur  in  neurotic 
children  or  females,  the  outlook  is  not  so  gloomy,  as  they  probably  do  not  depend 
upon  an  actual  lesion  in  the  brain. 

Sometimes  acute  otitis  viedia  produces  violent  headache  and  finally  symptoms 
of  meningitis,  but  its  presence  is  often  unrecognized  as  a  cause  imtil  a  disciiarge 
takes  place  from  the  ear. 

Neuritis,  generalized  or  localized,  is  met  with  occasionally  in  the  later  stages, 
producing  wrist-drop  or  toe-drop,  and  sometimes  causing  severe  pain.  When 
there  is  a  multiple  neuritis  the  sjinptoms  may  closely  resemble  locomotor  ataxia 
or  anterior  poliomyelitis.  Sometimes  the  skin  of  the  toes  or  of  the  whole  foot 
becomes  exquisitely  sensitive. 

When  hemiplegia  occurs,  which  is  quite  rare,  it  results  from  cerebral  embolism 
or  thrombosis  or  very  rarely  from  actual  hemorrhage. 

Complications  in  the  Bones,  Joints,  and  Muscles. — Secondary  disease 
of  the  bones,  consisting  of  post-ti/phoidal  osteomyelitis  due  to  the  specific  bacillus 
or  to  infection  by  associated  microorganisms,  may  occur.  The  tibia  and  the  ribs 
are  the  bones  most  commonly  involved,  and  the  changes  are  subacute  or  chronic 
rather  than  acute.  So,  too,  arthritis  maj'  be  due  to  pyogenic  microorganisms  or 
to  the  Eberth  bacillus,  and  is  usually  of  a  subacute  or  chronic  type.  Spontaneous 
dislocation  of  the  hip  may  occur  in  very  rare  instances. 

Many  years  ago  V.  P.  Gibney,  of  New  York,  described,  under  the  name  of 
typhoid  spine,  a  condition  in  which  there  develops,  often  some  days  after  the  patient 
is  up  and  about,  and  often  only  after  some  very  slight  jar  or  trauma,  great  tenderness 
of  the  spine,  with  pain  in  the  back,  and  in  the  legs  when  they  are  moved.  It  has 
been  held  that  this  condition  is  not  dependent  upon  a  spondylitis,  neuritis,  or 
Pott's  disease,  and  is  probably  a  neurosis  closely  allied  to  the  neuroses  seen  in 
cases  of  severe  trauma,  but  in  most  cases  it  is  probably  spondylitis.  In  most  cases 
it  is  probably  due  to  periostitis.  Fraenkel  has  recently  shown  that  in  fatal  cases 
of  tN-phoid  fever  the  bacillus  may  be  obtained  from  the  cancellous  tissue  of  the 
bodies  of  the  vertebrae  and  some  of  these  cases  of  so-called  typhoid  spine  may  be 
instances  of  osteomyelitis  involving  these  structures. 

Sometimes  in  the  stage  of  con\'alescence  a  curious  state  is  developed  in  which 
the  muscles  of  the  lower  extremities  become  painful,  somewhat  brawny,  and  e\-en 
slight  redness  may  appear  in  the  skin  covering  them.  Usually  this  is  unilateral, 
but  it  may  be  bilateral.  Most  commonly  it  affects  the  calf  of  the  leg,  and  pain  is 
developed  on  pressure  or  on  movement,  acute  or  passive.  This  is  due  to  a  niyosili.s-. 
It  should  not  be  confused  with  phlegmasia  dolcns  due  to  thrombosis. 


TYPHOID  FEVER  41 

Typhoid  Fevee  Complicating  Pregnancy. — In  a  very  large  number  of  cases 
of  typhoid  fever  complicating  pregnancy,  abortion  or  premature  labor  comes  on. 
Corbin  collected  364  cases  of  typhoid  fever  occurring  in  pregnant  women,  and 
Fellner,  of  Vienna,  has  added  7  others  to  this  number,  making  a  total  of  .371  cases. 
Of  these  371  cases  228,  or  61  per  cent.,  ended  in  premature  births,  and  in  202  cases 
pregnancy  terminated  before  the  sixth  month.  Most  of  the  full-term  children 
were  born  dead,  and  those  who  were  born  alive  were  weak  and  did  not  long  survive. 
The  mortality  in  the  mother  under  these  circumstances  is  about  16  per  cent. 

Diagnosis. — The  diagnosis  of  typhoid  fever  is  to  be  based  on  the  characteristic 
ascent  of  the  temperature,  the  general  malaise  of  the  patient,  the  peculiarly  coated 
tongue  with  red  edges,  the  tumid  belly,  and  the  development  of  the  rash  about  the 
seventh  to  the  ninth  day.  If  to  these  symptoms  are  added  an  enlargement  of  the 
spleen  and  liver,  the  diagnosis  becomes  still  more  certain,  and  is  confirmed  if  the 
laboratory  tests  mentioned  on  the  following  pages  are  positive.  The  laboratory 
aids  to  diagnosis  are  the  Widal  or  agglutination  test;  the  isolation  of  the  bacillus 
from  the  blood,  from  the  stools,  from  the  urine,  and  from  the  rose  spots,  and  the 
diazo-reaction.  The  objection  to  these  tests  is  the  difficulty  as  to  technique  for  the 
general  practitioner,  and,  more  important  still,  the  fact  that  some  of  them  are 
obtainable  in  many  instances  so  late  in  the  course  of  the  disease  as  only  to  confirm 
the  clinical  diagnosis  already  made.     (See  page  43.) 

Typhoid  fever  must  be  separated  from  a  number  of  maladies  which  closely 
resemble  it.  Pure  typhoid  infection  may  result  in  the  production  of  a  fe\'er  which 
closely  follows  the  remittent  or  intermittent  malarial  types,  and  which  is  often  asso- 
ciated with  so  much  gastric  disturbance  and  vomiting  and  so  lacking  in  the  more 
prominent  typhoid  symptoms  usually  seen  that  the  picture  of  remittent  malarial 
fever  is  clear,  while  the  true  picture  of  tj'phoid  fever  is  clouded.  Again,  there  can 
be  no  doubt  that  cases  of  true  malarial  infection  occur  in  which  the  symptoms  so 
closely  resemble  those  of  t^-phoid  fever  that  a  purely  clinical  diagnosis  is  almost 
impossible  if  an  epidemic  of  typhoid  fever  is  in  full  swing  at  the  time.  Finally, 
there  can  also  be  no  doubt  that  it  is  possible  for  the  patient  to  have  a  double  infection 
with  the  bacillus  of  Eberth  and  the  plasmodium  of  Laveran,  in  which  case,  however, 
the  malarial  manifestations  are  usually  dwarfed  by  the  typhoid  poison,  and  are 
marked  only  at  the  onset  of  the  enteric  fever  and  at  its  termination.  To  this  mixed 
infection  the  term  typhomalarial  fever  may  be  correctly  applied  to  indicate  not  a 
separate  disease,  but  a  double  infection.  Etymologicallj^,  this  term  might  also 
be  used  to  define  a  condition  of  malarial  fever  in  which,  because  of  profound  debilitj', 
the  patient  was  in  a  typhoid  state — that  is,  in  a  condition  of  which  typhoid  fever 
is  a  type.  Practically,  however,  it  should  be  discarded  or  limited  in  its  use  to 
the  double  infection  just  described. 

How  far  constant  fever  occurring  day  after  day  and  associated  with  manifestations 
of  general  loss  of  strength  and  debility  can  be  relied  upon  in  the  diagnosis  of  typhoid 
fever  is  hard  to  determine.  Certain  it  is  that  if  a  physician  makes  a  diagnosis  of 
enteric  fever  upon  these  symptoms  alone,  without  bearing  in  mind  the  fact  that 
similar  conditions  are  equally  well  developed  under  other  forms  of  infection,  he 
will  find  himself  in  error  in  not  a  few  instances.  Chief  among  these  conditions 
may  be  mentioned  tuberculosis  of  the  lungs  or  peritoneum,  that  form  of  influenza 
in  which  the  chief  symptoms  are  abdominal,  cases  of  ulcerative  endocarditis, 
septicemia,  and  pyemia,  and  those  of  cholecystitis  with  ulceration,  as  from  impacted 
gallstones.  It  must  not  be  forgotten,  too,  that  syphilitic  fever  may  in  very  suscept- 
ible persons  resemble  typhoid  infection.  The  febrile  movement,  rose  rash  (if  it 
be  scanty),  malaise,  and  signs  of  general  infection  in  this  disease  may  readily  mislead 
the  physician.  Again,  in  the  more  advanced,  or  tertiary,  stages  of  syphilis  a 
prolonged  low,  septic  fever  may  be  present.  Any  case  of  so-called  typhoid  fever 
which  lasts  more  than  four  weeks  without  the  attack  being  prolonged  by  a  relapse 


42 


DISEASES  DUE  TO  A  SPECIFIC  INFECTIOX 


is  almost  certainly  suffering  from  another  disease,  often  tiihereiilosis.  It  is  not  to 
be  forjjotten  that  trichiniasis  may  resemhle  typhoid  fever,  for  in  it  we  have  fever, 
IJitins  in  tlie  iiinhs  and  back,  headache,  stupor,  and  nausea,  with  i)ain  in  the  belly 
and  diarrliea.  The  differentiation  of  typhoid  from  other  fevers  is  aided  by  a  study 
of  the  following  table : 


Typhoid  Fever. 

Onset  gi-adual. 

Face  dull  and  apathetic. 

Delirium  a  late  symptom. 

Coma  a  late  symptom. 

Eruption  very  late. 

Eruption  chiefly  on  trunk,  well  defined,  and 

appears  in  several  crops  of  small  rose-red 

spots. 
Leukocytes  decreased. 
Widal  test  positive. 
Bacilli  of  Eberth  in  blood. 

Typhoid  Fever. 

Rash  appears  in  crops. 
Profuse  sweats  rare. 
Temperature  curves  regular. 
Pulse  rarely  over  100. 
Bacillus  of  Eberth  in  blood. 
Widal  test  positive. 
No  eye  changes. 
Respirations  slightly  increased. 
Cyanosis  rare. 


Typhus  Fever. 

Onset  abrupt. 

Face  livid,  anxious,  swollen,  conjunctiva  red- 
dened.    Pupils  contracted. 

Delirium  an  early  symptom. 

Coma  an  early  symptom. 

Eruption  early. 

Eruption  over  trunk  and  limbs  and  ill- 
defined.  Does  not  appear  in  crops,  and  is 
dusky  red  or  petechial  in  character. 

Leukocytes  increased. 

Widal  test  negative. 

Bacilli  absent. 

Acule  Miliary  Tuheradosis. 

Rash,  if  present,  not  in  crops. 
Profuse  sweats  constant. 
Temperature  cm-ves  inegular. 
Pulse  usually  rapid. 
Absent  from  blood. 
Negative. 

Choroidal  tubercles. 
Greatly  increased. 
Cyanosis  common. 


Typhoid  Fever  of  the  Cerebral  Type. 

Regular  temperature. 
Na  marked  blood  change. 
Herpes  very  rare. 
Rose  rash  on  trunk  chiefly. 
Cerebrospinal  fluid  negative. 

Typhoid  Fever. 

Onset  gradual. 
Fever  gi-adually  rises. 
Chills  rare  in  onset. 
Unaffected  by  quinine. 
Heavy  facial  expression. 

Herpes  rare. 

Early  delirium  rare. 

Anamia  moderate. 

Moderate  reduction  in  leukocytes. 

Rose  rash. 

Bacilli  in  blood. 

Typhoid  Fever. 
Onset  gradual. 
Enlarged  spleen. 
Rose  rash. 
Prostration  gradual. 
Lasts  several  weeks. 

Typhoid  Fever. 

Onset  gradual. 

Nervous  symptoms  moderate. 

No  leukocytosis. 

Widal  tost  positive. 

Bacilli  in  blood. 

Lasts  weeks. 

Disease  of  youth. 


Cerebral  Meningitis. 

In'cgular  temperatiu'e. 

Increase  in  polynuclear  white  cells. 

Very  common. 

Petechiae  over  whole  surface. 

Positive  for  the  specific  bacillus. 

Estivo-axdumnal  Fever. 

Onset  acute. 
Fever  rises  iiTegularly. 
Severe  chills  common. 
Improved  by  quinine. 

Anxious  facies  with  slightly  icteroid  conjunc- 
tiva. 
Herpes  common. 
Early  deluium  common. 
Ansemia  marked. 
Great  reduction  in  leukocytes. 
No  rash. 
Plasmodium  in  blood. 

Influenza. 
Onset  sudden. 
No  enlargement  of  silicon. 
No  rash. 

Prostration  rapid. 
Lasts  a  few  days. 

Typhoid  Pneumonia. 

Onset  more  rapid. 
Nervous  symptoms  severe. 
Some  leukocytosis. 
^^■idal  test  negative. 
None  in  blood. 
Lasts  a  sliorter  time. 
Disease  of  old  age. 


TYPHOID  FEVER 


43 


Typhoid  Fever. 

No  cardiac  murmurs. 
Regular  temperature. 
Sweats  rare. 
No  leukocytosis. 
No  cardiac  dyspnocna. 
No  petechiffi. 
No  infarctions. 
No  leukocytosis. 
Widal  test  positive. 
No  retinal  emboli. 
No  chills. 
Bacilli  in  blood. 

Typhoid  Fever. 

Rose  rash. 
Face  not  swollen. 
Muscles  normal. 
Eosinophiles  decreased. 
A  common  disease. 


Ulcerative  Endocardilis. 

Cardiac  murmurs. 

Irrffriilnr  pcpHc  temperature. 

Sur,-,l       rohlMM.Il. 

Ahiik.'.l  l.iil.Mcytosis. 
Cardiac  Uyipuu'a. 
Petechia;. 
Infarctions. 
Leukocytosis. 
Negative. 
Retinal  emboli. 
Repeated  chills. 
No  bacilli  in  blood. 

Trichiniasis. 

No  rash. 
Face  swollen. 
Myositis. 

Eosinophiles  numerous. 
A  rare  disease. 


For  the  diagnosis  of  paratyphoid  fever  from  typhoid  fe-\er,  see  the  article  on 
that  disease. 

Tests. — The  so-called  Widal  test  depends  upon  the  fact  that  if  a  small  amount 
of  blood,  or  blood-serum,  or  even  the  breast  milk  or  tears  from  a  patient  having, 
or  recently  having  had,  typhoid  fever,  are  brought  in  proper  dilutions  in  contact 
with  living  typhoid  bacilli,  these  organisms  soon  cease  to  move,  that  is,  lose  their 
motility,  and  gradually  come  together  in  clumps,  or,  in  other  words,  agglutinate. 

The  typhoid  bacilli  to  be  employed  in  the  test  are  not  such  as  have  been  recently 
isolated  from  a  case  of  typhoid  fever,  but  those  which  have  been  modified  by 
repeated  transplantation  on  artificial  media.  These  bacilli  are  kept  in  sealed 
tubes  of  nutrient  agar-agar  in  an  ice-chest;  from  such  a  stock  culture  inoculations 
are  made,  and  when  the  test  is  to  be  used  are  placed  in  broth-bouillon,  incubated 
for  twenty-four  hours  at  a  temperature  of  37°  C.,  and  then  employed  for  the  test. 
It  is  essential  that  it  be  proved  beforehand  that  this  culture  is  composed  of  organisms 
reacting  to  known  tjqjhoid  serum  and  not  to  healthy  serum.  From  this  test 
culture  a  proper  dilution  is  made  by  adding  the  bacilli  to  blood  diluted  with  normal 
salt  solution.  A  hanging  drop  is  now  placed  under  the  microscope  and  examined 
with  a  magnifying  power  of  about  800  diameters.  The  bacilli  should  appear  as 
actively  motile  organisms  which  do  not  clump. 

The  finger-tip  or  lobe  of  the  ear  is  pricked,  and  by  means  of  the  "white  pipette" 
of  a  blood-cell  counting  apparatus  the  blood  is  drawn  up  to  the  mark  0.5.  Then 
the  pipette  is  dipped  in  distilled  water  and  the  water  is  drawn  up  till  the  figure  11 
is  reached.  This  gives  us  a  dilution  of  1 :  20.  One  drop  of  the  mixture  of  bacilli  in 
salt  solution  and  one  drop  of  the  diluted  blood  are  then  placed  on  a  cover-glass, 
which  is  inverted  over  a  hollow  slide  and  the  drop  examined.  A  positive  reaction 
consists  in  an  absolute  immobilization  of  all  the  bacilli  and  of  a  clumping  of  a 
majority  of  them.  This  reaction  should  occur  in  five  minutes  if  the  dilution  of 
blood  has  been  1 :  20,  and  in  thirty  minutes  if  it  has  been  1 :  40,  and  in  two  hours  if 
the  dilution  has  been  1 :  60.  A  rapid  clumping  with  a  weak  dilution  is  to  be  regarded 
as  a  very  positive  test.  On  the  other  hand,  it  is  to  be  remembered  that  a  dilution 
of  blood  in  the  porportion  of  1 :10  may  give  a  reaction  even  if  normal  blood  is  used. 
An  exact  estimate  of  the  strength  of  the  solution  and  of  the  time  of  reaction  is 
therefore  of  importance. 

This  test  is  an  exceedingly  accurate  one,  if  properly  employed.  The  chief 
difficulty  about  it  is  that  the  reaction  is  often  absent  until  the  seventh  or  even 
the  twelfth  day  of  the  disease.  Out  of  over  8000  cases  reported  by  a  number  of 
observers,  the  test  was  positive  in  94  per  cent.    A  negative  result  is  unimportant  if 


44 


DISEASES  DUE  TO  A  SPECIFIC  INFECTION 


it  is  obtained  prior  to  the  third  week.  But  cases  have  been  recorded  in  wliich  bacilli 
were  isolated  from  the  blood  during  life  and  at  autopsy  the  lesions  were  those 
of  typhoid  fever,  yet  at  no  time  during  the  course  of  the  disease  did  the  blood 
yield  the  agglutinative  reaction.  Repeated  tests  should  also  he  made  before  it  is 
decided  that  the  lilood  does  not  give  the  reaction.     \Yboii  dried  1)I(i(m1   is  u>fi\ 


Agglutomclcr  for  the  iigsjlutinalicm  test  for  typhoid  ami  paratyphoid  fever. 


its  volimic  as  near  as  may  l)e  should  be  restored  by  the  adilition  of  distilled  water, 
and  from  this  the  proper  dilution  is  to  be  prepared  and  the  resulting  dilution  used 
as  already  indicated.  The  fallacies  of  this  test  lie  in  the  i)ossibility  that  the  patient 
may  have  had  typhoid  fever  at  some  previous  time  and  so  give  the  reaction,  and 
in  mistaking  irregular  and  delayed  clumping  as  true  agglutination  or  as  a  partial 
reaction.    The  time  of  appearance  of  the  Widal  reaction  has  distinct  prognostic 


TYPHOID  FEVER  45 

as  well  as  diagnostic  value.  When  it  occurs  in  high  dilution  and  early,  that  is  in 
the  first  week  of  the  illness,  the  course  is  usually  mild,  and  when  it  occurs  as  late  as 
the  fourteenth  or  sixteenth  day  the  illness  is  usually  a  severe  one  and  lasts  longer. 

This  test  has  now  been  brought  within  the  reach  of  everyone  by  the  use  of  an 
agglutometer  which  has  been  placed  on  the  market  by  a  well-known  house.  (Sec 
Fig.  12.) 

This  apparatus  is  designed  to  obviate  the  use  of  the  microscope  andthe  fresh 
live  culture  of  typhoid  bacilli  necessary  in  the  Widal  test  when  made  in  the  old 
way.  Laboratory  experiments  have  showai  it  equal  in  delicacy  to  the  former 
method.    The  limits  of  the  reaction  are  more  distinct  than  in  the  old  process. 

One  bottle  of  a  sterile  permanent  suspension  of  typhoid  bacilli  is  furnished, 
together  with  four  test-tubes,  one  lancet  and  tube  for  collecting  l)lood,  one  vial  for 
diluting  the  serum,  one  small  pipette  for  distributing  the  diluted  serum,  and  one 
large  pipette  with  two  graduations  (each  corresponding  to  ten  drops  of  the  size 
delivered  by  the  small  pipette)  for  filling  the  tubes  with  suspension.  The  three 
tubes  labelled  50,  100,  and  200,  are  to  be  used  for  the  test;  the  fourth  is  a  control 
tube  to  which  no  serum  should  be  added. 

Let  blood  flow  into  the  blood-tube  until  the  bottom  is  covered  with  a  layer 
one-eighth  to  one-fourth  inch  thick.  The  blood  will  flow  much  more  rapidly  if 
the  lobe  of  the  ear  is  squeezed  imtermittently  between  the  thumb  and  index  finger. 

Cork  the  tube  and  replace  in  an  upright  position. 

In  a  short  time  (an  hour)  the  serum  will  have  separated,  or  may  be  readily 
made  to  do  so  by  carefully  loosening  the  edges  of  the  clot  with  the  lancet. 

After  the  serum  has  separated,  insert  the  pipette  into  the  blood-tube,  the  point 
resting  in  the  lateral  depression,  and  incline  both  slightly,  when  the  serum  will 
readily  enter  the  pipette. 

Add  one  drop  of  serum  to  ten  drops  of  clear  water  in  the  diluting  tube,  and  shake 
well.  If  the  diluted  serum  is  cloudy,  let  it  clear  by  standing  a  few  minutes  before 
distributing  to  the  tubes  of  suspension. 

By  means  of  the  large  pipette  put  20  drops  (two  graduations)  of  the  suspension 
of  typhoid  bacilli  in  each  of  the  four  test-tubes. 

Add  the  serum  dilution  to  the  typhoid  suspension  by  means  of  the  small  pipette, 
in  the  following  amounts:  four  drops  added  to  the  tube  marked  50  gives  a  dilution 
of  1:50;  two  drops  added  to  the  tube  marked  100  gives  a  dilution  of  1: 100;  one 
drop  added  to  the  tube  marked  200  gives  a  dilution  of  1 :  200. 

No  serum  should  be  added  to  the  control  tube. 

After  adding  the  serum  dilution,  cork  the  tubes  and  shake  well.  Put  away  in  a 
warm  place. 

Examine  the  tubes  at  the  end  of  one  and  four  hours,  and  again  on  the  following 
day.  The  rapidity  of  the  reaction  depends  both  upon  the  agglutinating  power 
of  the  blood-serum  and  the  temperature  at  which  the  tubes  are  kept.  The  reaction 
may  be  seen  with  the  greatest  distinctness  when  one  stands  near  the  middle  of 
the  room  facing  a  window.  The  tubes  should  be  held  on  a  level  with  the  eye  and 
inclined  slightly  away  from  the  observer. 

When  the  reaction  is  positive,  floccules  appear  in  one  or  more  of  the  tubes, 
depending  upon  the  agglutinating  power  of  the  serum  tested.  These  flakes  are 
small  at  first  and  disseminated  through  the  fluid.  They  gradually  increase  in 
size  and  settle  to  the  bottom  of  the  tube. 

In  a  complete  reaction  the  supernatant  fluid  is  perfectly  clear. 

In  a  positive  but  incomplete  reaction,  floccules  are  seen  in  the  still  cloudy  fluid. 

In  a  negative  reaction  the  fluid  in  the  tubes  remains  uniformly  clouded,  as  in 
the  control. 

All  apparatus  and  corks  should  be  thoroughly  washed  before  using  a  second  time. 

The  diazo-reaction,  sometimes  called  Ehrlich's  reaction,  depends  upon  the  fact 


46  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

that  in  typhoid  fever  the  urine  of  the  patient  contains  a  chromof;en  which,  when 
treated  with  diazo-benzine-sulphonic  acid  and  ammonia,  proihices  a  distinct 
red  Inie  in  the  urine,  which  may  be  as  deep  as  garnet  red.  Other  diseases  give 
this  reaction,  such  as  tuberculosis  and  some  cases  of  pneumonia,  but  it  is  of  consider- 
able value  in  determining  the  presence  of  typhoid  fever  if  taken  in  conjimction 
with  other  signs.  It  is  usually  present  as  early  as  the  sixth  day,  and  lasts  initil 
about  the  eighteenth  day.  The  test  itself  consists  in  using  two  solutions.  One 
of  these  consists  of  a  5  per  cent,  solution  of  hydrochloric  acid  to  which  has  l)eeii 
added  sulphanilic  acid  in  the  proportion  of  1  gram  for  each  KJO  c.c.  The  other  is 
a  0.5  per  cent,  solution  of  sodium  nitrate.  When  the  test  is  to  be  made  the  two 
solutions  are  mixed  in  the  porportion  of  40:1.  Equal  parts  of  urine  and  this  mixture 
are  then  shaken  together  and  rendered  alkaline  by  the  addition  of  animoninm 
hydrate,  which  is  allowed  to  flow  down  the  side  of  the  tube,  forming  the  layer 
above  the  mixture  just  named.  At  the  dividing  line  between  the.se  two  fluids 
the  reaction  appears.  If  tj'phoid  fever  is  present  a  garnet-red  hue  develops.  If 
it  is  not  present,  only  an  orange  tint  is  seen  unless  one  of  the  other  maladies  which 
give  this  test  is  present.  After  the  test  tube  containing  these  liquifls  has  stood 
for  some  time  a  green  sediment  forms,  which  Ehrlich  considers  very  characteristic 
of  a  true  reaction. 

Another  method  of  reaching  a  positive  diagnosis  is  the  examination  of  tliu  blood 
itself  for  the  specific  bacillus,  which,  as  already  stated,  is  present  in  this  fluid  in 
nearly  all,  if  not  all,  cases  of  typhoid  fever.  While  it  is  true  that  this  examination 
is  not  possible  for  one  who  is  not  trained  in  its  technique  from  the  bacteriological 
stand-point,  it  is  also  a  fact  that  this  test  is  not  open  to  the  fallacies  of  the  Widal 
test,  and  that  the  bacilli  are  often  found  as  early  as  the  fifth  day,  whereas  the  Widal 
test  is  frequently  not  positive  till  the  ninth  day,  or  even  later.  The  urine  and 
stools  may  be  examined  for  the  specific  infecting  microorganism,  but  they  are 
rarely  discoverable  in  these  discharges  early  enough  to  aid  the  diagnosis. 

The  Widal  test  and  the  discovery  of  the  bacillus  of  Eberth  in  the  blood  enable 
us  to  difl'erentiate  true  typhoid  fever  from  paratyphoid  fever. 

Finally,  it  is  to  be  remembered  as  a  valuable  diagnostic  fact  that  the  fever  of 
the  first  stages  of  typhoid  fever  is  more  resistant  to  the  cold  bath  than  in  any 
other  malady,  although  it  yields  readily  enough  later  on  in  the  course  of  the  nialad\- 
to  this  therapeutic  measure. 

Prognosis. — The  prognosis  in  typhoid  fever  depends  upon  several  iiufjortant 
factors.  One  of  these  is  the  time  at  which  the  patient  comes  under  medical  care, 
not  because  active  medication  is  of  great  advantage,  but  rather  because  patients 
that  go  to  bed  late  in  the  onset  of  the  disease  usually  become  more  seriously  ill 
than  those  who  conserve  their  vital  forces  by  rest  from  the  very  beginning  of  the 
malady.  Patients  who  travel  long  distances  in  the  early  stages  of  typhoid  are 
wont  to  have  severe  attacks,  and  if,  after  the  disease  is  well  developed,  travelling 
is  resorted  to  the  illness  nearly  always  increases  in  violence.  Another  factor  is 
the  state  of  the  patient  at  the  beginning  of  the  malady,  as  to  his  vital  resistance 
and  general  health.  Fat  persons  usually  do  not  bear  typhoid  fever  well.  Children 
nearly  always  reco\er  from  typhoid  fe^•er  in  its  iuicom])licated  forms,  and  aged 
persons,  while  rarely  aft'ected,  succumli  when  attacked  in  direct  proi^ortion  to 
their  years.     (See  F'ig.  6.) 

A  third  factor  is  the  degree  of  toxemia  which  di'velops  in  severe  cases,  particularly 
if  they  are  not  treated  skilfully  at  first. 

Aside  from  these  general  con.siderations  it  is  inii)ossible  to  make  an  accurate 
prognosis  as  to  the  severity  of  the  attack  or  ])robai)le  recovery  of  the  patient  in 
the  first  week  of  the  disease,  because  the  malady  develops  slowly  and  because  a 
fatal  termination  is  nearly  always  due  to  some  intercurrent  complication  which 
cannot  be  foreseen.     Even  when  the  disease  is  ushered  in  with  violence  of  all  the 


TYPHOID  FEVER  47 

symptoms,  particularly  an  exceedingly  high  temperature,  it  often  happens  that  it 
follows  a  very  short  and  fairly  mild  course,  so  that  a  severe  onset  indicates  a 
speedy  recovery  in  many  instances.  When,  however,  complicating  conditions 
such  as  pulmonary,  cerebral,  or  meningeal  manifestations  develop,  the  prognosis 
is  of  course  correspondingly  grave. 

Recovery  in  typhoid  fever,  under  the  modern  and  favorable  methods  of  treat- 
ment, takes  place  in  about  93  per  cent,  of  cases  in  the  best  types  of  private  practice 
and  in  hospitals  in  which  the  patients  are  received  early  and  in  fairly  good  condition. 
In  private  practice  among  the  poor  the  mortality  is  much  higher.  In  army  practice 
the  mortality  may  vary  from  2  or  3  per  cent,  in  time  of  peace  to  50  per  cent,  in 
time  of  war,  illustrating  very  well  the  fact,  already  stated,  that  early  re.st  in  bed, 
perfect  quiet  of  mind  and  body,  and  proper  nursing  are  most  favorable  in  their 
influence,  whereas  an  absence  of  these  aids  to  recovery  is  most  harmful.  Under 
the  cold-bath  treatment  of  typhoid  fever,  when  it  is  instituted  early,  the  mortality 
of  about  7  per  cent,  is  largely  due  to  those  unavoidable  accidents,  hemorrhage 
and  perforation  of  the  bowel. 

Much  depends  in  all  cases  upon  the  severity  of  the  infection.  In  some  widespread 
epidemics  the  mortality  is  singularly  low  even  when  the  care  of  the  patients  is 
not  very  skilful ;  in  others  it  is  correspondingly  high.  In  the  United  States  army 
in  the  Spanish  war  it  was  only  7  per  cent.,  a  remarkably  low  rate  for  war  time; 
whereas  in  the  Boer  war  the  English  troops  suffered  from  a  death  rate  of  nearly 
21  per  cent. 

Sudden  death  sometimes  occurs  in  tj'phoid  fever  without  the  autopsy  revealing 
any  adequate  cause,  the  real  cause  being  in  all  probability  an  acute  cardiac 
dilatation. 

Treatment. — The  following  is  the  plan  pursued  by  the  author  in  the  treatment 
of  this  disease.  As  soon  as  the  patient  comes  under  observation,  unless  his  bowels 
have  already  been  moved  by  the  aid  of  calomel,. he  is  given  1  to  2  grains  of  this 
drug  in  quarter-grain  doses  every  hour.  If  his  bowels  are  not  moved  in  twelve 
hours,  a  movement  is  produced  by  the  aid  of  a  large  rectal  injection  of  soap  and 
water,  and  if  need  be  by  the  ingestion  of  a  Seidlitz  powder.  Twehe  hours  later 
he  receives  5  to  10  minims  of  dilute  hydrochloric  acid  with  a  teaspoonful  of  essence 
of  pepsin;  this  is  repeated  regularly  every  six  hours  throughout  the  disease  after  food. 
Hydrotherapy. — ^An  order  is  gi^-en  that  if  the  temperature  rises  as  high  as 
102.5°  the  patient  is  to  be  rubbed  with  tepid,  cool,  cold,  or  ice-water,  or  even  with 
a  piece  of  ice,  according  to  the  degree  with  which  his  temperatiu-e  resists  the  bath 
and  according  to  the  degree  of  toxemia  present.  If  toxemia  is  very  great,  it  is 
often  necessary  to  give  a  thorough,  brief  and  brisk,  rub-off  with  a  small  piece  of 
ice,  not  so  much  to  reduce  the  fever  as  to  cause  reaction  and  arouse  the  patient's 
vitality.  With  this  application  of  cold,  in  different  degrees  according  to  the  needs 
of  the  case,  there  must  be  employed  by  another  nurse,  or  by  the  free  hand  of  the 
nurse  who  uses  the  cold,  active  friction  to  the  skin  as  the  cold  comes  in  contact  with 
the  integument,  because  friction  increases  the  heat  loss  50  per  cent.,  aids  in  produc- 
ing those  most  essential  conditions  reaction  and  equalization  of  the  capillary 
circulation,  and  prevents  the  patient  from  being  chilled.  It  is  a  cardinal  rule  that 
if  the  patient  has  been  ill  so  long  that  reaction  does  not  occur  under  the  bath,  it  is 
contraindicated  and  we  must  endeavor  by  gentle  measures  and  the  use  of  tepid 
or  even  of  hot  water  to  redevelop  the  power  of  the  body  to  react.  In  other  words, 
that  temperature  of  water  should  be  used  which  is  necessary  when  combined  with 
active  friction  to  reduce  the  temperature  at  least  2°  in  fifteen  to  twenty  minutes, 
provided  reaction  can  be  produced.  Without  reaction  we  simph-  increase  internal 
congestions  by  the  use  of  cold  water.  It  is  interesting  to  note  that  Hirschfeld  has 
treated  over  1000  cases  with  tepid  immersion  baths  of  80°  to  90°  and  friction  with 
a  mortality  of  only  3.4  per  cent. 


48  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

AVlieiiever  cold  is  used,  an  ice-bag  or  cold  cloth  slioiild  he  apjilicd  to  tlic  licad  to 
l)rpvent  cerebral  congestion. 

Willie  the  method  of  bathing  just  described  is  that  nearly  always  jjursued  by 
the  writer,  it  is  proper  to  give  definite  information  concerning  the  so-called  Brand 
method  of  cold  bathing,  a  plan  which  was  introduced  by  Brand,  of  Stettin,  many 
years  ago,  but  which  has  only  received  its  full  share  of  credit  during  the  past  thirty- 
five  years.  This  plan  consists  in  immersing  the  patient,  when  his  temperature 
reaches  102°  or  102.5°,  in  a  tub  of  water  the  temperature  of  which  is  70°,  and  keeping 
him  there  with  active  friction  for  fifteen  or  twenty  minutes,  until  the  temperature 
is  reduced  to  100°.  In  order  to  combat  chilling  and  aid  the  circulation  it  is  custom- 
ary to  give  the  patient  one-half  to  one  ounce  of  whiskey  before,  during,  or  after 
the  bath.  The  bath  is  repeated  whenever  the  temperature  rises  to  102°.  Usually 
it  is  needed  every  two  or  three  hours.  In  order  that  the  patient's  strength  may 
be  conserved  he  should  be  lifted  into  and  out  of  the  tub. 

This  so-called  plunge  bath,  or  Brand  bath,  is  a  remedy  of  the  greatest  possible 
value,  but  is  not  needed  in  every  case  as  a  matter  of  routine.  When  used  it  is 
essential  to  produce  reaction  and  to  use  friction,  and  to  apply  ice  to  the  head.  The 
indications  for  its  use  are  identical  with  those  just  named.  It  is  actually  contra-indi- 
cated in  the  very  young  and  very  old,  in  whom  it  is  often  difficult  to  produce 
reaction,  and  if  the  case  comes  under  treatment  so  late  as  the  beginning  of  the  third 
week,  since  reaction  to  cold  is  usually  then  lost.  The  presence  of  a  complicating 
pneumonia  also  contra-indicates  it.  Its  disadvantages  are  that  the  back  cannot  be 
rubbed,  although  the  muscles  in  that  part  of  the  body  contain  much  heat;  this  part 
of  the  skin  is  most  prone  to  suffer  from  bed-sores,  and  the  patient  must  be  lifted 
or  raise  himself  out  of  the  tub.  The  temperature  of  the  plunge  bath  when  its 
use  is  deemed  wise  should  not  be  placed  at  a  tepid  level  and  then  reduced  while 
the  patient  is  in  the  water,  as  this  does  not  administer  a  stimulating  and  awakening 
shock  to  the  system,  but  simply  chills  the  patient,  thereby  doing  no  good,  for  the 
object  in  using  water  in  typhoid  fever  is  to  produce  reaction,  eliminate  poisons, 
and  reduce  temperature,  and  the  means  by  which  this  is  best  accomplished  can 
be  determined  in  each  case  by  the  physician. 

Personally  the  writer  has  never  failed  to  successfully  accomplish  all  these  results 
by  cold  rubbing,  with  friction,  if  it  is  properly  given,  but  many  physicians  prefer 
to  follow  the  method  of  Brand  as  a  routine  pratice.  An  enormous  array  of  statistics 
proA'c  its  value  as  a  life-saving  agent.' 

When  cold  is  properly  used  it  should,  after  the  first  week  of  the  disease,  produce 
changes  in  the  temperature,  as  shown  in  the  following  chart  (Fig.  13). 

Some  form  of  bath  at  least  once  a  day  is  absolutely  necessary,  even  if  the  tempera- 
ture never  exceeds  normal,  to  establish  cleanliness  and  equalize  the  circulation 
everywhere,  and  he  who  treats  t.\'])hoi(i  fc\-cr  \^itliout  resort  to  efficient  hydrother- 
apy, if  it  can  be  used,  is  not  doing  all  for  his  patient  tliat  can  be  done. 

The  use  of  hydrotherapy  greatly  lowers  the  mortality,  sa\-ing  about  10  in  everj' 
100  cases,  but  it  does  not  diminish  the  frequency  of  perforation  or  hemorrhage, 
and  it  apparently  increases  the  frequency  of  relapse.  This  may  be  due  to  the 
fact  that  more  are  saved  to  run  the  chance  of  relapse,  but  also  may  depend  upon 
the  fact  that  mild  cases  are  more  prone  to  relapse  than  severe  ones.  Hydrotherapy 
does  not  shorten  the  duration  of  the  fever,  but  it  often  shortens  the  length  of  the 
illness  by  preventing  complications. 

Diet. — The  diet  consists  of  milk  in  the  first  week  and  often  for  most  of  the 
second  week,  about  a  quart  to  a  quart  and  a  half  a  day  being  given,  so  divided 
that  the  patient  gets  it  every  three  or  four  hours.  It  is  followed  by  the  acid  and 
pepsin  already  named,  unless  the  stomach  is  irritable,  when  a  little  lime-water 

'  Sec  article  by  the  author  in  Therapeutic  Gazette  for  March,  1898. 


TYPHOID  FEVER 


49 


may  be  given  as  a  substitute,  or  a  little  Celestins  Vichy  water  may  be  used.  When 
the  digestion  of  milk  is  difficult  it  is  well  to  add  to  it  hot  water  or  to  dilute  it  with 
an  alkaline  or  carbonated  water.  If  the  taste  of  the  milk  is  unpleasant  to  the 
patient,  it  may  be  flavored  by  the  afldition  of  vanilla,  nutmeg,  coffee,  tea,  or  cocoa 
in  small  amounts.  After  the  first  week  or  ten  days  the  patient  is  allowed  from 
one  to  two  soft-boiled  eggs  twice  a  day,  so  soft  that  they  can  better  be  taken  as  a 
drink  than  eaten  with  a  spoon,  and  ifavored  with  a  little  salt.  Well-boiled  rice 
strained  through  a  fine  sieve,  and  even  thin  cornstarch  or  barley-gruel,  if  well 
cooked,  may  be  given  several  times  a  day  at  this  time  with  advantage,  particularly 
if  at  the  same  time  a  little  taka-diastase  is  used  to  aid  their  digestion.  The  author 
is  firmly  convinced  that  by  this  means  terminal  infections  and  general  feebleness 
can  be  largely  avoided  and  the  patient  brought  to  the  stage  of  convalescence  ready 
for  speedy  return  to  health  and  with  greater  vital  force.  Broths  and  other  liquid 
animal  soups  are  inadvisable,  for  they  are  good  culture  media,  and  often  tend  to 
increase  tympanites  and  diarrhea.    They  are  largely  used  by  many  physicians. 


Chart  showing  the  falls  in  temperature  and  reactions  following  the  use  of  cold  spongings  in  a  case  of 
typhoid  fever.  The  dotted  lines  show  the  fall.  The  broken,  nearly  horizontal  line  shows  the  morn- 
ing  and  evening  range  unaffected  by  sponging.    Thirty-four  baths  were  given  in  eight  days. 


but  never  by  the  writer.  When  curds  appear  in  the  stools,  the  quantity  of  milk 
should  be  diminished  or  it  should  be  peptonized,  or  its  digestion  aided  by  the  use 
of  pancreatin  given  after  it  is  taken.  The  use  of  5  to  10  grains  of  citrate  of  soda 
in  the  milk  will  also  prevent  the  formation  of  curds. 

Medicines. — Drugs  are  not  to  be  given  if  they  can  be  avoided — that  is,  they 
are  not  to  be  used  unless  they  are  certainly  needed  to  combat  some  definite  condition 
which  should  be  alleviated.  In  the  great  majority  of  cases,  if  not  in  all,  the  so-called 
antipyretic  drugs  are  not  only  useless  but  harmful,  and  particularly  harmful  if 
their  use  is  resorted  to  simultaneously  with  bathing.  Their  only  justifiable  use 
in  a  case  which  can  be  properly  nursed  and  bathed  is  for  the  purpose  of  relieving 
headache  and  backache,  when  they  may  be  given  in  small  doses,  such  as  2  grains 
of  acetanilid  three  or  four  times  a  day.  Quinine  is  of  little,  if  any,  value  except 
as  a  tonic  in  small  doses. 

Stimulants  are  to  be  used  when  the  pulse  is  actually  weak  and  the  cardiac  first 
sound  distant  or  feeble.  The  best  of  them  is  whiskey  or  brandy,  diluted  with 
4 


50  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

milk  or  water,  and  given  in  doses  of  half  an  ounce  every  three  to  six  hours  as  needed. 
Many  cases  do  better  without  any  stimulation,  whereas  others  need  much  larger 
doses  of  alcohol  than  those  just  named.  Digitalis  is  rarely  of  any  service  because 
it  does  not  act  well  in  the  presence  of  fever,  rarely  supports  the  degenerated  muscle 
fibers  of  the  heart,  and  is  apt  to  disorder  the  stomach.  When  the  cardiac  condition 
is  desperate,  Kofl'mann's  anodyne  in  dram  do.ses  every  two  hours  in  cool  water 
is  very  valuable.  When  profound  adynamia  develops  and  the  patient  is  critically 
ill,  nnich  good  may  result  from  the  injection  hypodermically  of  1  grain  of  camphor 
in  .'iO  drops  of  sterilized  olive  oil  every  eight  hours  for  five  or  six  doses.  Another 
metliod  of  value  wlien  the  vascular  system  is  relaxed  and  the  patient  adynamic 
is  the  use  of  normal  salt  solution  by  hypodermoclysis.  Strychnine  may  also  be 
used,  but  it  is  a  mistake  to  employ  it  for  more  than  a  few  doses  in  the  active 
stage  of  this  disease.  It  is  better  to  keep  it  in  reserve  for  attacks  of  sudden 
circulatory  failure. 

Antisepsis. — Absolute  intestinal  antisepsis  cannot  be  produced  by  any  known 
means,  although  it  is  possible  to  modify  very  materially  the  growth  of  micro- 
organisms in  the  bowel  by  the  use  of  proper  remedies.  If  the  physician  takes  the 
ground  that  by  the  use  of  these  substances  he  destroys  the  Bacillus  typhosus  and 
so  benefits  the  patient,  he  is  largely  in  error,  and  his  use  of  them  is  not  rational 
because  the  bacillus  is  widely  distributed  in  every  part  of  the  body.  If,  on  the 
other  hand,  these  remedies  are  given  to  combat  intestinal  fermentation,  as  shown 
by  foul-smelling  stools  and  tympanites  and  other  evidences  of  an  excessive  growth 
of  the  non-specific  bacteria  which  throng  the  bowel  during  the  progress  of  this 
disease,  his  use  of  them  is  rational  in  that  by  this  means  other  toxic  materials  are 
prevented  from  being  generated  in  excess.  Often  the  Bulgarian  lactic  acid  bacillus 
may  be  given  with  advantage  in  these  cases.  Another  remedy  is  the  sulphocarbo- 
late  of  zinc  in  the  dose  of  2  to  3  grains  in  pill  form  three  or  four  times  a  day.  Still 
another  drug  of  far  older  use  is  turpentine  in  emulsion  in  the  dose  of  10  to  20  drops 
three  or  four  times  a  day.  The  latter  I  prefer.  In  many  of  these  cases  also  the 
use  of  a  few  small  doses  of  calomel  or  salol  is  advantageous. 

AntitypJioid  Vaccine. — The  employment  of  antityphoid  vaccine  in  the  treatment 
of  a  patient  suffering  from  typhoid  fever  is  an  entirely  different  proposition  from 
its  use  to  protect  an  individual  by  rendering  him  immune.  In  the  patient  who 
is  ill  the  Bacillus  typhosus  has  already  more  or  less  overwhelmed  the  patient,  who 
is  suff'ering  from  ha^■ing  .set  free  in  his  body  the  poison  of  the  invaders,  for  the 
poison  of  the  bacillus  of  Eberth  is  endogenous  and  is  not  set  free  until  the  germ  is 
destroyed.  Given  to  a  healthy  man  the  vaccine  puts  him  in  such  a  condition  that 
he  is  an  unfavorable  field  for  the  growth  of  the  infection,  but  given  to  one  who 
is  ill  we  only  add  to  the  number  of  dead  bacilli  and  the  poisons  already  present. 
It  is  conceivable  that  the  use  of  vaccine  may  rouse  dormant  protective  processes 
to  active  effort,  but  it  is  more  conceivable  that  the  do.se  may  be  "the  last  straw 
that  breaks  the  camel's  back."  The  use  of  antityphoid  vaccine  after  the  disease 
is  developed  has  been  quite  largely  resorted  to,  but  the  results  have  not  been  very 
encouraging,  probably  for  the  reasons  given,  although  there  are  some  who  advo- 
cate its  use. 

Tkeatment  oe  Si'EciAi.  Sy.mitoms. — Constipation  is  to  be  relieved,  preferably 
by  the  use  of  enemata  of  soap  and  water,  to  which  may  be  added  in  obstinate  cases 
a  tabiespoonful  or  two  of  glycerin.  Many  of  these  patients  have  no  constipation 
in  the  sense  that  the  ileum  or  colon  is  sluggish;  but,  on  the  other  hand,  the  sigmoid 
flexure  becomes  packed  with  hardened  feces,  and  mechanical  obstruction  occurs. 
The  use  of  purgatives  by  the  mouth  is  therefore  useless  unless  very  strong  drugs 
arc  used,  which  are  dangerous.  If  it  is  thought  that  the  bowels  are  really  sluggish 
a  little  cascara  sagrada  (20  to  130  minims  of  the  non-bitter  extract)  may  lie  given 
each  evening. 


TYPHOID  FEVER  51 

Diarrhea,  if  excessive— that  is,  more  tlian  three  or  four  stools  a  day — may 
be  controlled  by  5-  to  10-drop  doses  of  aromatic  sulphuric  acid  in  simple  elixir 
several  times  a  day  or  by  adding  to  these  two  ingredients  a  half-dram  of  fluid- 
extract  of  hematoxylon.  If  much  fermentation  is  present,  an  intestinal  antisei)tic 
should  be  used,  such  as  zinc  sulphocarbolate. 

Vomiting  is  to  be  primarily  prevented  by  regulating  the  diet  as  already  referred 
to.  If  it  persists,  as  little  food  and  drink  should  be  given  as  possible  for  a  few 
hours  to  let  the  stomach  rest;  and  if  there  be  much  nervous  irritability,  GO  grains 
of  sodium  bromide  in  a  little  starch-water  should  be  given  by  the  rectum  to  quiet 
the  vomiting  centre.  Counterirritation  should  be  applied  over  the  epigastrium 
in  the  form  of  a  mustard  plaster  or  turpentine  stupe.  If  alcohol  is  being  used  as  a 
stimulant  its  use  must  be  stopped,  or,  if  this  is  impossible,  then  a  very  old  brandy 
or  wine  should  be  substituted  for  the  whiskey  and  given  often  in  very  small 
quantities. 

For  tym-panites  a  turpentine  stupe  is  to  be  placed  over  the  belly,  if  possible, 
before  the  gas  accumulates  in  any  amount,  and  if  it  persists  a  rectal  injection  of 
the  emulsion  of  asafetida,  with  or  without  a  dram  or  two  of  turpentine,  should 
be  given.  The  efficiency  of  this  injection  may  be  much  increased  in  the  way  of 
expelling  gas,  and  if  marked  adynamia  is  present,  by  adding  half  an  ounce  of  Hoff- 
mann's anodyne  to  the  injection.  Turpentine  in  the  dose  of  10  drops,  in  emulsion 
or  capsule,  may  also  be  given  by  the  mouth  for  this  condition.  When  the  gas  fails 
to  come  away,  its  passage  may  be  aided  by  the  introduction  of  a  long  rectal  rubber 
tube. 

Hemorrhage  from  the  bowel  does  not  offer  very  much  opportunity  for  direct 
rational  treatment.  In  the  majority  of  instances  the  best  we  can  do  in  the  way 
of  real  benefit  to  the  patient  is  the  maintenance  of  body  heat  by  the  application 
of  hot  bottles;  and  if  the  circulation  becomes  markedly  feeble,  the  employment  of 
normal  salt  solution  by  hypodermoclysis,  a  pint  of  it  being  given  once,  twice,  or 
thrice  in  the  succeeding  twenty-four  hours,  according  to  the  needs  of  the  patient. 
Bandages  may  be  applied  to  the  limbs  to  limit  the  circulation  to  the  vital  parts, 
and  th&  foot  of  the  bed  be  raised  for  a  similar  purpose.  The  large  number  of 
remedies  which  have  been  suggested  for  the  direct  control  of  the  hemorrhage 
indicate  how  feeble  they  all  are.  There  is  no  more  reason  for  supposing  that 
astringents  given  bj'  the  mouth  can  check  hemorrhage  from  an  ulcerated  vessel 
in  the  bowel  than  that  they  can  check  a  hemorrhage  from  a  branch  of  the  anterior 
tibial  artery;  and  when  they  are  given  and  hemorrhage  ceases,  the  arrest  is  due  more 
to  coincidence  than  to  the  eft'ect  of  any  drug.  If  any  remedy  of  this  type  is  of 
value,  it  is  probably  Monsel's  salt  (ferri  subsulphas),  which  should  be  given  in  a  hard 
pill  or  compressed  tablet  inclosed  in  a  capsule,  with  the  hope  that  it  will  escape 
from  the  stomach  into  the  intestine  without  being  dissolved,  and  thereby  exert 
its  styptic  influence.  Of  course,  if  it  is  dissolved  in  the  stomach,  its  chemical 
characteristics  are  altered.  Many  physicians  apply  a  small  ice-bag  over  the  centre 
of  the  belly  to  influence  the  circulation  in  the  small  intestine,  with  the  hope  that 
in  that  way  hemorrhage  will  be  controlled.  There  is  no  objection  to  this  plan 
of  treatment,  and  the  author  often  resorts  to  it;  but  it  should  be  used  with  caution, 
if  the  hemorrhage  is  se\'ere,  lest  it  aid  in  devitalizing  the  patient  by  abstracting 
heat.  Simultaneously  with  the  application  of  the  ice-bag  to  the  belly,  hot  bottles 
should  be  applied  to  the  other  parts  of  the  body,  for  it  is  to  be  remembered  that 
the  loss  of  bodily  heat  is  an  important  factor,  not  only  because  the  vital  processes 
cannot  be  well  performed  at  a  low  temperature,  but  also  because  the  sudden 
reduction  of  temperature  caused  by  the  hemorrhage  deprives  the  heart  and  other 
organs  of  the  stimidating  effect  of  the  fever  which  has  been  present  for  days.  An- 
other popular  method  of  treatment  is  the  administration  of  a  pill  containing  a 
grain  of  opium  and  a  grain  of  acetate  of  lead;  the  opium  being  expected  to  diminish 


52  DISEASES  DUE  TO  A  SPECIFIC  INFECTIOX 

peristalsis  and  so  aid  clottiiij;,  and  the  lead  to  act  as  a  styptic.  The  opium  is 
pr()l)at)l,v  of  value,  hut  it  is  doubtful  if  the  lead  e\er  reaches  the  bleeding  spot 
without  becoming  altered  by  the  gastric  and  intestinal  juices.  When  there  seems 
to  be  continued  oozing  of  blood  from  a  large  intestinal  ulcer  \vith<jut  free  hemor- 
rhage, the  administration  of  turpentine  and  the  use  of  horse  serum  or  coagulose  is 
to  be  seriously  considered,  as  there  is  rea.son  to  believe  that  they  control  cajiillary 
hemorrhage.  Wright  and  his  co-laborers  have  shown  that  the  hypodermic  use 
of  calcium  lactate  and  the  internal  use  of  calcium  chloride  increa.se  the  coagulability 
of  the  blood  and  these  salts  may  be  used.  (See  Purpura.)  After  the  hemorrhage 
has  ceased,  particularly  as  convalescence  is  begun,  small  doses  of  iron  should  be 
admini.stered  to  combat  the  anemia. 

The  treatment  of  perforation  of  the  bowel  from  a  medical  j^oint  of  view  consists 
in  giving  opium  to  relieve  pain,  and  employing  heat  and  stimulants  to  combat 
shock.  If  a  skilled  abdominal  surgeon  can  be  obtainetl,  all  such  ca.ses  .should  be 
operated  upon  at  once,  since  the  mortality  under  operation  is  less  than  with  no 
operation.  Statistics  seem  to  show  a  mortality  of  about  SO  per  cent,  with  operation 
and  95  per  cent,  without  it.  My  colleague,  Dr.  Keen,  has  published  158  cases. 
They  gave  a  recovery  percentage  of  2.3.41.  I  have  collected  54  cases  which  have 
been  reported  since  January  1,  1900,  and  find  that  .35  of  the  number  were  followed 
by  recovery.  This  gives  a  recovery  percentage  of  61.54,  which  is  far  too  high  for 
the  general  run  of  cases.  Harte  and  Ashhurst  place  the  recovery  after  operation 
at  26  per  cent.  The  statistics  of  Bagley,  who  extended  the  collection  of  cases 
from  1903  to  the  close  of  1909,  show  that  the  recoveries  after  operation  in  this 
second  period  were  42  per  cent.  Among  children  the  results  have  been  excellent. 
Out  of  25  cases  collected  by  Elsberg  16  recovered,  a  postoperative  mortality  of 
only  36  per  cent.  These  figures  are  of  value  as  showing  that  recovery  may  take 
place,  but  they  do  not  give  the  real  percentage  of  deaths,  for  most  of  the  ca.ses  that 
are  operated  upon  and  die  are  not  reported.  I  have  seen  3  of  these  within  a  year. 
To  be  successful  the  operation  ought  to  be  performed  at  the  earliest  possible  moment 
after  perforation,  although  if  the  patient  when  seen  is  profoundly  shocked  it  may 
be  necessary  to  rally  him  by  stimulation  before  the  operation  is  commenced  or 
even  postpone  operation  until  sufficient  time  has  elapsed  to  allow  him  to  rally. 

Statistics  clearly  prove  that  the  prosj^ect  of  recovery  from  perforation  treated 
by  operation  steadily  diminishes  with  each  hour  that  passes  after  the  accident 
occurs.  Cases  are  on  record,  however,  and  I  have  seen  more  than  one,  in  which 
j)erforation  took  place  and  recovery  occurred  without  operation. 

Persistent  insomnia  is  rarely  a  troublesome  symptom  in  typhoid  fever.  Although 
patients  complain  of  wakefulness  at  night,  careful  observation  will  usually  show 
that  they  get  sufficient  sleep  in  twenty-four  hours.  In  some  cases,  howe\cr, 
when  they  are  wakeful,  largely  because  of  active  delirium,  and  are  rapidly  exhausting 
their  vital  forces  by  contiiuied  nervous  activity,  life  can  be  saved  by  the  hyi)odermic 
injection  of  \  grain  of  morphine,  to  which  may  be  added  ,  u  if  grain  of  nitroglycerin 
to  prevent  .secondary  nausea  and  depression. 

The  ai)plicaflon  of  an  ice-bag  to  the  head  throughout  the  attack  will  usually 
prevent  ordinary  delirium  from  becoming  excessive. 

Bed-sores  are  usually  prevented  by  the  friction  apjjlicd  to  all  portions  of  the 
skin  in  the  baths  which  are  given  every  few  hours.  If  they  api)ear  over  the  sacrum, 
the  ]iatient  should  lie  as  much  as  jjo.ssible  on  his  sides,  all  bon\'  ])rominences  on 
which  the  patient  rests  being  protected  from  contact  with  the  bed  by  circular 
air-cushions.  When  the  skin  first  reddens  the  irritation  may  be  allayed  by  painting 
it  with  a  solution  of  nitrate  of  silver,  20  grains  to  the  ounce.  If  the  bed-sore  has 
begun  to  form,  a  u.seful  dressing  consists  in  equal  parts  of  powdered  chloretone  and 
boric  acid.  If  the  slough  becomes  large,  all  that  portion  which  is  actually  dead 
should  be  cut  away,  the  part  thoroughly  sprayed  with  peroxide  of  hydrogen,  dried 


PARATYPHOID  FEVER  53 

by  the  gentle  application  of  soft  lint,  and  then  dressed  with  the  dusting-powder 
just  named. 

The  treatment  of  the  other  complications  of  typhoid  fever  will  be  found  under 
the  headings  of  the  respective  diseases,  such  as  Pneumonia,  etc. 

During  conmlescence  the  patient  should  be  fed  with  increasing  quantities  of 
nutritious,  easily  digested  food,  but  stimulants  if  possible  should  be  avoideri.  If 
the  patient  is  out  of  bed  care  should  be  taken  that  food  is  not  ingested  until  after 
he  has  lain  down  to  rest,  in  order  that  he  may  not  be  tired  and  so  lack  nervous 
energy  during  the  progress  of  the  digestive  processes. 

As  already  pointed  out  when  discussing  the  prevention  of  typhoid  fever,  urotropin 
or  uritone  should  be  given  in  doses  of  5  to  10  grains  four  times  a  day  in  water,  to 
destroy  the  bacilli  which  are  usually  present  in  the  urine  and  bile. 

The  ordinary  diet  should  not  be  restored  until  from  ten  days  to  two  weeks  after 
all  fever  has  ceased.  The  author  has  often  been  impressed  with  the  fact  that  the 
use  of  green  vegetables,  such  as  lettuce,  spinach,  asparagus,  and  similar  substances, 
seems  to  exercise  a  most  valuable  influence  in  convalescence  in  typhoid  fever, 
perhaps  because  they  antagonize  scorbutic  tendencies. 


PARATYPHOID  FEVER. 

Paratyphoid  fever  is  a  disease  caused  by  infection  with  the  paratyphoid  bacillus, 
and  presents  a  symptom-complex  closely  resembling  or  indistinguishable  from  that 
of  typhoid  fever. 

Bacteriology. — The  paratj^ihoid  bacilli  belong  to  a  group  of  organisms  inter- 
mediate between  the  Bacillus  typhosus  and  Bacillus  coli  communis.  Buxton  has 
shown  that  by  appropriate  methods  organisms  occupying  this  position  may  be 
divided  into  several  groups;  one  resembling  the  colon  bacillus,  for  which  he  proposes 
to  use  the  name  paracolon;  another  group  closely  allied  to  the  typhoid  bacillus, 
called  the  paratyphoid,  and  producing  the  condition  termed  paratyhpoid  fever. 
The  last-named  group  may  by  appropriate  cultural  methods  be  further  divided 
into  a  species  culturally  unlike  the  paracolon  type,  and  a  second  distinct  species 
resembling  the  paracolon  group. 

The  differentiation  of  these  typhoid-colon  groups  and  their  components  is  a 
most  complex  bacteriological  problem.  It  is  probable  that  not  a  few  paratyphoid 
infections  are  diagnosed  typhoid  fever. 

Prevention. — The  same  measures  as  are  given  for  the  prevention  of  typhoid  fever, 
including  the  use  of  vaccine,  are  to  be  resorted  to.     (See  Tj^phoid  Fever.) 

Pathology. — Differing  anatomically  from  typhoid  fever  in  essential  details, 
this  disease  possesses  no  characteristic  morbid  anatomy,  resembling  in  this  respect 
the  other  forms  of  septicemia.  The  most  constant  change  is  splenic  enlargement, 
which  is  present  in  all  of  the  cases  coming  to  autopsy.  Saltykow  has  collected 
22  cases  of  which  14  showed  implications  of  the  lymphoid  tissue,  ulceration  being 
present  in  9.  He  describes  the  lesions  as  similar  to  those  of  typhoid  but  not  typical. 
The  mesenteric  glands  are  but  slightly  altered;  focal  necroses,  not  containing  endo- 
thelial cells,  occur  in  the  liver.  The  proliferative  and  phagocytic  endothelial  changes 
of  typhoid  fever  are  practically  absent.  There  are  no  constant  changes  found 
in  other  organs,  although  toxemia  in  severe  cases  may  induce  its  usual  anatomical 
changes.  Giitig  examined  the  blood  of  six  paratyphoid  patients  and  found  that 
the  neutrophiles  are  diminished  during  the  early  stages  of  the  disease.  The  lymph- 
ocytes also  are  diminished  at  first,  but  become  increased  later  in  the  disease,  and 
in  convalescence  they  constitute  more  than  half  the  entire  number  of  white  cells. 
The  eosinophiles  disappear  from  the  blood  during  the  fever,  but  reappear  just 
before  or  shortly  after  the  temperature  becomes  normal. 


54  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

Tlie  bacilli  heave  been  found  in  the  heart's  l)loof],  in  a  cardiac  thrombus,  in  the 
liver,  lungs,  spleen,  adrenal  bodies,  cerebral  cortex,  and  in  the  Huid  of  pericardial 
and  pleuritic  effusions. 

Cases  have  been  reported  from  France,  Germany,  Holland,  Iioumania,  iMiglaiid, 
the  United  States,  and  the  Philippine  Islands.  The  disease  affects  chiefly  young 
adults,  and,  like  typhoid  fever,  is  more  prevalent  in  autumn  than  at  other  seasons 
of  the  .year.  V.  Sion  and  V.  Negal  and  De  Feyfer  and  Keyser  found  that  the 
epidemics  under  their  observation  were  produced  by  drinking  infected  water. 
Hunermann  traced  several  cases  occurring  among  children  to  one  of  their  number 
who  had  suffered  from  a  mild  infection.  Of  the  other  recorded  cases  nothing 
definite  concerning  the  mode  of  infection  is  known.  Watt  reports  12  cases,  from 
which  BnciUus  paratyphosvs  /3  was  isolated,  occurring  in  an  epidemic  of  100  cases 
of  typhoid  in  Aberdeen.  He  believes  that  the  two  epidemics  were  independent 
and  did  not  arise  from  a  common  source. 

Symptoms. — The  disease  may  be  mild  or  severe.  The  onset  is  gradual,  and 
the  symptoms  of  invasion  are  the  same  as  those  met  with  in  typhoid  fever,  namely, 
headache,  lassitude,  and  slight  bronchitis.  During  the  course  of  the  disease  the 
spleen  becomes  enlarged,  rose  spots  may  appear,  and  the  patient  develops  the 
typhoid  state.  In  Cushing's  case  a  relapse  occurred.  Johnston  states  that 
diarrhea  and  termination  of  the  fever  by  crisis  are  of  more  frequent  occurrence 
than  in  typhoid  fever.  Brion  found  diarrhea  in  IS  per  cent,  of  the  recorded  cases. 
In  uncomplicated  cases  no  leukocytosis  has  been  observed.  Hemorrhage  from 
the  bowel  occurred  in  5  per  cent. 

Complications. — The  complications  of  paratyphoid  fever  are  of  about  the  same 
character  and  frequency  as  those  of  true  typhoid  fe\'er. 

Diagnosis. — The  diagnosis  depends  upon  the  isolation  and  cultivation  of  a 
paratyphoid  bacillus  from  the  patient's  blood,  urine,  or  feces,  or  from  a  localized 
lesion.  Bacilli  thus  obtained  should  be  agglutinated  by  the  patient's  blood-serum, 
and  the  latter  should  agglutinate  known  paratyphoid  bacilli.  In  case  an  organism 
cannot  l^e  recovered  Pratt  thinks  a  diagnosis  of  paratyphoid  is  justifiable  if  the 
patient's  blood-serum  agglutinates  known  strains  of  paratyphoid  bacilli.  The 
Widal  reaction  is  usually  negative,  or  positive  only  in  very  low  dilution,  but  all  cases 
in  which  it  is  negative  must  not  be  regarded  as  cases  of  paratyphoid  rather  than 
true  typhoid  fever.  The  agglutination  test,  when  employed,  in  paratyphoid 
fever  serves  to  separate  this  disease  from  true  typhoid  fever  and,  as  in  the 
Widal  test  for  enteric  fe^er,  the  earlier  the  reaction  appears  the  shorter  and  milder 
is  apt  to  be  the  course  of  the  illness. 

Prognosis. — The  prognosis  would  seem  to  be  favorable,  as  only  3  deaths  have 
occurred  in  S3  midoubted  cases  of  the  disease,  and  1  of  these  was  a  mixed  infection 
witli  the  Bacillus  typhosus. 

Treatment. — This  is  identical  with  that  of  true  typhoid  fever. 


TYPHUS  FEVER. 

Definition. — Typhus  fever  is  an  acute,  infectious,  self-limited  disease  of  sudden 
onset  which  is  characterized  by  fever,  mental  apathy,  and  the  development  of  a 
rash  which  does  not  recur  in  crops  as  does  the  rose  rash  of  typhoid  fever.  It  is 
particularly  prone  to  attack  large  numbers  of  persons  in  unhealthy  surroundings. 
The  period  of  incubation  of  typhus  fever,  as  a  rule,  varies  from  eight  to  fourteen 
days,  but  there  can  be  no  doubt  that  many  cases  have  been  attacked  within  seven 
days  after  exposure.  A  few  cases  are  said  to  ha\'e  developed  as  early  as  the 
fourth  day.  Under  the  conditions  mentioned  typhus  fever  is  one  of  the  most  con- 
tagious of  the  acute  infectious  maladies. 


TYPHUS  FEVER  55 

Some  confusion  has  arisen  in  the  past  between  typhus  and  typhoid  fever,  but 
at  present,  they  are  clearly  difi'erentiated,  although  it  is  worthy  of  note  that  the 
symptoms  of  enteric  fever  are  so  much  like  typhus  fever  in  their  degree  of  adynamia 
that  it  is  called  "typhoid"  or  like  typhus,  while  German  writers  of  the  present 
day  still  call  typhoid  fever  "  Uentyphis." 

Typhus  fever  is  sometimes  called  Spotted  Fever,  Ship  Fever,  Putrid  Fever, 
or  Hunger  Typhus. 

The  infection  which  at  one  time  was  supposed  to  spread  by  direct  contact  with 
the  patient  or  by  his  garments  or  discharges  is  in  many,  if  not  all  cases,  transmitted 
by  the  bite  of  the  louse  {yediculus  vestimenti).  Possibly  the  bed-bug  is  also  a 
transmitting  agent.  It  is  not  certain,  however,  than  an  insect  must  always  be 
the  transmitting  agent,  although  in  the  following  text  it  will  be  readily  seen  that 
the  conditions  favorable  to  its  transmission  by  the  air  are  usually  associated  with 
lice,  fleas  or  bed-bugs. 

History. — Tjphus  fever  was  first  described  as  occurring  in  10S3  by  Corradi, 
but  it  was  not  fully  recognized  as  a  distinct  malady  till  1546,  when  Gracastorius 
wrote  of  the  affection  as  he  had  seen  it  in  Verona  in  1.505  and  1508.  Several  epi- 
demics are  reported  as  having  occurred  during  the  last  half  of  the  sixteenth  century, 
in  the  eighteenth  century,  and  in  the  early  part  of  the  nineteenth  century  in  various 
parts  of  Europe;  a  most  virulent  epidemic  ravaging  Ireland  and  England  in  1846. 
In  America  it  first  appeared  in  the  New  England  States  in  1S07,  and  in  Philadelphia 
in  1812,  where  it  is  said  to  have  existed  in  isolated  cases  until  1836.  (See  Distribu- 
tion.) 

Distribution. — ^Tj'phus  fever  seems  to  occur  in  all  parts  of  the  world,  if  the  con- 
ditions favorable  to  its  development  are  present  in  the  sense  of  unhealthy  surround- 
ings and  provided  the  necessary  germ  is  introduced.  Because  of  its  intimate 
association  with  unsanitary  conditions  it  has  been  epidemic  in  great  armies,  during 
famine,  and  on  ships  in  which  the  crew  or  passengers  often  were  huddled  together 
for  long  periods  of  time.  On  the  continent  of  Europe  it  spreads  usually  from  east 
to  west  and  is  disseminated  chiefly  by  the  poorest  classes  when  they  travel  from 
place  to  place.  Petsia,  China,  Hungary,  and  Turkey  are  never  free  from  typhus 
fever,  and  small  epidemics  occasionally  arise  from  these  sources.  Sometimes 
small  epidemics  or  sporadic  cases  arise  without  it  being  possible  to  find  any  soiu-ce 
of  infection,  probably  because  lice  are  carried  great  distances  in  clothing.  In  its 
classic  form  the  disease  is  exceedingly  rare  in  the  United  States,  but  the  possi- 
bility of  its  occurrence  must  always  be  borne  in  mind  by  quarantine  officers  and 
physicians  in  charge  of  large  hospitals  in  crowded  cities.  This  is  the  more 
important  because  typhus  fever  in  a  modified  form  seems  to  be  present  in  all 
large  cities  at  times.  Since  Brill  of  New  York,  in  1898,  reported  several  cases 
lacking  certain  characteristics  of  enteric  fever  and  which  he  proved  was  not  this 
disease.  Brill's  disease,  so-called,  has  been  proved  hy  Anderson  and  Goldberger 
to  be  true  modified  typhus.  Typhus  fever  varies  greatly  in  virulence  in  different 
localities  and  in  different  epidemics.  The  so-called  Manchurian  Typhus  of  Asia 
is  as  mild  in  many  cases  as  Brill's  disease,  both  as  to  its  dissemination  and  its 
symptoms.  On  the  other  hand  Mexican  Typhus  (Tarbardillo)  is  exceedingly 
severe  and  lethal. 

Etiology. — As  already  stated,  typhus  fever  is  a  malady  which  depends  upon 
a  specific  cause  and  the  presence  of  unsanitary  conditions  for  its  development. 
The  specific  contagion,  whatever  it  may  be,  retains  its  virulence  for  long  periods 
of  time  in  garments  and  in  furniture.  Much  difference  in  its  infectiousness  also 
exists,  for  in  some  epidemics  nearly  everyone  exposed  is  taken  ill,  whereas  in  others 
but  few  are  affected.  The  specific  microorganism  has  never  been  isolated,  although 
several  investigators  have  claimed  its  discovery  and  Anderson  and  Goldberger 
have  transmitted  the  disease  to  monkeys  and  thereby  induced  immunity  to  Mexican 


56  DISEASI':.^  nVE  TO  A   SPRCIFir  IXFEC'TJOS 

typhus  fe\-er.  Nicolle  believes  it  belongs  with  the  filtral)le  viruses,  l)ut  Rickctts 
and  Anderson  in  tliis  eountry  do  not  agree  with  this  view.  The  disease  ean  be 
transferred  to  moni<eys  and  guinea-pigs. 

Exposure  for  a  eonsiderable  ])eriod  of  time  to  tlie  atnios])lierc  of  a  ro(]ni  wliic  h 
is  poorly  ventilated  and  winch  contains  typhus  patients  is  tiie  most  etl'ecti\e  way 
ot  contracting  tJie  disease,  whereas,  if  ventilation  is  good  and  the  e.xjjosed  person 
in  perfect  health  there  is  much  less  danger  of  infection.  When  a  large  muiiber  of 
cases  of  typhus  fe^•e^  are  grou])ed  together  in  a  ward,  the  infection  becomes  \-ery 
virulent  and  both  the  attendants  and  tlie  piiysicians  are  extremely  ])rone  to  contract 
the  disease. 

The  most  infectious  period  of  the  di.sease  is  in  tiie  early  stages  and  at  tiie  height 
of  the  fever,  although  Moore  asserts  that  it  is  most  contagious  during  convalescence. 
It  is  also  infectious  even  during  the  stage  of  incubation.  Mild  cases  are  i)robably 
as  capable  of  spreading  the  infection  as  severe  ones.  After  the  febrile  condition 
has  passed  away  there  is  reason  to  believe  that  the  jiatient  ceases  to  be  a  direct 
•source  of  infection,  and  if  an  attendant  who  conies  in  contact  with  him  for  the  first 
time  now  contracts  the  disease,  it  must  be  from  the  i)ois()n  which  has  found  lodg- 
ment in  the  clothing  of  the  patient  during  his  illness.  So  far  as  we  know,  the  most 
common  means  liy  wliich  infection  gains  access  to  the  body  is  by  the  organs  of 
respiration  and  perchance  by  the  skin.  Indeed,  some  clinicians  of  experience 
assert  that  actual  contact  between  the  body  of  the  patient  and  that  of  the  attendant 
is  necessary  for  infection  to  take  place,  but  this  is- not  generally  conceded.  Cer- 
tain it  is  that  a  very  brief  period  of  exposure  is  sufficient  for  the  transmission  of  the 
disease.  The  infectious  agent  or  agents  of  typhus  fe\'er  is  rarel\',  if  ever,  carried 
by  water  or  other  liquid  media.  Lowered  vitality  of  the  inclividual  naturally 
increases  his  susceptibility.  The  influence  of  age  and  sex  is  very  slight,  for  all  ages 
after  early  infancy  seem  equally  susceptible,  the  greater  predominance  of  the 
malady  between  twenty  and  forty  probably  being  due  to  increased  opportunities 
for  exposure. 

The  influence  of  climate  and  season  upon  the  spread  of  typhus  f'c\cr  is  only  an 
indirect  one,  in  that  the  poor  ventilation  of  the  houses  of  the  lower  classes  during 
the  winter  months  aids  in  the  dissemination  of  the  disease  among  the  occupants, 
whereas  in  summer  the  better  supply  of  fresh  air  and  the  greater  amount  of  out-door 
life  tends  to  diminish  the  danger  of  infection. 

Prevention. — There  is  no  disease  in  the  prevention  of  which  fresh  air  plays  so 
large  a  part  as  it  does  in  typhus  fever.  Indeed,  it  may  be  stated  that  if  a  healthy 
man  be  supplied  with  plenty  of  fre.sh  air  while  in  the  presence  of  the  sick  he  will 
have  a  fair  chance  of  escape,  whereas  if  the  air  of  the  room  be  impure,  infection 
is  almost  certain,  for,  as  already  stated,  typhus  fever  is  a  malady  of  darkness  and 
poor  ventilation.  Practical  experience  seems  to  indicate  that  the  various  disinfect- 
ants usually  employed  have  little  value  in  pre^■enting  its  spread  unless  they  are 
used  in  concentrated  form  upon  the  garments  which  have  been  infected.  By 
far  tlie  best  means  of  preventing  the  spread  of  typhus  fever  are  the  admission  of  a 
plentiful  sui)ply  of  fresh  air  and  sunshine,  the  application  of  steam  or  scalding 
water  to  all  woodwork  and  clothing,  or  the  use  of  dry  heat  if  steam  heat  cannot  be 
employed.  The  bed-clothing  and  mattresses  should  be  destroyed  by  fire.  The 
value  of  formaldehyde  gas  as  a  disinfectant  is  still  undetermin<'d  for  pre\enting 
the  si)read  of  this  disease. 

Pathology  and  Morbid  Anatomy. — Typhus  fever,  unlike  typhoid  fever,  has  no 
peculiar  UKirbid  anatomy,  and  it  is  therefore  impossible  from  autopsy  findings 
alone  to  determine  that  the  cause  of  death  has  been  typhus.  The  skin,  it  is  true, 
may  show  very  soon  after  death  numerous  petechiie,  and  early  decomposition 
constantly  occurs  after  death  from  this  disease.  The  body  is  usually  not  greatly 
emaciated  because  the  disease  lasts  so  short  a  time.     The  muscles,  which  are 


TYPHUS  FEVER  57 

somewhat  dry,  may  also  show,  when  examined  under  the  microscope,  signs  of 
granular  or  fatty  degeneration  just  as  they  do  in  tyi)hoid  fever.  Waxy  or  Zenker's 
degeneration  of  the  heart  and  skeletal  muscles  is  a  frequent  finfling. 

The  respiratory  passages  may  be  inflamed  or  congested.  Thus  there  may  be 
laryngeal  ulceration  as  in  typhoid  fever  and  a  considerable  degree  of  bronchitis. 
Often  hypostatic  congestion  of  the  lungs  is  present.  In  other  instances  a  true 
lobar  pneumonia  occurs.  Indeed,  Curschmann  says  it  occurred  in  15  per  cent, 
of  his  cases.  The  heart  muscle  is  friable  and  suffers  from  the  form  of  myocarditis 
seen  in  all  infectious  diseases,  and  the  blood  is  found  to  be  darker  and  more  liquid 
than  normal.  It  is  a  noteworthy  fact  that  the  intestines  show  no  lesions  whate\er 
either  in  Peyer's  patches  or  in  the  solitary  glands.  If  such  lesions  are  present  the 
disease  is  typhoid,  not  typhus,  fever.  The  liver  is  usually  swollen  and  is  found  to 
be  the  seat  of  cloudy  swelling,  while  the  spleen  is  also  enlarged  to  some  degree,  but 
very  soft.  It  may  contain  infarcts.  The  kidneys  are  also  the  seat  of  cloudy 
swelling. 

Symptoms. — The  symptoms  of  typhus  fever  are  quite  characteristic.  Unlike 
those  of  typhoid  fever,  the  iiivasion  is  usually  abrupt,  the  patient  suddenly  feeling 
ill  about  twelve  days  after  exposure,  and  being  seized  by  a  chill  or  series  of  chills, 
with  headache,  backache,  and  general  prostration.  The  fever  rises  rapidly,  reaching 
its  acme,  it  may  be  as  early  as  the  second  day,  but  as  a  rule  it  rises  steadily  during 
the  first  four  or  five  days,  and  during  this  period  of  rise  the  characteristic  morning 
remissions  of  typhoid  fever  do  not  occur  to  so  marked  a  degree.  By  the  fifth 
day  the  temperature  often  reaches  105°  or  even  107°,  but  when  the  infection  is 
not  severe  it  may  not  go  above  103°.  After  having  reached  its  highest  point  it 
remains  fairly  constant  with  a  slight  decrease  each  morning,  the  e\'ening  tempera- 
ture, however,  remaining  high  until  the  period  of  crisis,  at  about  the  fourteenth 
day.  In  cases  characterized  by  severe  infection  the  temperature  may  continue 
to  rise  until  it  reaches  as  high  as  109°,  when  death  usually  occurs.  To  those  cases 
in  which  the  temperature  reaches  this  very  high  point  within  the  first  few  days 
of  the  illness  the  term  Typhus  Siderans  is  usually  applied. 

The  pulse  is  full  and  rapid,  but  usually  not  so  feeble  as  in  the  early  stages  of 
typhoid  fever.  The  face  is  deeply  flushed,  the  conjunctiva  congested,  and  the 
expression  one  of  apathy,  although  in  some  cases  delirium  varying  from  mild 
wandering  to  actual  maniacal  violence  may  be  met  with.  Sometimes  the  delirium 
is  wild  (delirium  ferox),  sometimes  it  is  like  that  of  delirium  tremens,  and  sometimes 
it  is  low  and  muttering — the  typhomania  of  Galen.  If  the  toxemia  is  severe 
extreme  prostration  and  feebleness  may  ensue  by  the  tenth  day. 

In  from  three  to  five  days  the  eruption  appears  upon  the  abdomen  and  chest, 
and  soon  spreads  to  the  legs,  arms,  and  face.  It  possesses  two  peculiar  character- 
istics. In  the  first  place  it  is  papular,  as  in  typhoid  fever,  but  the  spots  are  rarely 
as  rosy  as  they  are  in  that  disease,  and  may  finally  become  as  dark  as  actual  petechise, 
which  indeed  they  really  are.  The  second  peculiarity  is  that  there  seems  to  be 
a  subcuticular  eruption  or  area  of  congestion,  or  mottling,  so  that  the  skin  is  marbled 
or  mottled.  Unlike  the  rash  of  typhoid  fever,  that  of  typhus  does  not  disappear 
on  pressure,  and  is  distinctly  manifest  after  death.  Even  if  the  case  is  mild  the 
petechial  character  of  the  rash  is  present.  In  some  instances  the  skin  is  said  to 
give  off  a  peculiar,  musty  or  mouse-like  odor.  In  children  the  rash  may  be  so 
profuse  as  to  resemble  an  attack  of  malignant  measles. 

As  the  disease  advances  to  the  second  week  the  evidences  of  toxemia  become 
more  marked.  The  active  delirium  which  perchance  was  present  at  first  is  replaced 
by  stupor  and  coma  vigil  with  subsultus  tendinum,  the  tongue  is  dry  and  heavily 
coated,  the  teeth  covered  with  sordes,  and  the  heart's  action  rapid  and  feeble. 
The  respirations  are  quickened  but  shallow,  and  diarrhea  may  be  marked.  This 
stage  is  called  the  "putrid,"  "malignant,"  or  "typhoid"  stage  of  the  malady.     It 


58  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

is  essentially  one  of  profound  toxemia,  and  the  patient  lies  in  a  state  of  deeji  prostra- 
tion, indift'erent  to  all  sounds  and  objects  in  the  immediate  vicinity,  munihliiif,^ 
a  few  disjointed  sentences,  his  tongue  being  so  coated  and  dry  that  it  is  almost 
impossible  for  him  to  move  it.  The  pupils  are  often  strongly  contracted  and  the 
tendons  twitch,  while  there  may  also  be  carphologia,  or  picking  at  the  bedclothes. 
Finally,  if  the  illness  becomes  more  severe,  the  patient  lies  with  ojjen  eyes,  gazing 
into  space,  with  dilated  pupils,  a  thready,  imperceptible  pulse,  and  a  cold,  clammy 
skin,  which  heralds  the  approach  of  death,  which  is  due  to  the  toxemia,  asthenia, 
and  hypostatic  pulmonary  congestion. 

If  tiie  patient  survives  the  early  stages  of  attack,  the  fever  usually  ends  by  the 
twelfth  or  fourteenth  day  and  the  temperature  undergoes  much  more  rapid  deferves- 
cence than  it  does  in  typhoid  fever.  Indeed,  it  is  generally  thought  that  the  fever 
ends  by  crisis;  so  that  the  patient  passes,  during  a  prolonged  sleep,  from  a  state 
of  severe  illness  with  a  clouded  mind  to  early  convalescence  with  a  clear  mind,  a 
critical  fall  of  temperature  taking  place.  This  remarkable  change  in  the  aspect 
of  the  case  has  been  alluded  to  by  some  authors  as  quite  pathognomonic  of  typhus 
fe\'er,  but  the  statement  that  the  fall  of  the  temperature  is  always  by  crisis  is  not 
universally  conceded  to  be  correct.  Thus,  Moore,  of  Dublin,  states  that  the  end 
is  by  crisis;  while  Cur.schmann  a.sserts  that  in  the  great  majority  of  cases  it  ends  by 
lysis,  although  he  admits  that  a  critical  fall  occasionally  takes  place,  covering  a 
period  of  from  two  to  three  days.  This  is  hardly  a  crisis  in  the  usual  acceptation 
of  the  term. 

Whatever  may  be  the  true  method  of  the  fall  of  temperature,  it  is  certainly  a 
fact  that  convalescence  is  rapidly  established;  so  that  the  patient  proceeds  to 
complete  recovery  more  rapidly  than  after  typhoid  fever,  health  being  completely 
restored,  it  may  be,  by  the  end  of  a  month. 

Relapse  in  typhus  fever  very  rarely  takes  place,  and  in  the  vast  majority  of 
cases  one  attack  produces  immunity  against  further  infection. 

The  complications  of  typhus  fever  are  tho.se  which  we  would  expect  to  meet 
with  in  the  presence  of  any  severe  infection.  Bronchopneumonia  or  lobar  pneu- 
monia may  occur.  In  very  poorly  nourished  individuals  noma  may  develop,  and 
symptoms  of  generalized  paralysis  develop  as  the  result  of  neuritis.  So,  too, 
septic  arthritis  and  infection  of  the  parotid  glands  may  occur. 

Diagnosis. — Several  characteristics  of  typhus  fever  have  already  been  emphasized. 
The  most  noteworthy  of  these  are:  the  sudden  accession  of  the  disease,  the  raj)id 
rise  of  temperature  without  morning  remission,  the  development  of  a  peculiar 
rash  between  the  third  and  fifth  day,  the  dusky  appearance  of  the  face,  the  musty 
odor  of  the  skin,  and  the  early  appearance  of  active  delirium  or  profound  apathy. 
All  the.se  symptoms  are  cjuite  different  from  those  met  with  ordinarily  in  typhoid 
fever,  but  it  is  not  to  be  forgotten  that  sometimes  typhoid  fever  begins  suddenly 
and  i)resents  manifestations  closely  resembling  those  of  typhus;  so  that  during 
the  presence  of  an  epidemic  of  typhus  or  typhoid  fever  cases  of  either  one  of  these 
diseases  may  readily  be  overlooked.  In  the  differentiation  the  early  develojiment 
of  the  rash  (third  to  fifth  day)  in  typhus  fever  is  of  great  practical  value,  and  the 
distribution  of  the  rash  is  still  more  helpful  in  aiding  a  decision;  for  the  rash  of 
typhus  fever,  if  profuse,  involves  the  extremities  as  well  as  the  trunk,  whereas 
that  of  typhoid  fever  is  chiefly  limited  to  the  body;  a  profuse  and  dusky  rose  rash 
on  the  hands  and  legs  is  therefore  distinctly  in  favor  of  typhus  fever.  Again, 
the  rash  of  typhus  fever  is  constant,  whereas  that  of  typhoid  fever  fades  and  recurs 
in  crops.  Sometimes  however,  the  rash  of  typhus  fever,  like  that  of  typhoid  fever, 
is  very  scant,  only  a  few  rose  spots  being  present.  Indeed,  the  disease  may  occur 
without  any  exanthema  being  manifest. 

As  the  illness  progresses  much  additional  differential  information  can  be  gained 
if  the  case  be  one  of  tj"phoid  fever  by  the  disco^■e^y  of  tiie  \\  idal  reaction,  the 


TYPHUS  FEVER 


59 


recovery  of  the  Bacillus  typhosus  in  tlie  blood  and  in  the  rose  spots.  Then,  too, 
typhoid  fever  does  not  end  so  abruptly  nor  so  early  as  does  typhus  fever.  Malig- 
nant measles  and  variola  may  in  their  earliest  stages  resemble  typhus,  but  their 
later  course  clearly  separates  them. 


Fig 

.  14 

3ETWEEN 
rHE  AGES 

OF 
0  AND  30 

BETWEEN 

THE  AGES  OF 

30  AND  40 

BETWEEN 
THE  AGES  OF 
40  AND  50 

BETWEEN 

THE  AGES  OF 

50  AND  60 

73        I 

1       ,l!l 

1  1 

1  ; 

'1 

.    1       : 

-/--    -'--r 

~i        1 

71 

-L    :: : 

TO 

O'J 

1       1   !   1   i 

«s 

"Till, 

1  1 

07 

1    h  1  ^ 

/ 

1     i 

Cfi 

1     ,  1  1 

'     i 

I'm 

4-  4U- 

'  1  1 

(il         ' 

t  lU 

. 

iSS 

'.          1   1   ; 

CI 

(jO 

i 

' 

1  . 

5!) 

ill' 

1  .     .1 

58 

MM 

. 

M      !      i 

57 

, 

')!■. 

' 

' 

.'.l 

1  ■  1 

:y:. 

;     ! 

b2       1 

!            '    M 

51          1 

1     MM 

j 

1  1 

■Ml     1  1  1 

50         1 

!     MM 

,  ■ 

Ml      ill 

■lt>        ; 

1     ■  ■  ■ 

■18 

,     .       __.    . 

'  1  1 

IT 

': 

1 

Jii 

1 

'  1 

1 

■1-j 

'  1 

-11            ; 

,     .  1  '  1 

'   ''        /     ' 

i;i      1 

1     ,  1  ;  1 

41 

1    /                   J 

1 

10 

3'J 

'      MM 

,    ; 

1 

! 

as       ! 

i     Mil 

T  r 

1  1 

i 

,   1 

a7       1 

1  '1 

1  1 

1 

30         ■ 

!     M  '  ' 

"i 

3J 

!     MM 

' 

31         ! 

^ 

'Si          i 

1 

",■1 

[    1  M  1" 

i     i  1 

;{i 

■       1 

:iu 

■2'.' 

III       I 

■zn 

/ 

1 '    1  i  { 

/ 

L'l; 

7 

:iO 

/ 

21 

yl 

i  1 

.  V 

^\ 

/ 

21 

20       ! 

i;i       1 

> 

18          1 

1 

\ 

. 

IT          1 

V 

10 

/ 

10          1 

s.,^ 

II    1 

It 

^^ 

^ 

i;; 

U. 

"^ 

vz 

i        '^ 

N^ 

11 

\     :/  M 

! 

1 

1 

^\ 

10         1 

1   v*:   M   ' 

1 

1 

■^ 

'J 

■       ;   .   1   ; 

1 

1 

i 

s 

^\l  1         1 

7         : 

■'1 

1 

M^     I 

0        i 

■       !   M   1 

i  ■■ 

■::| 

1    1    1    .    1    !    1    M 

M  <  1  M  M      1 

Showing  the  decreasing  morbidity  and  increasing  mortality  percentage  of  typhus  fever  n-ith  advancing 
years.  Solid  line  represents  morbidity  from  Murohison's  statistics.  Broken  line,  mortality  percentage 
from  the  statistics  of  Murchison,  Guttstadt,  and  CmBchmann. 


Relapsing  fever  is  separated  from  tj-phus  fever  by  the  clear  mental  condition 
of  the  patient  notwithstanding  his  high  temperature,  by  the  lack  of  petechise,  and 
the  absence,  as  a  rule,  of  severe  initial  symptoms. 

Prognosis. — The  prognosis  in  typhus  fever  varies  greatly  with  the  previous 
condition  of  the  patient,  and  also  to  some  degree  with  the  severity  of  the  epidemic. 


60  DISEASES  DUE  TO  A  SPECIFIC'  IXFECTIOX 

Usually  the  mortality  rate  varies  from  10  to  20  per  cent,  in  young  afhilts,  but  in 
children  it  is  often  much  less  than  this.  In  advanced  years  the  mortality  is  very 
high. 

Curschmann  has  stated  that  "old  age  makes  itself  felt  as  early  as  the  furtictli 
year  and  that  after  fifty  almost  50  ])er  cent,  die."  The  accompanying  chart. 
Fig.  14,  made  from  the  statistics  of  Murchison,  Guttstadt,  and  Curschmann  indi- 
cates the  influence  of  age  on  the  prognosis. 

Death  in  typhus  fever  rarely  occurs  before  the  second  week.  After  the  end  of 
the  .second  week  it  seldom  takes  place  except  as  the  result  of  some  untoward  com])li- 
cation. 

Treatment. — The  treatment  of  typhus  fever  is  in  many  respects  identical  with 
that  now  recognized  as  useful  in  typhoid  fever.  The  patient  .should  be  isolated, 
of  course,  anrl  provided  with  an  abundance  of  light  and  air.  As  already  stated, 
in  no  disease  are  these  aids  to  health  more  es.sential  for  recovery.  As  the  course 
of  the  malady  is  one  toward  profound  asthenia,  easily  assimilated  or  predige.sted 
foods  .should  be  given  as  freely  as  the  patient  can  utilize  them.  Milk  to  which  is 
added  a  little  pancreatin  and  sodium  bicarbonate,  barley-  and  rice-gruel  in  which 
is  placed  some  takadiastase,  and  copious  draughts  of  water  to  flu.sh  the  kidneys 
and  aid  in  the  elimination  of  poisons  are  to  be  administered.  The  fever  is  to  be 
treated  by  cool  or  cold  bathing  as  the  patient  lies  in  bed,  according  to  the  directions 
given  under  typhoid  fever,  and  cold  is  to  be  kept  applied  to  the  head  continuously. 
The  coal-tar  antipyretics  are  not  to  be  used  if  they  can  be  avoided.  When  signs 
of  cerebral  and  pulmonary  hypostatic  congestion  manifest  themselves  the  patient 
may  be  immersed  in  a  bath  of  about  90°,  and  cold  water  at  60°  poured  over  his 
head  and  shoulders  as  a  douche,  active  friction  of  the  body  and  limbs  being  performed 
by  the  nurse  for  several  minutes  before  the  sick  man  is  returned  to  his  bed.  Should 
the  circulation  fail,  alcohol  in  the  form  of  whiskey  or  brandy,  well  diluted  with 
water,  is  to  be  employed  for  the  purpose  of  equalizing  the  circulation  and  cjuieting 
the  nervous  system.  Camphor  in  1-grain  doses  is  useful  for  this  purpose.  If  the 
nervous  restlessness  of  the  patient  is  sufficient  to  endanger  life  by  the  resulting 
exhaustion,  a  hypodermic  injection  of  morphine  may  be  given  to  prorlucc  sleep  or 
nervous  quiet. 

The  bowels  should  be  kept  open  by  the  use  of  gentle  laxatives,  or  be  evacuated 
by  a  saline  purge  if  obstinately  confined.  The  activity  of  the  kidneys  must  also 
be  maintained  by  the  u.se  of  alkaline  diuretics  and  sweet  spirit  of  nitre  and  by  the 
free  administration  of  a  pure  drinking-water.  As  retention  of  urine  often  occurs, 
the  state  of  the  bladder  must  be  carefully  watched. 

VARIOLA. 

Definition. — Variola,  or  smallpox,  is  an  acute  infections  disease  aiTecting  the 
entire  body,  but  manifesting  itself  chiefly  by  the  (le\elo]jiuent  upon  the  skin, 
more  particularly  that  of  the  face  and  forearms,  of  an  exanthem  which  is  at  first 
macular,  then  paj)ular,  then  vesicular,  pustular,  and  finally  umbilicated. 

History. — Smallpox  is  one  of  the  ancient  diseases,  for  records  exist  which  show 
it  to  have  occurred  many  centuries  before  the  time  of  Christ.  The  first  authentic 
medical  record  of  the  malady  did  not  appear,  however,  before  the  tenth  century, 
when  Rhazes,  of  Bagdad,  wrote  his  Treatise  on  Smallpox  and  Mea.slrs.  It  is 
generally  considered  that  smallpox  did  not  gain  entrance  to  Europe  till  about 
.\.D.  710,  when  the  Arabs  conquered  the  Spaniards.  It  reached  Germany  about 
the  tenth  century,  at  which  time  it  also  appeared  in  England.  At  times  since  the 
tenth  century  it  has  swept  away  thousands  of  persons  in  a  single  epidemic,  and 
very  few  escaped  its  ravages.  Indeed,  a  large  part  of  the  population  of  London 
were  at  one  time  pock-marked.     It  was  first  introduced  into  Mexico  in   1520, 


VARIOLA  61 

destroying  3,500,000  persons,  and  into  Massachusetts  in  1633.  I'ntil  the  introduc- 
tion of  vaccination  it  was  one  of  the  most  death-dealing  maladies  known  to  man. 
(For  tlie  influence  of  vaccination  in  diminishing  smallpox  see  article  on  Vaccinia.) 

Distribution. — Smallpox  has  occurred  in  all  parts  of  the  civilized  world,  from  the 
Arctic  to  the  Tropics,  and  is  of  ecjual  virulence  in  very  cokl  and  in  very  warm 
climates.  The  disease  affects  persons  who  may  be  exposed  to  it  at  all  ages,  and  re- 
markably few  people  who  are  unvaccinated  are  able  to  resist  the  infection,  not  more 
than  from  1  to  5  per  cent.  The  negro  race  is  peculiarly  susceptible,  and  in  this  race 
the  rate  of  mortality  from  the  disease  is  usually  very  high.  Smallpox  affects  males 
more  frequently  than  females.  It  is  more  common  in  the  winter  and  spring  than 
in  the  summer,  perhaps  because  of  the  crowding  in  the  homes  of  the  poor  during 
the  cold  months. 

Etiology. — Variola  is  believed  by  some  to  be  due  to  a  parasite  named  by  Guar- 
nieri,  in  1892,  the  Cytorydcs  variolw,  and  carefully  studied  by  Wasielewski  in  1901. 
Its  evolution  has  become  more  fully  known  by  the  labors  of  Councilman,  ]\Iagrath, 
and  Brinckerhoff  in  1903,  and  Brinckerhoff  and  Tyzzer  in  1905,  the  latter  research 
being  an  extensive  investigation  of  experimental  variola  and  vaccine  in  Philippine 
monkeys.  These  in  every  respect  confirm  the  previous  findings  in  human  beings. 
Basing  his  views  upon  previously  accomplished  work,  but  especially  upon  the  study 
of  Councilman  and  his  students.  Calkins  has  attempted  to  formulate  the  different 
stages  in  the  life  history  of  the  parasite.  A  full  review  of  these  and  previous 
inquiries  into  the  nature  of  the  organism  of  variola  and  vaccinia  will  be  found  in 
the  Journal  of  Medical  Research,  February,  1904,  vol.  xi.  No.  1,  pp.  8-360  and 
January,  1906,  vol.  xiv,  No.  2,  pp.  209-359.  (For  the  process  of  the  development 
of  this  organism  see  Pathology  and  Morbid  Anatomy.)  Notwithstanding  these 
studies  many  authors  still  regard  the  cause  as  unknown. 

The  contagion  of  smallpox  is  spread  in  several  ways — viz.,  directly,  that  is, 
by  contact  with  the  patient's  body  and  his  clothing;  and  indirectly,  by  the  air. 
Stokes  has  recently  published  a  paper  indicating  that  the  infection  usually  enters 
the  body  through  the  lungs.  A  nurse  may  convey  the  disease  from  a  patient  to  a 
healthy  individual,  and  rats,  mice,  and  flies  may  do  likewise.  The  patient  ill  of 
smallpox  is  capable  of  infecting  a  healthy  person  from  the  initial  stage  of  the  disease 
to  the  moment  when,  recovery  having  occurred,  every  particle  of  pustule  or  desqua- 
mating skin  has  been  cast  off.  The  most  contagious  periods  are,  howcA-er,  those 
of  vesication,  pustulation,  and  exfoliation. 

The  fact  that  the  disease  is  spread  by  aerial  convection  is  never  to  be  forgotten, 
and  it  may  be  carried  in  this  way  from  a  few  feet  to  several  yards  (Fig.  15).  Much 
difference  of  opinion,  however,  exists  among  those  who  have  studied  the  question 
of  aerial  convection.  Power,  of  Fulham,  and  Barry,  of  Sheffield,  England,  found 
a  noticeable  influence  exercised  by  the  propinquity  of  a  smallpox  hospital,  but 
Savill,  from  investigations  carried  on  at  Warrington,  came  to  the  conclusion  that 
aerial  currents  influenced  the  spread  of  the  disease  but  little.  It  must  be  remem- 
bered, moreover,  that  before  we  accept  figures  as  to  aerial  convection  we  must 
be  sure  that  the  contagion  was  actually  carried  by  the  air  and  not  by  insects  or 
animals.  I  know  of  one  smallpox  hospital  from  which  flies,  mice,  rats,  and  cats 
passed  freely,  and  surrounding  which  smallpox  was  almost  constantly  present. 

Bodies  dead  of  smallpox  can  also  spread  the  disease  among  those  who  handle 
them. 

The  severity  of  the  infection  depends  not  so  much  upon  the  violence  of  the 
disease  in  the  giver  as  in  the  susceptibility  of  the  receiver  of  the  malady.  A  mild 
case  may  therefore  be  provocative  of  most  virulent  epidemic. 

Incubation. — The  period  of  incubation  of  smallpox  varies  from  five  to  twenty 
days,  but  as  a  rule  it  is  about  twelve  days.  Cases  occurring  in  less  than  five  days 
after  exposure  are  very  rare. 


62  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

Prevention. — Tlierc  is  one  measure  above  all  others  to  be  used  in  the  pre\'eiitioii 
of  smallpox,  and  that  is  vaceination,  which  by  its  beneficent  influence  has  changed 
smallpox  from  a  common  and  fearful  scourge  of  mankind  to  a  disease  so  rare  that 
many  jihysicians  practise  a  lifetime  without  seeing  a  case.  (See  Frequency  and 
Vaccinia  and  Vaccination.) 


0.(12  piT  esni. 
Diagram  sliowiiig  the  percentage  of  aerial  convection  of  smallijox.     (iMoore.) 

It  is  very  important  to  bear  in  mind  the  clinical  fact  that  vaccination  not  only 
protects  the  patient  who  may  be  sulisequently  exposed  to  smalli)ox,  Init  also  that 
it  protects  the  patient  who,  having  been  so  exposed,  is  subsequently  vaccinated. 
Even  if  the  vaceination  be  performed  so  long  after  the  exposure  that  smallpox 
nevertheless  develops,  the  severity  of  the  disease  will  be  modified,  the  degree  of 
modification  being  in  direct  ratio  to  the  lengtJi  of  time  between  vaccination  and  the 
appearance  of  the  variola. 

A  most  interesting  illustration  of  this  has  been  sent  me  most  kindly  by  Dr. 
Allan  Warner,  of  the  Borough  Isolation  Hospital,  Leicester,  England.  The  history 
of  the  eases  is  as  follows: 

A  boy,  aged  fourteen  years,  unvaccinated,  sickened  with  smallpox  on  April  14. 
He  was  removed  to  the  hospital  on  April  IS,  where  he  had  a  severe  confluent  attack. 
The  father  consented  to  his  wife  and  three  children  lieing  vaccinated,  stating  that 
personally  he  would  not  be  vaccinated,  but  would  be  a  "test,"  to  see  if  there  was 
anything  in  it.  Ten  days  later  his  daughter,  aged  three  years,  developed  smallpox 
eruption;  she  had  less  than  one  hundred  spots  and  never  appeared  ill.  No  other 
person  in  the  house  suffered  from  smallpox  except  the  father,  vaccinated  in  infancy, 
his  eruption  appearing  fourteen  days  after  the  son  had  been  removed  to  the  hospital. 
A  photograph  of  the  father  and  daughter,  taken  on  the  twelfth  day  of  the  father's 
eruption,  may  be  seen  in  Fig.  IG,  and  requires  no  conmieut. 


VARIOLA 


63 


In  cases  of  urgency  it  is  generally  held  that  humanized  virus  is  more  valuable 
than  calf  virus,  but  as  humanized  virus  is  often  difficult  to  obtain  it  is  better  to 
vaccinate  the  patient  in  different  places  with  glycerinated  vaccine  made  by  difl'erent 
manufacturers,  since  in  this  way  there  is  httle  doubt  but  that  one  will  surely  take. 


Father  and  child  suffering  from  smallpox.     The  child  was  vaccinated  in  the  incubation  period. 
(Allan  Warner's  cases.) 


The  second  preventi\^e  measiu-e  of  importance  is  the  absolute  isolation  of  the 
patient,  and  the  third  the  complete  disinfection  or  destruction  of  all  garments 
and  bedclothing  which  have  been  about  the  sick  person,  including  those  worn 
by  his  attendants.  Finally,  all  individuals  exposed  to  the  contagion  should  be 
quarantined  for  a  period  of  twenty-one  days,  in  order  that  the  physician  may  be 
sure  that  they  are  not  going  to  be  attacked  and  so  spread  the  infection. 


64  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

Frequency. — Smallpox  is  so  constantly  present  in  the  poorer  part  of  large  cities 
that  it  may  be  said  to  be  almost  endemic  in  all  of  them,  but  to  a  very  moderate 
degree.  Occasionally  when  a  considerable  number  of  unvaccinated  persons  have 
accumulated  in  a  city  or  country  district,  the  disease  bursts  out  in  a  small  epidemic, 
and  sometimes,  without  any  such  apparent  cause,  certain  districts  seem  to  be 
affected,  many  unvaccinated  persons  being  attacked.  During  the  winter  of  1901 
and  1902  smallpox  appeared  almost  all  over  the  United  States  in  .scattererl  localities. 
It  can,  however,  always  be  stamped  out  by  house-to-house  \'accination,  and  its 
spread  depends  upon  imperfect  quarantine  and  inefficient  vaccination. 

As  an  illustration  of  the  extraordinary  effect  of  vaccination  and  sanitation  upon 
this  malady  it  is  interesting  to  note  that  during  the  eighteenth  century  fully  two- 
thirds  of  all  children  born  in  Europe  were  sooner  or  later  attacked  by  smallpox, 
and  an  average  of  one-twelfth  died  of  the  disease.  On  the  other  hand,  the  death 
rate  from  smallpox  in  the  latter  part  of  the  nineteenth  century  in  London  was 
98.5  per  cent,  less  than  one  hundred  years  before.  To  put  it  differently,  the  death 
rate  from  smallpox  in  18.38  was  1064  per  million,  while  in  1889  it  was  1  per  million, 
and  in  1890  nil  per  million. 

During  1904  the  disease  was  totally  eradicated  from  New  York  and  Pliiladei[)liia 
by  \'acci nation  and  quarantine. 

Pathology  and  Morbid  Anatomy. — The  most  noteworthy  lesion  produced  by  small- 
pox takes  place  in  the  skin.  The  dermal  paillie  become  hypcremic,  the  cells  of 
the  rete  Malpighii  swell  and  so  raise  the  epiderm,  and  under  this  epiderm  serum 
exudes  and  pushes  the  stratum  still  farther  upward.  The  cells  of  the  rete  are  more 
or  less  elongated,  pigmented,  and  form  fibrils  extending  from  the  epiderm  to  the 
base  of  the  inflamed  zone  in  the  derma,  constituting  the  vacuolar  focal  degeneration 
described  by  Councilman,  Magrath,  and  Brinckerhoff'.  Into  this  reticulum  still 
further  serous  exudation  occurs,  and  so  forms  a  vesicle  which  increases  at  its  margin, 
where  the  exudation  takes  place  very  rapidly,  while  degenerative  and  necrotic 
changes  progress  in  the  epithelium  of  the  area,  involved.  As  a  result  the  area 
under  and  around  the  vesicle  becomes  indurated  and  we  have  the  characteristic 
hard  pock  of  variola.  The  persistence  of  this  free  exudation  at  the  margin  of  the 
pock  and  the  greater  densit\'  of  the  centre  lead  to  depression  of  the  latter,  giving 
rise  to  innbilication.  Wright  has  shown  that  the  central  depression  in  the  pock 
may  be  due  to  diptheroid  degeneration.  It  may  also  be  due  to  retraction  by  a 
hair  or  small  gland.  Councilman,  Magrath,  and  Brinckerhoff'  do  not  believe  that 
the  pock  is  always  produced  by  the  same  cause,  but  that  a  number  of  factors  enter 
into  its  formation. 

Following  this  stage,  the  serum  in  the  pock  is  infiltrated  with  leukocytes,  and 
these  becoming  great  in  number,  the  contents  of  the  pock  become  opaque  or 
turbid,  and  finally  resemble  pus.  Sometimes  if  the  inflammation  in  the  adjoining 
pocks  is  very  se\ere  the  deeper  layers  of  the  skin  become  involved,  undergo  necrosis, 
and  so  great  local  destruction  of  tissue  takes  jilace.  After  this  stage  epithelial 
regeneration  progresses  beneath  the  scab,  which  dries  up  and  ultimately  falls  off, 
leaving  a  reil  or  pink  depression  in  the  skin,  which  (le])ends  for  its  dejith  upon  tiie 
degree  of  pustulation  or  necrosis  present  during  the  acute  stage.  Not  only  do 
vesicles  form  on  the  skin,  but  upon  the  mucous  membrane  of  the  mouth,  pharynx, 
tongue,  and  even  tiie  rectum,  anus,  vagina,  penis,  and  conjunctiva  in  some  cases. 

Myocardial  degeneration  is  present  in  most  cases,  and  a  variolous  myocarditis 
has  been  flescribed. 

In  general  the  cardiovascular  ciiangcs  of  smalliJox  resemble  similar  alterations 
occurring  in  other  infectious  diseases. 

Proliferative  changes  occur  in  the  hematoi)oictic  organs  (spleen,  lymph  nodes,  and 
marrow),  associated  with  the  production  of  basophilic  monoinielear  cells  which 
enter  the  circulation  and  also  phagocytic  endothelial  elements.     The  basophilic 


VARIOLA  (io 

mononuclear  cells  infiltrate  the  testicle  and  usnall.>-  the  kidney,  liver,  and  adrenals. 
Cloudy  swelling  occurs  in  the  glandular  viscera  and  a  diffuse  toxic  degeneration 
takes  place  in  the  liver,  kidneys,  adrenals,  and  testicles. 

The  kidneys  are  more  or  less  altered  in  all  cases;  in  milder  degrees  this  may 
amount  to  little  more  than  intense  cloudy  changes,  hut  in  other  cases  acute  diffuse, 
glomerular,  or,  less  commonly,  suppurative  nephritis  occurs. 

Many  of  the  lesions  produced  in  the  internal  organs  in  smallpox  are  the  result 
of  a  secondary  infection  from  the  skin  and  respiratory  tract,  and  this  usually' 
depends  upon  the  presence  of  the  Streptoroccvs  pyogenes. 

When  hemorrhagic  smallpox  takes  place  we  have  transudations  of  blood  into 
the  pocks  and  into  the  conjunctiva,  the  retina,  the  muscles,  the  subpleural  tissues, 
into  all  the  abdominal  organs,  and  into  the  kidneys  and  the  perirenal  fat.  Submu- 
cous extravasations  also  take  place  in  all  the  organs  of  the  body  lined  with  mucous 
mem]:)rane.     Such  cases  are  nearly  always  fatal. 

Symptoms. — After  an  incubation  period  of  about  twelve  days  the  symptoms 
develop.  As  in  many  acute  infections,  headache  and  backache  are  the  predominant 
initial  symptoms  of  smallpox,  but  they  are  peculiar  in  their  severity  in  this  disease, 
so  that  their  very  intensity  possesses  diagnostic  significance.  Sometimes  the  pain 
in  the  back  extends  down  the  posterior  portions  of  the  legs.  Rigors  also  occur 
and  pain  in  the  epigastrium  and  vomiting  may  come  on.  Sometimes  drowsiness 
and  sleep  with  muscular  twitching  develops  as  a  prominent  initial  sign  in  children. 
The  urine  is  often  scanty,  loaded  with  urates,  and  usually  contains  some  albumin. 
The  temperature  in  smallpox  is  usually  high  from  the  onset,  so  that  it  may  reach 
104°  as  early  as  the  latter  part  of  the  first  day,  and  105°  or  106°  by  the  end  of  the 
first  forty-eight  hours.  It  maintains  this  high  degree  with  \ery  slight  remission 
until  the  eruption  is  developed.  The  jJuIse  w  rapicl,  often  as  high  as  120  per  minute, 
in  adults,  and  unless  profound  depression  is  very  early  manifested  it  is  fairly  strong. 
The  abdominal  organs  present  no  signs  of  any  importance,  but  constipation  is 
more  frequently  present  than  is  diarrhea. 

The  true  variolous  eruption  makes  its  appearance,  in  the  majority  of  cases,  on 
the  third  day,  although  many  writers  state  that  it  appears  most  commonly  on  the 
fourth  day,  while  others  insist  that  it  appears  on  the  second.  The  facts  are  that 
the  time  of  the  appearance  of  the  rash  varies  materially  in  different  cases,  for  it  is 
delayed  in  mild  attacks  and  develops  early  in  severe  ones.  Sydenliam  said  of  the 
confluent  form  of  this  disease:  "This  kind  usually  comes  out  on  the  third  day, 
sometimes  earlier,  but  scarcely  ever  later;  whereas  the  distinct  (discrete)  form 
appears  on  the  fourth  day  or  later,  but  rarely  before."  Boerhaave  said:  "The 
slower  the  small  pocks  come  out,  the  milder  they  prove  and  the  better  they  ripen. 
Those  appearing  on  the  first  day  of  the  illness  are  esteemed  the  worst  kind;  those 
on  the  second,  milder;  those  on  the  third,  still  more  gentle,  and  on  the  fourth  the 
more  favorable."  Very  rarely  indeed  the  rash  may  be  delayed  till  the  fifth  day, 
but  this  is  an  unfavorable  sign. 

It  must  be  borne  in  mind  that  the  first  signs  of  the  eruption  may  be  very  scanty. 
But  one  or  two  papules  may  be  present  on  the  face,  or  hand,  or  forearm.  In  other 
iastances  the  papules  are  very  numerous  on  the  face,  the  extensor  surfaces  of  the 
forearms,  and  then  on  the  trunk,  these  being  the  parts  which  are  particularly 
prone  to  present  the  first  sign  of  the  eruption.  In  still  other  cases  the  entire  surface 
of  the  body  is  speedily  covered  and  the  mucous  membrane  of  the  mouth,  pharynx, 
and  vulva  also  are  involved.  The  portion  of  the  skin  least  affected  in  most  cases 
is  that  of  the  anterior  part  of  the  thorax,  the  abdomen,  and  the  flexor  surfaces  of 
the  extremities. 

The  eruption  of  smallpox  proceeds  through  the  following  five  stages  of  develop- 
ment with  considerable  rapidity :  For  the  first  few  hours  minute  bright-red  macules 
are  present,  which  disappear  on  pressure.  They  soon  become  hard  and  ele^'ated — 
5 


66 


DISEASES  DUE  TO  A  SPECIFIC  IXFECTION 


that  is,  the  macules  become  i)a|)ules.  By  the  end  of  the  first  twenty-four  hours 
of  the  eruption  the  papule  begins  to  show  at  its  apex  a  tiny  vesicle,  which  rapidly 
develops  so  that  by  the  fourth  or  fifth  day  of  the  rash  the  vesicular  stage  has  reached 
its  full  development.  This  vesicle  is,  as  a  rule,  less  than  a  sixth  of  an  inch  in  diam- 
eter, contains  fairly  pearly-looking  fluid  (lactescent),  and  is  surrounded  by  a  narrow 
areola  of  red.  A  peculiarity  of  the  vesicle  of  smallpox  is  that  though  some  serum 
may  escape  when  it  is  pinched,  it  never  empties  itself  or  collapses,  because  of  the 
fibrilla  which  are  present  in  the  cavity  of  the  vesicle,  as  already  described.  ^Yith 
the  advent  of  the  fifth  or  sixth  day  the  centre  of  the  vesicle  is  seen  to  be  slightly 
depressed,  showing  the  beginning  of  the  stage  of  iimbilication. 


Well-developed  variola. 


The  fluid  in  the  vesicle  now  rapidly  becomes  cloudy  and  purulent,  the  surface 
of  the  pock  gradually  loses  its  umbilication,  and  by  the  seventh  or  eighth  day  of 
the  eruption  exists  as  a  pustule,  which  by  the  tenth  day  is  dome-like  and 
surrounded  by  an  areola.  This  pustule,  when  it  is  punctured  and  pressed 
upon,  discharges  pus  and  cloudy  scrum.  If  the  pustule  is  not  meddled  with  it 
ruptures  in  about  twenty-four  to  forty-eight  hours  and  the  pus  escapes,  dries,  and 
forms  a  dirty-looking  .scab,  so  that  by  the  eleventh  day  of  the  eruption  the  primary 
macule  has  advanced  through  its  stages  of  maturation  to  the  ruptured  pu.stule. 
These  scabs  produce  a  disgusting  odor.  Sometimes  the  pustule  does  not  rupture, 
but  simpl\-  dries  uji;  when  the  scab  falls  off  it  leaves  under  its  former  site  a  red  or 
pink  depression  in  the  skin,  the  future  pockmark.    This  st^ge  of  desiccation  or 


VARIOLA  07 

drying,  followed  by  exfoliation,  may  last  in  severe  cases  for  several  weeks,  and  it  is 
followed  by  a  period  of  desquamation  of  fine  scales  of  epidermis,  during  which 
time  the  reddened  pockmark  gradually  heals  and  cicatrizes.  This  desquamation 
rarely  takes  place  earlier  than  the  sixteenth  and  often  about  the  eighteenth  day. 

The  eruption  on  the  mucous  membranes  runs  a  much  more  rapid  course  than 
that  on  the  skin,  so  that  as  early  as  the  fifth  day  the  pu.stule  ruptures,  leaving 
an  ulcerated  surface,  which,  if  the  eruption  on  the  mucous  membrane  of  the  mouth 
has  been  confluent,  may  resemble  the  ragged,  dirtj'-looking  exudate  of  diphtheria. 

There  are  two  additional  facts  of  importance  in  connection  with  the  eruption 
not  yet  named — viz.,  a  peculiarity  of  the  papule  of  smallpox  is  that  when  the  finger 
is  drawn  over  it,  it  feels  indurated  as  if  a  shot  were  under  or  in  the  skin.  The  second 
point  is,  that  the  rash  does  not  all  appear  at  once,  but  different  parts  of  the  body 
are  affected  one  after  the  other,  so  that  one  part  may  present  vesicles  while  another 
is  beginning  to  show  pustules. 

Another  point  of  interest  from  a  diagnostic  stand-point  is  the  characteristic 
course  of  the  fever.  Primarily  high  until  the  eruption  begins,  it  speedily  falls  to 
99°  in  moderate  cases,  or  to  100°  in  confluent  ones,  and  remains  low  until  pustulation 
begins,  when  the  so-called  secondary  fever  develops,  which  rises  to  102°  or  even  104°. 
This  fever,  unlike  the  primary  fever,  has  morning  remissions  of  1°  to  2°,  and  grad- 
ually ends  by  lysis,  so  that  about  the  twelfth  day,  which  is  the  period  at  which 
the  pustules  rupture  or  become  dry,  the  temperature  reaches  normal. 

As  would  be  expected  from  the  severity  of  the  eruption,  the  skin  during  the  active 
stage  of  the  disease  is  deeply  inflamed  and  so  greatly  swollen  that  the  features  of 
the  patient  may  be  unrecognizable.     (See  Fig.  17.) 

In  many  cases  the  mind  is  clear  throughout  the  illness,  but  in  others  it  is  clouded, 
and  active  delirium,  which  may  be  violent,  is  met  with  in  se^-ere  cases. 

In  the  earliest  stages  of  variola  initial  raphes  may  precede  the  true  eruption 
and  mislead  the  physician  if  he  be  not  on  his  guard.  In  some  instances  an  erythema, 
like  that  of  early  scarlet  fever,  is  present,  and  in  still  others  a  rash  appears  which 
strongly  resembles  the  early  stages  of  the  eruption  of  measles.  These  rashes 
may  last  from  a  few  hours  to  a  few  days,  and  usually  appear  on  the  trunk  and  limbs 
and  but  slightly  on  the  face.  The  scarlatiniform  rash  is  to  be  separated  from  that 
of  scarlet  fever  by  the  fact  that  it  is  not  so  punctate,  nor  so  bright  in  hue,  and  is 
not  associated  with  the  presence  of  the  sore  throat  of  that  disease.  The  rash 
which  resembles  measles  is  scarcely  raised  at  all,  as  is  the  real  rash  of  that  disease; 
it  develops  much  more  rapidly,  covering  the  entire  body  in  a  few  hours,  and  dis- 
appears with  a  speed  equal  to  that  of  its  onset,  rarely  lasting  over  thirty-six  hours. 

In  some  cases  both  the  scarlatiniform  and  morbilliform  rashes  appear  in  very 
small  patches  on  the  wrists  or  about  other  joints.  These  initial  rashes  possess  a 
considerable  degree  of  prognostic  importance,  since  they  usually  appear  in  mild 
cases. 

Still  another  initial  skin  lesion,  of  some  importance  because  of  its  prognostic 
features,  is  an  intensely  red  rash,  which  appears  on  the  second  day  of  the  illness  and 
spreads  over  the  body  so  that  the  surface  may  after  a  few  hours  look  as  if  it  were 
affected  by  a  generalized  erysipelas  in  its  early  stages.  Such  a  rash  is  said  to  indi- 
cate the  future  development  of  the  hemorrhagic  or  malignant  type  of  the  disease. 

Petechial  rashes  also  occur  as  initial  or  preliminary  lesions.  They  usually 
involve  the  suprapubic  or  inguinal  regions,  but  sometimes  thej^  appear  in  the 
infraclavicular  areas.  The  individual  petechise  may  be  bright  red,  or  dull  red, 
or  purple  in  appearance.  In  still  other  cases  an  eruption  which  closely  resembles 
that  of  true  purpura  develops.  In  very  malignant  cases  death  may  occur  before 
any  typical  eruption  of  smallpox  appears. 

Something  more  must  be  said  in  regard  to  the  variations  which  occur  in  the 
eruption  of  smallpox.     In  the  first  place,  it  is  possible  for  smallpox  to  occur  without 


68 


i)/si<:.\siis  DC]':  to  a  spkcific  isfectiox 


('riii)ti()n,  altli()uj:;li,  of  course,  sucli  instaiifcs  arc  exceedingly  rare.  In  all  proljahility, 
careful  examination  of  such  patients  will  reveal  one  or  two  papules  whicli  otherwise 
niii^ht  he  o\erlookefl.  Inileed,  this  type  of  smallpox  may  he  considered  as  belonging 
to  so-called  varioloid,  and  to  occur  in  those  patients  who  liaxc  been  imperfectly 
l)r<)tected  by  early  \accination. 

^  ery  rarely  in  the  pustular  stage,  the  epiderm  at  the  base  of  a  pustule  may  be 
displaced  by  the  formation  of  a  bulla,  or  blel),  which  contains  a  clear,  straw-colored 
serum,  and  which  holds  in  its  centre  the  pustule. 

Councilman,  ^NTagrath,  and  Brinckerhofi'  describe  secondar\-  vesicles  usually 
formed  on  the  surface  of  the  primary  vesicle,  but  occasionally  seen  in  the  base. 


hIt^^ 

/  -^ 

^' 

^^ 

> 

riola  in  a  child  with  scant  eniption.      (Schainbirr.) 


Conjluent  sniaUixj.v,  as  its  name  implies,  may  be  localized  or  general;  that  is 
to  say,  the  confluence  of  the  various  pocks  may  occur  only  in  certain  i)ortions  of 
the  body,  while  in  other  instances  all  portions  of  the  body  may  be  covered  l)y  a 
coalescence  of  the  eruption.  In  these  cases  there  is  always  an  extensixe  dermatitis. 
There  is  usually  great  restlessness,  delirium,  marked  circulatory  disturbance,  and 
death  very  frecjuently  occurs  from  the  ninth  to  the  ele\enth  day.  It  is  in  this 
type  of  case,  too,  that  the  greatest  degree  of  the  edema  of  the  subcutaneous  tissues 
appears,  and  the  temperature  usually  maintains  a  high  degree.  .Sometimes,  how- 
ever, in  confluent  smallpox,  the  vesicles  do  not  seem  to  reach  as  great  a  degree  of 
fulness  as  in  ordinary  cases,  and  there  is  not  the  same  degree  of  swelling  of  the 
subcutaneous  tissues,  although  the  skin  is  apt  to  be  harsh  and  thickened.  This  form 
of  confluent  smallpox  is  considered  by  experts  to  be  more  frequently  followed  by 
death  than  that  form  in  which  the  eruption  seems  to  be  more  completely  matured. 

1  nder  the  name  of  hemorrJuKjic  or  black  smallpox,  which  is  by  no  means  rare, 
and  which  takes  place  both  in  sjjoradic  and  epidemic  cases,  a  form  of  the  disease 
occurs  in  which  the  initial  symjitoms  are  always  very  severe,  and  in  which  hemor- 
rhages into  the  skin  occur  early.  Not  only  do  the  spots  become  puri)uric  by  extrava- 
sations of  blood  into  the  skin,  ])articularly  about  the  joints,  but  the  hemorrhages 
also  occur  on  the  eyelids  under  the  conjuncti\a,  and  even  on  the  tongue,  the  palate, 
the  fauces,  and  the  \agina.     Bleetling  also  frequently  takes  place  from  the  gums. 


VARIOLA  G9 

and  nosebleed,  bloody  vomit,  and  bloody  stools  may  occur.  Sometimes  hematuria 
also  develops.  In  these  patients  the  temperature  usually  does  not  rise  above 
100°,  and  the  mind  remains  clear  and  unclouded,  but  they  are  distinctly  typjhoid 
in  type,  and  death  often  occurs,  sometimes  as  early  as  the  third  day,  but  more 
commonly  between  the  third  and  sixth  day,  as  the  result  of  the  profovmd  toxemia 
and  associated  cardiac  failure. 

Under  the  name  variola  jmstvhsa  hemorrhagica,  a  form  of  the  disease  is  dcscriljcd 
in  which  the  eruption  does  not  become  hemorrhagic  until  the  stage  of  pustulation 
is  reached.     This  type  is  not  so  severe  as  that  just  described. 

Under  the  name  of  variola  juhninans,  an  exceedingly  fatal  form,  with  a  high 
temperature  of  105°,  delirium,  coma,  and  collapse  occur.  In  these  cases  death 
comes  on  within  a  few  hours  after  the  onset  of  the  disease,  and,  while  no  hemorrhages 
are  manifest  in  the  skin,  since  the  eruption  is  as  yet  scarcely  developed,  internal 
hemorrhages  are,  nevertheless,  found  at  autopsy.  It  is  much  more  apt  to  occur 
in  unvaccinated  than  in  vaccinated  persons. 

Smallpox  almost  never  occurs  a  second  time  in  the  same  individual.  In  nearly 
every  instance  where  a  second  attack  is  stated  to  occur,  there  has  been  an  error 
in  diagnosis,  either  at  the  time  of  the  first  or  second  illness. 

Varioloid. — While  the  symptoms  detailed  up  to  this  point  maj'  be  considered 
as  those  of  ordinary  smallpox  which  runs  a  natural  course,  it  is  not  to  be  forgotten 
that  a  modified  form  of  the  disease  quite  frequently  occurs,  in  which  by  reason  of 
vaccination  many  years  before,  or  natural  immunity,  or  lack  of  virulence  the  mani- 
festations of  the  affection  are  quite  markedly  modified.  To  this  type  of  the  disease 
the  term  varioloid  is  applied. 

The  whole  of  the  eruption  may  appear  within  half  a  day  after  the  first  papule 
is  developed.  The  vesicles  which  in  an  ordinary  case  reach  their  maturity  by  the 
fourth  or  fifth  day,  in  these  cases  become  fully  developed  in  seventy-two  hours, 
and  they  are  often  very  small.  Instead  of  the  fluid  in  the  pock  becoming  cloudy 
on  the  fifth  day,  this  change  develops  as  early  as  the  third  or  fourth  day,  and  many 
of  the  vesicles  never  become  pustules,  but  dry  up.  Those  that  do  develop  into 
pustules  reach  this  condition  by  the  fifth  or  sixth  day,  instead  of  as  late  as  the 
seventh  or  eighth  in  the  unmodified  form  of  the  disease.  It  is  evident,  therefore, 
that,  as  most  persons  in  all  civilized  coimtries  have  been  vaccinated,  physicians 
will  often  meet  with  a  modified  type  of  smallpox  rather  than  the  severe  form. 

The  temperature  in  these  cases  runs  a  very  mild  course,  often  remaining  at 
the  normal  point  as  soon  as  the  rash  develops,  and  never  partaking  of  a  secondary 
rise.  Indeed,  the  entire  symptom-complex  of  the  illness  may  be  of  the  mildest 
possible  type  as  to  objective  symptoms,  suffering,  or  discomfort.  The  appetite 
is  good,  the  patient  sleeps  well,  no  complications  develop,  and  convalescence  is 
rapid. 

The  important  fact  to  be  remembered  concerning  these  mild  or  modified  cases 
is  that  they  are  quite  as  competent  to  spread  the  disease  as  are  the  more  severe 
types  of  variola,  and  they  require  as  strict  quarantine  as  severe  cases  of  the  dis- 
ease. There  is  therefore  every  reason  why  a  case  of  varioloid  should  be  quaran- 
tined most  strictly.  Chapin  points  out  that  in  1896  such  a  mild  type  prevailed  in 
the  Southern  United  States,  and  rarely  caused  death,  but  gradually  spread  over  a 
very  wide  area.  Unrecognized  it  developed  a  host  of  ludicrous  names  such  as: 
"Cuban  itch,"  "elephant  itch,"  "Spanish  measles,"  "Japanese  measles," 
"bumps,"  "impetigo,"  "Porto  Rico  scratches,"  "Manilla  scab,"  "Porto  Rico 
itch,"  "army  itch,"  "African  itch,"  "cedar  itch,"  "Manila  itch,"  "Bean  itch," 
"Dhobie  itch,"  "Filipino  itch,"  "nigger  itch,"  "Kangaroo  itch,"  "Hungarian 
itch,"  "Italian  itch,"  "bold  hives,"  "eruptive  itch,"  "bean-pox,"  "water-pox,"  and 
"swine-pox." 

P^ven  in  some  cases  of  modified  smallpox,  coalescence  or  confluence  takes  place 


70  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

with  associated  edema.  In  these  instances  the  confluence  is  not  to  be  regarded 
as  a  very  grave  omen,  since  the  pocks  mature  early,  frequently  do  not  rupture, 
and  convalescence  may  begin  as  early  as  the  eightli  or  ninth  day  of  the  illness. 

Variola  sine  eniptione  is  a  well-recognized  mild  form  of  the  disease  occurring 
usually  in  hosj)ital  attendants,  about  twelve  days  after  exposure  to  a  case  of  variola. 
There  is  general  wretchedness,  headache,  backache,  fever,  and  nausea.  Often  the 
patient  is  not  ill  enough  to  stop  work.  These  symptoms  last  only  two  or  three  daj's. 
The  initial  rashes  may  appear  but  the  pocks  do  not.  This  condition  may  be  con- 
sidered as  a  modified  form  of  mild  smallpox  or  variola,  but  in  the  latter  pocks 
appear  and  the  disease  differs  from  true  variola  only  in  its  severity,  ^'ariola  sine 
eruptione  is  infectious  but  does  not  cause  smallpox  as  does  varioloid  in  the  un- 
vaccinated.  Ashburn,  Vedder,  and  Gentry  believe  it  is  due  to  the  fact  tiiat  vac- 
cination with  cow-pox  protects  the  individual  from  the  eruptive  pustular  stage  or 
form  of  variola  but  not  from  the  whole  infectious  agent.     (See  Vaccinia). 

Complications  and  Sequelae. — When  the  severity  of  variola  as  an  infectious  disease 
is  considered,  it  is  remarkable  that  it  has  so  few  severe  complications,  and,  aside 
from  the  state  of  the  skin,  so  few  serious  sequelte.  In  some  instances  where  the 
infection  of  the  skin  seems  to  be  very  severe,  multiple  abscesses  may  develop,  varying 
in  size  from  a  small  bean  to  a  large  .slough.  They  usually  do  not  appear  until  after 
the  eruption  has  passed  on  to  the  stage  of  desiccation,  but  they  may  persist  for  a 
long  period  of  time  and  so  prolong  the  illness.  Moore  speaks  of  a  case  in  which 
a  patient  who  suffered  from  this  condition  could  not  be  discharged  from  the  hospital 
until  after  a  period  of  nine  months  and  nine  days,  because  he  had  forty-two  large 
abscesses  following  confluent  smallpox.  The  most  common  seat  for  these  abscesses 
is  upon  the  extremities  and  about  the  buttocks  and  shoulders,  and  occasionally 
on  the  scalp.  Much  more  rarely  abscesses  which  are  more  deeply  situated  form, 
as,  for  example,  ischiorectal  abscess.  Such  abscesses  may  produce  marked  systemic 
symptoms,  but  ordinarily  evidences  of  septicemia  are  not  severe. 

Occasionally  erysipelas  occurs  as  a  late  complication  of  the  disease,  either  upon 
the  face  and  scalp  or  on  the  scrotum.  Under  these  circumstances  it  is  a  most 
serious  malady,  and  frequently  destroys  the  patient,  since  he  has  not  the  vital 
resistance  to  withstand  the  new  infection. 

Bed-sores  are  rare  if  proper  nursing  has  been  carried  out,  but  boils  may  occasion- 
ally occur,  and  are  caused  most  frequently  bj-  the  Staphyloeoccus  pyogenes  aitreiis. 

Gangrene  of  the  skin  complicating  smallpox  is  almost  unknown.  But  when  it 
occurs  it  usually  affects  the  scrotum.  The  eyelids  sometimes  become  the  seat  of 
abscesses,  or  more  rarely  slough,  as  the  result  of  the  swelling  and  edema,  but  actual 
disease  of  the  eyeball  complicating  smallpox  is  not  common.  The  ears,  on  the 
other  hand,  are  not  rarely  affected,  and  deafness  occurs  in  a  certain  proportion  of 
cases.  When  earache  is  complained  of,  the  possibility  of  an  extension  of  the 
suppurative  process  to  the  ma.stoid  should  be  borne  in  mind,  as  this  sometimes 
occurs  with  serious  results. 

So  far  as  the  respiratory  organs  are  concerned,  it  is  important  to  note  that  small- 
pox sometimes  produces  laryngitis,  \-arying  in  severity  from  a  catarrhal  to  an 
ulcerative  type.  As  in  typhoid  fever,  the  development  of  aphonia,  due  to  ulcerative 
laryngitis,  is  an  exceedingly  serious  complication,  since  the  cartilages  of  the  larynx 
may  become  eroded.  Bronchitis  and  bronchopneumonia  may  develop,  and  occasion- 
ally pleurisy  results  from  an  extension  of  the  infection  from  the  lung  or  by  direct 
involvement  of  the  pleura  by  pyogenic  organisms. 

The  circulatory  system  does  not  suffer  with  anything  like  the  degree  of  severity 
which  we  would  expect. 

Pericarditis  and  endocarditis  are  exceedingly  rare  complications. 

Myocarditis,  on  the  other  hand,  is  more  frequently  met  with  as  a  result  of  the 
infection,  as  it  is,  indeed,  in  all  of  the  acute  infectious  diseases. 


VARIOLA  71 

The  kidneys,  aside  from  the  ordinary  albuminuria  of  ail  acute  infectious  maladies, 
usually  escape,  as  does  also  the  nervous  system.  That  there  is  irritation  of  the 
kidneys  is  evident  from  the  fact  that  Arnaud,  in  1S98,  found  alt)uniinuria  in  95 
per  cent,  of  his  cases. 

Septic  arthritis  occasionally  occurs. 

The  occurrence  of  smallpox  in  a  pregnant  woman  very  frequently  results  in 
abortion,-  but  if  the  mother  goes  to  term,  the  child  is  to  some  extent  protected 
from  smallpox,  although  cases  are  on  record  in  which  children  have  ai)parently 
had  smallpox  in  utero,  and,  extraordinary  to  relate,  there  are  instances  reported 
in  which  the  child  bore  the  eruption  at  birth,  although  the  mother  seemingly 
did  not  have  smallpox.  MacCombie  even  states  that  one  case  is  recorded  in  which 
the  mother  contracted  smallpox  from  her  newborn  infant. 

Diagnosis. — In  the  later  stages  of  well-developed  smallpox  there  is  little  difficulty 
in  making  a  positive  diagnosis;  but  in  the  early  stages,  when  the  initial  skin  lesions 
which  have  been  named  are  present,  the  diagnosis  may  be  for  a  time  impo.ssible. 
Indeed,  great  difficulty  may  be  experienced  in  expressing  a  positive  opinion  as  to 
the  presence  of  smallpox,  even  when  the  papular  stage  is  in  its  early  development. 
The  unusually  severe  headache  and  backache,  with  chills,  and  pain  in  the  epigas- 
trium, are  strongly  in  favor  of  smallpox,  particularly  if  there  is  a  history  of  exposure 
to  this  disease  within  the  incubation  period  already  named.  The  absence  of  throat 
symptoms,  of  enlargement  of  the  cervical  and  submaxillary  glands,  and  of  the 
peculiar  coating  of  the  tongue  of  scarlet  fever  may  enable  us  to  determine  that  the 
initial  scarlatiniform  rash  sometimes  seen  is  probably  to  be  followed  by  smallpox, 
and,  furthermore,  as  has  already  been  pointed  out,  this  scarlatiniform  rash  lacks 
the  punctated  appearance  of  true  scarlet  fever. 

On  the  other  hand,  it  is  to  be  borne  in  mind  that  in  persons  in  whom  the  protective 
effect  of  an  early  vaccination  is  waning,  it  not  rarely  happens  that  true  smallpox, 
or  varioloid,  develops  in  so  mild  a  manner  as  to  present  but  a  few  pocks  and  very 
mild  systemic  symptoms.  A  similar  state  may  also  be  present  in  those  who  possess 
a  natural  immunity  even  if  they  have  never  been  vaccinated.     (See  Sjinptoms.) 

"When  the  measles-like  rash  is  present,  the  absence  of  the  characteristic  catarrhal 
symptoms  of  that  disease,  with  its  cough,  running  at  the  nose,  and  puffiness  of 
the  face,  should  cause  the  physician  to  hesitate  in  making  a  diagnosis  until  a  suffi- 
cient time  has  elapsed  for  the  eruption  to  be  well  developed.  The  papules  which 
form  in  measles,  while  they  are  often  confluent,  do  not  possess  the  shot-like  feeling 
so  typical  of  the  early  papular  stage  of  smallpox.  Finally  the  measles-like  rash 
preceding  smallpox  disappears  in  twelve  to  twenty-four  hours,  leaving  no  stain 
on  the  skin,  while  that  of  true  measles  pursues  a  course  lasting  several  days.  (See 
Measles.) 

Chicken-pox  is  one  of  the  diseases  which  is  most  frequently  confused  with  small- 
pox. In  this  disease,  however,  the  initial  sjTnptoms  are  always  mild,  and  the  tem- 
perature does  not  rise  as  rapidly  as  it  does  in  variola.  Then,  too,  in  variola,  the 
eruption  occurs  on  the  arms  and  face;  whereas,  in  chicken-pox  it  is  most  abundant 
on  the  trunk,  and  sometimes  on  the  scalp.  It  is  always  discrete,  and  it  appears  in 
successive  groups.  The  vesicles  of  varicella,  when  punctured,  collapse,  since  they 
are  unilocular;  while,  as  has  already  been  pointed  out,  those  of  smallpox  are  multi- 
locular,  and  so  do  not  completely  discharge  their  contents  when  punctured.  The 
vesicles  in  chicken-pox  also  reach  their  full  development  in  twenty-four  hours 
after  the  appearance  of  the  papule;  whereas,  in  smallpox  they  are  not  completely 
developed  for  five  days. 

Next  to  varicella,  syphilis  may  be  considered  as  the  disease  which  most  frequently 
produces  confu.sion  in  diagnosis,  for  variola  must  be  separated  from  that  form  of 
pustular  syphiloderm  which  is  sometimes  called  variolaform  syphilide.  In  most 
in.stances  pustular  syphiloderm   is   preceded   by   macular  or  papular   syphilitic 


72  DISEASES  DCE  TO  A   SPECIFIC  IXFECTIOX 

eruptions,  but  in  certain  instiuicos  a  liistory  f)f  these  previous  ern])tions  may  not 
be  present.  Pustular  syphiloderm  is  more  Frecjnentiy  met  with  in  nejiroes  tiian 
in  tile  wliite  race,  and  occurs,  as  a  rule,  somewhere  lictween  the  sixtii  montli  and 
the  second  year  of  the  sy])hilitic  infection.  Important  [joints  in  tlie  dilVcrcntiation 
are  tliat  in  ])ustidar  syphiloderm,  the  ])iitient  does  not  jjresent  the  wcil-marki'd 
prodromal  symptoms  of  smali|)ox,  such  as  intense  backache,  althouf^ii  tiiere  may 
be  a  moderate  fever  and  some  pain  and  achin<;.  Afjain,  in  syphiloderm  there  is 
no  marked  remission  of  the  temperature  such  as  occurs  when  the  erujjtion  a])pears 
in  small])ox,  and  syphilitic  patients  jiresenting  such  an  eruption  do  not,  as  a  rule, 
appear  very  ill  or  have  to  take  to  their  beds.  Further  than  this,  the  .syijhilitic 
eruption  comes  out  in  successive  crops,  is  often  profu.se  upon  the  trunk,  and  the 
individual  pustules  never  become  so  large  and  deep  seated  as  do  those  of  variola. 
Again,  they  are  practically  always  non-confluent.  Many  cases  of  syphilitic  eru])tion 
have  associated  with  the  vesicles  coppcr-cf)lored  papules,  which  shoidd  render 
the  diagnosis  easy. 

Drug  eruptions,  which  are  sometimes  ])apular  and  pustular,  arc  diltVrentiated 
by  the  alisence  of  fever  and  of  constitutional  symptoms. 

Prognosis. — The  prognosis  of  smallpox  differs  greatly  in  ditt'erent  e])idemics 
and  in  ditt'erent  individuals.  The  greatest  difference,  of  course,  exists  between 
those  who  are  vaccinated  and  those  who  are  not  vaccinated.  The  mortality 
present  in  the  unvaccinated  may  be  said  to  amount  to  nearly  45  per  cent.,  and  in 
the  vaccinated  to  about  8  per  cent.  If  a  patient  has  been  vaccinated  more  than 
once,  the  mortality  of  the  disea.se  is  wonderfully  decreased.  Thus,  while  among 
those  who  have  been  vaccinated  once  the  mortality  may  be  8  per  cent.,  those  who 
have  been  vaccinated  twice  have  a  mortality  of  less  than  4  per  cent.  If  the  mark 
of  both  vaccinations  is  a  satisfactory  one,  the  prognosis  is  exceedingly  favorable, 
for  death  very  rarely  occurs  unless  the  patient  is  already  sutt'ering  from  some 
serious  disease  which  has  undermined  his  constitution  and  therefore  aids  materially 
in  causing  death.  In  most  of  the  instances  in  which  .smallpox  has  occurred  after 
even  a  single  vaccination,  the  vaccination  mark  has  been  so  unsatisfactory  that 
there  has  be£n  grave  doubt  as  to  whether  the  patient  has  been  protected  at  all. 

The  age  of  the  patient  influences  the  prognosis  materially.  It  is  much  more 
grave  in  early  infancy  and  after  thirty  years  of  age,  and  best  at  about  the  end  of 
the  second  decade  of  life.  Chronic  alcoholism  and  the  presence  of  any  antece- 
dent disease  in  the  heart,  lungs,  or  kidneys  makes  the  prognosis  more  grave. 

Marked  severity  of  onset  is  an  evil  prognostic  sign,  but  a  mild  onset  docs  not 
necessarily  promise  recovery,  for  in  many  instances  cases  which  seem  mild  afterward 
become  severe  and  fatal.  Petechial  rashes  are  always  of  evil  import,  whereas 
early  maturation  of  the  eruption  or  an  aborted  maturation,  so  that  it  does  not  go 
on  to  pustulation,  is  a  favorable  omen.  Confluent  smallpox,  if  it  has  not  been 
modified  by  previous  vaccination,  is  more  dangerous  than  the  discrete  form,  and 
varies  in  its  mortality  with  the  age  of  the  patient.  Young  children  almost 
invariably  die  from  it.  Older  children  and  adults  often  recover,  and  it  may  be 
said  that  prognosis  is  favorable  in  confluent  cases  in  direct  proportion  to  the  age 
of  the  patient  until  after  the  third  decade. 

•  Great  swelling  of  the  hands  and  feet,  associated  with  salivation  and  swelling 
of  the  face,  in  confluent  smallpox  has  long  been  regarded  by  physicians,  who  have 
had  a  large  ex])erience,  as  possessing  considerable  prognostic  value,  since  if  the 
eruption  fails  to  appear  the  patient  very  frequently  dies.  The  swelling  is,  of 
course,  due  to  non-maturation  of  the  pustules. 

Hemorrhagic  smallpox,  if  well  developed,  always  ends  in  death. 

When  death  takes  place  from  smallpox,  it  most  commonly  occurs  about  the 
twelfth  or  sixteenth  day,  as  the  result  of  pneumonia,  hypostatic  congestiim  nf  the 
lungs,  or  from  the  profound  exhaustion  and  septicemia. 


VARIOLA  73 

Treatment. — As  in  most  infectious  diseases,  the  treatment  of  smallpox  consists 
chiefly  in  good  nursing  and  the  maintenance  of  vitality  by  the  use  of  proper  nourish- 
ment and  care.  The  air  of  the  room  should  he  fresh  and  cool,  and  frecjuently 
changed.  Draughts  should  be  avoided,  and  food  should  be  given  fretjueiitl.v  in 
small  quantities.  Water  should  be  given  freely  for  the  purpose  of  allaying  thirst 
and  flushing  the  kidneys,  and  there  is  no  objection  to  the  patient  receiving  a  small 
quantity  of  ice  to  relieve  the  dry  condition  of  the  mouth.  If  the  urine  is  scanty 
5-grain  doses  of  citrate  of  potassium  or  citrate  of  lithium  should  be  given  every  six 
hours.  Stimulants  are  not  needed,  unless  there  are  evidences  of  circulatory  feeble- 
ness, when  alcohol  is  considered  by  most  practitioners  of  experience  to  be  valuable. 
Good  brandy  and  whiskey  are  the  best  forms  of  alcohol  to  employ.  For  the  relief 
of  intense  nervous  irritation,  opium  or  morphine  may  be  administered  in  small 
doses,  particularly  if  the  condition  of  the  skin  seems  to  be  the  chief  cause  of  the 
patient's  suffering.  These  drugs  are  also,  perhaps,  the  best  for  the  purpose  of 
allaying  excessive  delirium,  since  they  do  not  irritate  the  kidneys  as  do  some  of  the 
newer  hypnotics.  Where  the  deliriimi  is  active  and  threatens  to  exliaust  the 
patient,  a  hypodermic  injection  of  |  to  |  grain  of  morphine  will  often  produce 
several  hours  of  restful  sleep,  with  benefit. 

For  the  relief  of  the  intense  irritation  of  the  skin  all  over  the  body,  a  very  useful 
dressing  is  ordinary  carron  oil — that  is,  lime-water  and  olive  oil  mixed  in  equal 
parts.  To  this  may  be  added  1  per  cent,  of  carbolic  acid  for  its  local  antiseptic 
and  anesthetic  properties,  and  where  great  pain  is  experienced,  because  of  the 
occurrence  of  the  eruption  in  the  thick  skin  of  the  hands  and  feet,  prolonged  hand- 
baths  and  foot-baths  of  lukewarm  water  may  be  employed,  or  hot  poultices  used. 
An  ointment  of  aristol  of  the  strength  of  one  drachm  to  the  ounce  may  also  be  used. 

It  seems  to  be  generally  considered  that  local  applications  to  the  eruption  are 
of  little  value  in  the  sense  of  modifying  its  severity,  although  certain  parts  of  the 
skin  which  seem  to  suffer  from  an  excessive  degree  of  irritation  may  be  relie\'ed 
by  cool  compress  or  by  the  application  of  antiseptic  poultices.  MacCombie 
states  that  the  best  dressing  for  the  face  is  a  mask  with  holes  cut  for  the  eyes,  nose, 
and  mouth.  Upon  this  mask  is  smeared  on  its  inner  surface  a  small  linseed  poultice, 
over  which  is  placed  some  vaselin  which  contains  iodoform.  This  poultice  should 
be  changed  every  two  hours.  It  aids  materially  in  separating  the  crusts,  and  so 
leaves  the  skin  free  for  the  application  of  the  dressings,  which  tend  to  prevent 
ulceration  and  the  formation  of  scars.  The  local  use  of  antiseptic  drugs  to  the 
surface  of  the  entire  body  has  not  met  with  favor. 

The  mucous  membrane  of  the  mouth  should  be  kept  cleansed  by  mouth-washes 
of  boric  acid  or  chlorate  of  potassium  and  myrrh.  When  the  mouth  is  exceedingly 
dry,  flaxseed-tea,  sweetened  with  a  little  white  sugar  and  acidulated  with  lemon- 
juice,  may  be  used. 

The  primary  fever  of  smallpox  does  not  last  long  enough  to  require  treatment, 
but  the  secondary  fever  may  be  sufficiently  high  to  demand  relief.  Cold  compresses 
may  be  applied  to  the  head,  and  sponging  the  body  with  cool  or  tepid  water  may 
be  emplo^yed,  but  the  cold-bath  treatment,  so  successfully  employed  in  typhoid 
fever,  has  not  apparently  given  good  results  in  smallpox,  and  it  is  practically  never 
employed. 

Should  any  irritation  or  inflammation  of  the  eyes  appear,  thej^  should  be  carefully 
washed  every  few  hours  with  boric  acid  solution,  and,  if  necessary,  cold-wet  com- 
presses should  be  applied,  great  care  being  taken  that  the  warmth  of  the  body 
does  not  speedily  change  the  cool  compress  into  a  hot  poultice. 

During  the  suppurative  stage,  it  is  exceedingly  important  that  the  nutrition 
and  vitality  of  the  patient  be  preserved  by  the  frequent  administration  of  easily 
digested  and  predigested  food. 

In  considering  the  general  condition  of  a  patient  who  is  sufl'ering  from  smallpox. 


74  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

it  must  be  borne  in  mind  that  the  disease  is  essentially  one  whicli  is  prone  to  produce 
profound  toxemia,  since  it  is  incredible  that  such  widespread  infection  can  take 
place  all  over  the  body  without  simultaneously  resulting  in  septic  absorption  on 
the  one  hand,  or  profound  exliaustion  on  the  other.  For  this  reason  the  degree 
of  suppuration  should  be  controlled  as  far  as  possible,  measures  should  be  introduced 
to  aid  in  the  escape  of  pus,  and  the  treatment  should  be  stimulating  and  supporting. 

Finally,  mention  should  be  made  of  the  so-called  red-light  treatment  of  smallpox, 
in  which  patients  are  kept  in  rooms  to  which  no  light  is  allowed  to  enter  save 
through  red  glass,  it  being  claimed  by  advocates  of  this  method  that  the  severity 
of  the  eruption,  and  so  indirectly  the  severity  of  the  disease,  is  greatly  modified, 
and,  further,  that  scarring  of  the  skin  is  diminished.  Suffice  it  to  state,  that  while 
certain  European  clinicians  have  claimed  to  have  obtained  excellent  results  from 
this  method,  Welch  and  Schamberg  in  Philadelphia,  and  others,  have  found  it 
entirely  useless.  When  repeated  attacks  of  boils  occur  in  convalescence,  staphj'- 
lococcus  vaccine  may  be  used. 

There  are  several  points  in  the  treatment  of  variola  which  should  be  carefully 
avoided.  For  the  relief  of  the  severe  backache  and  headache,  counter-irritation 
is  sometimes  employed  in  the  early  stages  of  the  disease.  Such  treatment  frequently 
results  in  severe  ulceration  or  sloughing  of  the  part  to  which  the  irritation  is  applied. 
Again,  the  application  of  powders,  antiseptic  or  otherwise,  is,  as  a  rule,  disadvan- 
tageous. The  opening  of  individual  pocks  by  means  of  a  needle  or  the  fine  blade 
of  a  knife  is  not  advisable. 

VACCINIA  AND  VACCINATION. 

History. — Little  is  known  of  the  history  of  vaccinia,  save  that  it  has  been  recog- 
nized for  many  years  as  a  disease  which  affects  heifers  and  cows,  and  that  it  causes 
an  eruption  to  appear  on  the  teats  and  udder  or  neighboring  parts. 

Although  it  was  known,  among  those  persons  who  milked  these  animals,  or  other- 
wise handled  them,  that  the  disease  coidd  be  transmitted  from  the  cow  to  the  himian 
being,  and  although  many  of  these  persons  also  knew  that  this  transmission  protected 
the  human  being  from  smallpox,  it  was  not  until  Jenner,  on  May  14,  1796,  first 
inoculated  a  patient  with  the  contents  of  a  cow-pock  that  the  preventi\'e  Influence 
of  vaccination  was  first  tried  in  a  scientific  manner.  Two  years  before  this  an 
English  farmer,  by  the  name  of  Benjamin  Jesty,  inoculated  his  wife  and  two  children 
in  a  similar  manner,  but  at  the  time  no  report  of  the  procedure  was  made.  From 
this  small  beginning  so-called  vaccination,  or  the  inoculation  of  human  beings  with 
vaccine  virus,  has  spread  all  over  the  world,  and  is  a  well-recognized  procedure, 
by  which  millions  of  lives  have  been  saved.  There  are  a  few  persons,  not  medical 
men  as  a  rule,  who  still  express  doubt  as  to  Its  efficacy,  but  they  are  not  worthy 
of  credence,  and  the  statistics  of  every  civilized  land  prove  that  vaccination  Is  one 
of  the  greatest  blessings  yet  discovered  for  mankind.  It  Is  only  necessary  here  to 
state  that  vaccination  Is  now  obligatory  in  most  civilized  lands,  and  that  the 
frequency  of  smallpox  is  in  direct  ratio  to  the  laxity  with  which  vaccination  laws 
are  enforced.  Immense  statistics  as  to  its  protective  value  are  to  be  fomid  in  all 
works  on  public  health. 

In  the  Philippine  Islands,  about  Manila,  with  a  population  of  about  1,000,000, 
there  had  been  for  years  an  annual  mortality  from  this  disease  of  about  6000. 
From  1907  when  the  United  States  Government  Instituted  vaccination,  until  1911, 
not  one  death  from  this  disease  occurred  among  vaccinated  persons.  Heiser  also 
states  that  in  May,  1904,  the  United  States  Army  transport  Liscitm  left  Manila 
with  26  cabin  passengers,  170  steerage  passengers,  16  officers,  and  SO  members 
of  crew,  or  a  total  of  292  souls  on  board.  During  the  first  week  smallpox  broke 
out  aboard  the  vessel,  in  an  unvaccinated  child,  in  the  steerage.     An  examination 


VACCINIA  AND  VACCINATION  75 

of  the  personnel  on  board  showed  that  3  members  had  never  been  vaccinated. 
Within  a  period  of  two  weeks  these  unvaccinated  persons  were  stricken  with  tlic 
disease  and  not  one  of  the  289  remaining  persons  contracted  it.  If  the  patient 
contracts  smallpox  many  years  after  a  vaccination,  the  severity  of  the  disease 
is  usually  modified.  Thus  in  58,278  cases  of  variola  collected  from  various  sources, 
occurring  in  individuals  who  had  been  vaccinated,  but  in  whom  the  "takes"  were 
not  known  to  be  good,  there  were  4872  deaths,  a  percentage  of  8.35;  whereas  in 
23,360  cases  of  variola,  occurring  in  individuals  who  had  not  been  vaccinated, 
there  were  8682  deaths,  a  percentage  of  32.88. 

Vaccination,  when  properly  performed,  and  when  an  active  vaccine  is  used, 
may  be  said  to  be  a  sure  preventive  of  smallpox  for  a  very  considerable  space  of 
time,  if  not  for  the  lifetime  of  the  individual;  but  it  is  safer  to  be  vaccinated  every 
few  years,  and  every  year  if  exposed  during  an  epidemic.  Not  only  does  vaccination 
protect  the  individual  for  a  long  period  of  time,  but  it  also  modifies  the  severity 
of  smallpox  if  the  patient  contracts  this  disease  before  the  vaccinia  can  completely 
protect  him.  This  has  been  proved  by  practical  experience  so  often  that  it  is  a 
fact  bej'ond  all  doubt,  and  it  bears  this  important  truth  with  it,  namely,  that  when 
a  person  who  has  not  been  recently  vaccinated  is  exposed  to  smallpox  he  should 
be  revaccinated  at  once,  since  if  the  vaccine  fails  to  confer  complete  immunity 
it  will  modify  the  disease  if  it  develops.  The  degree  of  immunity,  or  the  degree 
of  modification,  if  smallpox  develops,  depends  upon  the  space  of  time  elapsing 
between  exposure  to  the  smallpox  and  the  vaccination.  The  influence  of  a  primary 
vaccination,  which  has  been  successful,  upon  the  susceptibility  of  an  individual 
to  a  second  inoculation  and  indirectly  as  to  his  susceptibility  to  smallpox,  is  illus- 
trated by  the  results  of  Kitasato  who  analyzed  931  revaccinations.  His  results 
were  as  follows:  After  one  year,  14  per  cent.;  after  two  years,  33  per  cent.;  after 
tliree  years,  47  per  cent.;  after  four  years,  57  per  cent.;  after  five  years,  51  per  cent.; 
after  six  years,  64  per  cent.;  after  seven  years,  73  per  cent.;  after  eight  years,  SO  per 
cent. ;  after  nine  years,  85  per  cent. ;  after  ten  years,  89  per  cent. 

Difference  of  opinion  exists  as  to  the  scope  of  vaccine  protection.  Some  hold 
that  it  protects  against  all  the  phases  of  smallpox;  others  that  it  protects  against 
only  one  phase  of  the  disease,  that  is  the  virus  that  produces  the  eruptive  forms 
of  the  disease.  One  fact  that  supports  this  view  is  the  development  of  variola  sine 
eruptione  in  vaccinated  persons.  Ashburn,  Vedder,  and  Gentry  support  this  view 
but  Ricketts  and  Bayles  oppose  it.  It  is  well  recognized  that  vaccinia  is  not  a 
modified  form  of  variola,  since  if  the  virus  that  causes  all  the  sjTnptoms  of  malig- 
nant smallpox  in  man  be  passed  through  monkeys  or  cattle  for  several  generations 
it  loses  all  its  virulence  as  to  local  lesions,  although  it  causes  systemic  illness. 
Unlike  certain  infectious  agents,  small-pox  vaccine  never  regains  its  lost  power  for 
evil  even  when  it  is  passed  through  human  beings  which  are  favorable  fields  for 
the  growth  of  smallpox  virus  for  100  years  (Immermann).  If  the  views  of  Ash- 
burn, Vedder,  and  Gentry  are  correct  we  would  expect  variola  sine  eruptione  to 
be  a  fatal  disease  without  eruption,  instead  of  the  mild  one  which  it  is.  (See 
Variola.) 

Method  of  Vaccination. — The  skin  on  the  arm  or  calf  of  the  leg,  having  been 
cleansed  by  washing  it  with  soap  and  water,  is  scarified  or  scratched  by  a  needle 
or  knife-blade  in  such  a  manner  as  to  remove  the  epiderm  and  expose  the  true 
skin  over  an  area  of  about  an  eighth  of  an  inch  in  all  directions.  Care  should  be 
taken  that  the  spot  is  not  so  deeply  scratched  as  \.o  cause  free  bleeding.  Upon 
this  area  is  now  deposited  the  vaccine,  which  is  then  gently  rubbed  into  the  part 
and  allowed  to  dry  before  any  clothing  comes  in  contact  with  it.  Several  forms  of 
vaccine  are  used,  but  that  most  commonly  employed  at  present  is  known  as  "  glycer- 
inated  vaccine  lymph,"  prepared  from  the  contents  of  the  vaccine  vesicles  as  the.y 
have  developed  on  the  belly  of  a  heifer.    This  glycerinated  lymph  is  put  up  in 


76  DISEASES  DUE  TO  A  SPECIFIC  IXFECTJOX 

small  glass  tubes,  which  are  hermetically  sealed  at  the  ends,  so  that  it  may  not  be 
contaminated  before  it  is  used.  Schamberg  and  Koimer  have  shown  that  the 
apphcation  of  a  solution,  made  up  of  picric  acid  4  grams,  iorline  1  gram,  ak-oh(»l 
100  c.c,  forty-eight  hours  after  vaccination  ])revcnts  secondary  inflammation. 
Another  plan  which  has  the  advantage  of  avoiding  a  scab  is  to  make  two  or  tlirce 
superficial  incisions  in  tlic  skin  and  to  ml)  the  \'accinc  into  the  cuts. 

Children  should  always  be  vaccinated  during  the  first  >ear  of  life,  or  inmicdiately 
after  birth,  if  exposed  to  smallpox.  Vaccination  shoukl  be  re[)eatcd  through  life 
every  five  years,  and  oftener  if  smallpox  is  prevalent.  If  one  inoculation  fails  it 
should  be  repeated  at  least  three  times,  since  sometimes  primary  failure  is  due  to 
poor  vaccine  or  to  an  error  in  technique.  If  after  three  attempts  no  "take"  is 
])rodnced  the  ])atient  may  be  considered  as  immune,  at  least  for  a  time. 

Primary  Vaccinia  in  Man. — Three  or  four  days  after  vaccination  has  been  per- 
formed the  infected  area  begins  to  be  slightly  reddened,  and  this  reddening  increases 
while  at  the  same  time  a  reddish  papule  develops  which  by  the  fifth  day  begins 
to  look  like  a  vesicle,  particularly  if  the  margin  of  the  area  inoculated  be  examined. 
This  vesicle  increases  in  size,  becomes  filled  with  thin,  clear  lymjjh,  and  b\-  the 
eighth  day  reaches  its  greatest  development.  At  this  time  the  contained  fluid 
begins  to  be  more  opaque  and  yellow  and  the  top  of  the  vesicle  is  seen  to  be  slightly 
sunken — that  is,  the  early  stage  of  its  umbilication  has  been  reached.  The  skin 
surrounding  the  vesicle  is  now  surrounded  by  a  zone  or  areola  of  red  which  by  the 
ninth  or  tenth  day  becomes  very  well  developed,  so  that  it  extends  for  a  consider- 
able distance  in  all  directions;  the  spot  inoculated  is  painful  and  the  neighboring 
lymphatic  glands  may  be  swollen  and  tender.  At  this  time,  too — that  is,  about  the 
tenth  day — constitutional  symptoms  may  come  on  and  the  patient  suffer  from  mofl- 
erate  chills,  a  slight  rise  of  temperature,  and  malaise.  Sometimes  roseola  {roseola 
mccinosa)  may  develop  over  the  body.  By  the  eleventh  or  twelfth  day  these  sym]> 
toms  are  modified,  the  vesicle  begins  to  desiccate,  and  by  the  end  of  the  fifteenth 
day  it  is  completely  dried  up,  although  the  scab  may  not  fall  off  till  the  twenty-first 
or  twenty-fifth  day.  The  crust  or  scab  is  dark  red  in  color  and  thin  at  its  centre 
and  at  its  edges,  but  there  is  a  thickened  area,  or  ridge,  between  the  centre  and  the 
periphery.  After  the  crust  falls  oft'  it  leaves  a  pink  spot  which  gradually  fades 
and  leaves,  after  some  months,  a  foveated  or  pitted  mark  from  which  small  scars 
may  radiate.  It  is  to  be  borne  in  mind  that  in  some  cases  the  constitutional 
symptoms  are  so  mild  as  not  to  be  worthy  of  note,  while  in  others  they  ma\'  be 
quite  severe.  To  be  a  true  "take,"  the  full  development  of  the  pock  by  the  stages 
named  is  essential,  but  it  is  possible  for  the  "take"  not  to  ensue  for  a  month  after 
inoculation.  (See  Plate  II.)  If  the  vaccinated  area  becomes  very  much  inflamed 
and  painful  the  part  should  be  put  at  rest  and  dressed  with  lead  water  and  laudanum. 

Secondary  Vaccinia  in  Man. — ^^ery  few  persons  who  ha\-e  once  been  successfully 
vaccinated  i>rcscnt  the  conditions  just  described  when  inoculated  a  second  time. 

The  difference,  however,  is  one  of  degree,  not  one  of  kind,  and  vesiculation 
and  umbilication  should  iippear  in  all  cases.  The  variations  depend  upon  the 
degree  of  immunity  induced  and  persisting  from  the  first  \accination.  If  immunity 
is  complete  there  is  no  "take."  If  not  complete  the  ])rimary  papule  may  occur  a 
day  earlier  than  usual  and  a  typical  pustule  may  be  reached  as  early  as  the  end 
of  the  seventh  day  with  the  development  of  more  or  less  severe  systemic  symp- 
toms as  early  as  the  fourth  or  sixth  day. 

It  is  a  point  worthy  of  note  that  the  so-called  "raspberry  excrescence"  which 
sometimes  follows  vaccination  on  the  fourth  or  fifth  day,  looking  like  a  small  nevus, 
is  not  a  vaccine  pock  and  confers  upon  the  patient  no  immunity  to  smallpox — 
that  is,  it  is  not  to  be  considered  as  a  "take."  Care  must  be  taken,  too,  that  the 
sore  or  mark  |)roduced  by  the  injury  of  the  operation  be  not  taken  fur  the  sj)ccific 
k'sion  of  \-Mcci?iia. 


S  I    s 


I  Q 


VARICELLA 


VARICELLA. 


Definition. — Varicella  is  often  called  chicken-pox.  It  is  an  acute  infectious 
disease  which  usually  occurs  in  children  under  ten  years  of  age,  and  rarely  attacks 
individuals  after  puberty.  In  adults  it  is  still  more  uncommon,  although  Tyzzer 
reports  38  cases  occurring  in  adult  male  Filipinos  and  states  that  at  tiie  time  of  the 
last  observation  .300  cases  had  been  recorded.  The  men  were  prisoners,  and  this, 
together  with  race  and  climate,  are  considered  possible  factors  in  increasing  suscep- 
tibility. In  all  probability  one  of  the  reasons  for  its  rarity  in  those  of  mature 
years  is  that  it  affects  so  large  a  proportion  of  all  children  that  most  atlults  are 
rendered  immune  by  an  attack  in  childhood.  The  most  marked  characteristic 
of  the  disease  is  the  appearance  within  the  first  twenty-four  or  forty-eight  hours 
of  fever  and  malaise  and  of  papules,  followed  by  vesicles,  upon  the  skin  of  the  fore- 
head and  face,  or  upon  the  chest  and  back.     (See  Fig.  19.) 


Chicken-pox.     (Schambcrg.) 


Etiology. — Like  all  acute  infectious  diseases,  chicken-pox  is  produced  by  a  micro- 
organism, but  as  yet  it  has  not  been  isolated.  Tyzzer  found  specific  nuclear  and 
cytoplasmic  inclusions  in  all  the  lesions,  but  obtained  no  evidence  favoring  the 
hypothesis  that  they  are  parasites.     It  also  resembles  the  other  acute  infectious 


78  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

eruptive  diseases  in  that  it  occurs  in  epidemics,  althougli  at  times  isolated  cases 
take  place  that  cannot  be  traced  to  any  source  of  contagion.  While  the  eruption 
in  its  peculiarities  resembles  to  some  extent  that  caused  by  smallpox,  chicken-pox 
bears  absolutely  no  relation  to  that  malady  and  in  no  way  protects  a  patient  from 
developing  a  typical  attack  of  variola.     (See  Variola.) 

Symptoms. — At  a  time  varying  from  ten  to  fifteen  days  after  exposure  to  varicella 
ihe  child  usually  manifests  some  evidence  of  a  beginning  illness.  If  very  young  it 
may  be  unusually  restless  and  fretful,  there  may  be  some  disorder  of  the  digestive 
apparatus,  and  vomiting  may  occur.  Fever  is  an  early  symptom  and  it  may  be 
moderately  high — that  is,  about  10.3°  or  even  104°.  Often,  however,  it  fails  to 
reach  such  a  height.  If  the  child  is  old  enough  to  describe  its  sensations,  some 
aching  in  the  back  or  in  the  limbs  may  be  complained  of. 

After  about  twenty-four  hours  the  eruytion  appears  in  the  form  of  red  papules, 
which  speedily  become  vesicles  containing  clear  or  turbid  serum.  The  vesicle 
is  superficial,  it  is  not  surrounded  by  a  zone  of  induration,  as  it  is  in  smallpox,  and 
it  does  not  become  umbilicated,  although  the  top  of  the  vesicle,  when  it  is  ripe, 
may  be  flattened.  By  the  end  of  thirty-six  to  forty-eight  hours  the  vesicle  becomes 
a  true  pock,  the  previously  clear  serum  becoming  opacjue  but  not  purulent  unless 
it  is  denuded  by  scratching,  and  then  infected.  These  pocks  speedily  shrivel  and 
by  the  fourth  day  form  crusts,  which  readily  fall  ofl"  and  rarely  leaA'e  a  scar  unless 
the  skin  be  scratched  by  the  child  so  that  the  deeper  layers  become  infected.  Many 
individuals  bear  scars  of  this  sort  upon  the  face,  and  they  are  particularly  well 
marked  in  women  with  a  fair  skin. 

The  eruption  of  chicken-pox  develops  in  a  series  of  crops,  or,  to  speak  more  accu- 
rately, it  continues  to  develop  in  new  areas  as  those  which  were  afl'ected  first  begin 
to  pass  into  the  stage  of  crusts.  An  examination  of  the  patient  on  the  third  day 
may  therefore  reveal  the  eruption  in  all  stages  of  development. 

It  is  a  noteworthy  fact  that  the  eruption  of  varicella  is  always  discrete  and  ne\'er 
confluent.  It  is  never  profuse  as  in  smallpox.  Rarely  the  vesicles  appear  on  the 
mucous  membranes. 

The  severity  of  the  fever  and  of  the  signs  of  general  illness  vary  greatly  in  children 
affected  by  varicella.  In  some  cases  the  disease  runs  so  mild  a  course  that  the 
child  is  not  kept  in  bed,  in  others  it  causes  a  considerable  degree  of  illness;  but  in 
the  majority  of  instances  it  is  a  very  mild  malady.  In  children  who  arc  weakened 
by  previous  disease  it  sometimes  develops  into  a  dangerous  malady,  in  that  the 
associated  digestive  disturbance  still  further  impairs  vitality,  or  because  the  lesions 
of  the  skin  become  infected  and  sloughing  or  gangrene  appears.  Sometimes 
erysipelas  is  developed  in  this  manner  in  poorly  nourished  children.  Karely,  if 
the  child  is  exposed  to  cold,  nephritis  develops.  Allaire  reports  peripheral  neuritis 
of  the  left  arm  following  an  attack  of  varicella  in  a  child  aged  eight  years,  the  pocks 
having  suppurated. 

Diagnosis. — The  eruption  of  chicken-pox  must  be  separated  from  that  of  modified 
(ir  mild  smallpox.  The  most  important  factors  in  this  separation  are  the  superficial 
character  of  the  pock,  the  lack  of  the  sense  of  induration  when  it  is  taken  lictwcen 
the  thuml)  and  finger,  the  early  appearance  of  the  rash  on  the  chest  rather  than 
on  the  forearms,  as  in  smallpox,  and  the  mild  character  of  the  general  symptoms, 
combined  with  the  brief  course  of  the  disease  and  the  speedy  completion  of  the 
illness. 

Additional  diagnostic  factors  are  the  presence  of  a  good  vaccination  mark  which 
largely  excludes  variola.  Again,  the  onset  of  varicella  is  usually  devoid  of  pro- 
dromes, whereas  smallpox  presents  for  some  days  backache,  vertigo,  fever,  nausea, 
and  chills.  The  mere  fact  that  the  eruption  is  scanty  does  not,  however,  exclude 
smallpox.  The  vesicles  of  varicella  do  not  become  umbilicated  as  do  those  of 
variola,  but  they  rapidly  dry  up  and  make  a  dark-colored  scab.    The  eruption 


SCARLET  FEVER  79 

of  smallpox  comes  out  in  one  crop,  that  of  varicella  in  several  crops;  that  of  smallpox 
lasts  from  ten  to  twelve  days  in  typical  cases,  never  less  than  six  days,  whereas 
chicken-pox  lasts  but  from  two  to  four  days. 

Prognosis. — The  prognosis  is  always  favorable  unless  the  unfavorable  preliminary 
states  just  noted  are  present. 

Treatment. — Medicinal  treatment  of  varicella  is  usually  unnecessary.  Careful 
nursing  that  prevents  exposure  to  cold  and  wet,  regulation  of  the  diet,  and  the  \  je 
of  a  few  drops  of  sweet  spirit  of  nitre  in  a  teaspoonful  of  liquor  potai'sii  citratis 
every  four  hours,  to  keep  the  kidneys  active,  are  all  that  is  needed  in  most  cases. 
The  fever  runs  so  brief  a  course  that  antipyretic  measures  are  not  necessary. 

SCARLET  FEVER. 

Definition. — Scarlet  fever  is  an  acute  infectious  disease  which  chiefly  affects 
children  under  fifteen  years  of  age.  It  is  characterized  by  the  development  of 
an  intensely  scarlet,  punctated  rash  on  the  second  day  of  the  illness,  accompanied 
by  a  marked  febrile  movement.  It  is  sometimes  called  "scarlatina,"  and  it  is 
to  be  clearly  understood  that  this  word  is  synonymous  with  scarlet  fever  and  that 
it  does  not  describe  a  modified  or  diminutive  form  of  the  malady,  although  the  laity 
often  employ  the  term  in  this  manner. 

History. — Hirsch  states  that  the  oldest  reference  to  an  epidemic  of  scarlet  fever 
dates  from  Sicily  in  1543,  but  Sydenham,  of  London,  first  differentiated  it  from 
measles.     Prior  to  his  time  it  had  been  considered  a  form  of  measles. 

Distribution. — Like  almost  all  of  the  acute  infectious  maladies,  scarlet  fever 
occurs  in  all  parts  of  the  world,  although  it  seems  to  be  much  more  prevalent  in  the 
temperate  zone  than  elsewhere.  In  the  United  States  it  occurs  less  frequently 
in  the  Southern  States  than  in  the  Northern  States.  It  did  not  develop  in  the 
United  States  until  1735,  nor  in  South  America  until  1830.  In  Australia  and  in 
Polynesia  the  disease  first  appeared  in  1848,  assimiing  a  mild  type,  but  a  severe 
epidemic  occurred  in  Melbourne  in  1876.  It  is  said  that  only  imported  cases  are 
met  in  India,  and  only  one  case  has  been  reported  in  Greenland.  It  does  not 
occur  nearly  so  frequently  as  does  measles,  and  very  many  persons  reach  adult 
life  without  having  sufJered  from  it.  This  is  in  part  due  to  the  fact  that  it  is  not 
so  readily  transmitted  as  some  of  the  other  acute  infectious  fevers,  and  also  because 
a  large  number  of  persons  seem  to  be  resistant  to  the  disease.  Johannessen  states 
that  of  185  children  exposed  only  28  per  cent,  developed  scarlet  fever,  and  out  of 
314  adults  exposed  only  5  suffered  from  the  malady.  If  the  same  number  of 
cases  had  been  exposed  to  the  infection  of  measles,  very  few  of  the  children  would 
have  escaped. 

Scarlet  fever  is  more  apt  to  occur  in  the  winter  months  than  at  any  other  time, 
but  statistics  differ  as  to  the  winter  months'  frequency.  Thus,  Whitelegge  from 
his  statistics  based  upon  cases  occurring  in  nine  English  towns,  found  in  the  first 
quarter  219  cases;  second  quarter,  194;  third  quarter,  327;  fourth  quarter,  460; 
and  Reece  has  supported  his  conclusions  by  the  accompanying  chart.     (See  Fig.  20.) 

On  the  other  hand,  Seibert,  of  New  York,  gives  a  statistical  table  which  shows 
that  the  last  winter  months  are  those  of  greatest  frequency.     (See  Fig.  21.) 

August  Hirsch  gives  the  following  statistics  based  on  an  analysis  of  435  epidemics 
occurring  in  all  parts  of  Europe  and  North  America:  178  epidemics  occurred  in 
winter;  157  in  spring;  173  in  summer;  213  in  autumn. 

The  frequency  and  mortality  of  scarlet  fever  have  greatly  decreased  in  the 
last  sixty  years.     (See  Fig.  22.) 

Etiology. — Scarlet  fever  does  not  disseminate  itself  through  the  air  as  does 
measles;  direct  contact  or  near  association  with  the  infected  person,  being  needful 
for  the  transmission  of  the  disease.    The  desquamated  skin  has  been  recently  denied 


80 


DISEASES  DUE  TO  A  SPECIFIC  INFECTION 


Jim. 

Fell. 

]lar. 

Apr. 

3i«r 

tUM 

Jul, 

in?. 

Sf|.l. 

Ucl. 

.\.». 

llcr. 

^ 

^ 

/ 

\ 

/ 

\ 

/ 

\ 

/ 

~\ 

/ 

\ 

\ 

7 

■ 

s 

/ 

\ 

.     r> 

■^ 

/ 

Ni 

^. 

+  70 
+  00 
+  60 
+  10 
+  30 
+  80 
+  10 
McanO 
-  lU 


Showing  seasonal  mortality  of  scarlet  fever  in  all  ages  and  both  sexes  in  England 
and  Wales.     (Reece.) 


JAN.     n 

'M.       MAR,   1  APRIL  1    MA"i 

!    1  JUNE  {  JULY       AUG. 

SEPT.  [   OCT.   1    NOV.   1   DEC. 

200  '•■""■'-]■"' 

w»£::^::"^;i'-    rc-:c 

S    KlwtSS  K«*S«ro««|m 

is  w'*iS  S;Sf?3:S  "S5  «S  s  S 

1 

160 

150 

140- 
130  — 

■ 

120  —   - 
110 

100 

90 

SO 

70 
,60 

50 

-f'  ;- 

! 

B              1 

»B..aEiiiii[ 

40 1 

30' 

1 

20  -         - 

1 

10! 

1     ]_ 

^          ^ 

1 

Frequency  of  scarlet  fever,  by  weeks,  throughout  the  year.  A  comparison  of  Charts  20  and  21  shows 
that  although  the  greatest  morbidity  is  in  the  first  five  months,  the  greatest  mortality  is  in  the  last  five 
months  of  the  year.     (Seibert.) 

Fig.  22 


Showing  the  decreasing  mortality  of  scarlet  fever  in  England  and  Wales.    Deaths  per  100,000 
population.     (Modified  from  Wilson  and  Reece.) 


SCARLET  FEVER 


81 


as  a  cause.  The  disease  is  usually  transmitted  by  the  nasal  mucus  as  in  sneezing, 
and  by  clothing,  and  other  articles  which  have  been  in  contact  with  the  patient. 
Thus  books,  cards,  letters,  and  pets,  such  as  dogs  and  cats,  and  other  means  of 
conveyance  may  assist  in  spreading  the  infection.  The  clothing  of  the  nurse  and 
physician  may  convey  the  disease,  and  cases  are  very  numerous  in  which  physicians 
have  so  communicated  scarlet  fever  to  their  own  children  after  visiting  patients 
ill  with  this  malady. 

The  persistence  of  the  infection  in  articles  of  clothing  is  very  remarkable.  No 
other  acute  disease  renders  the  surroundings  of  the  patient  a  source  of  danger 
for  so  long  a  period.  Instances  in  which  clothing  or  upholstered  goods  have 
transmitted  the  disease  to  healthy  children  two  years  after  recovery  of  the  first 
patient  are  recorded. 

Articles  of  food  may  also  convey  the  infection.  Thus  Ekholm  has  reported 
an  instance  in  which  six  families  who  partook  of  milk  from  a  dair\-  in  which  there 
was  a  milkmaid  who  had  a  phlegmonous  pharyngitis,  suffered  from  scarlet  fever. 


UNDER 
1    YEAR 

BETWEEN 

1  AND  2 

BETWEEN 

2  AND  3 

BETWEEN 

3  AND  4 

BETWEEN 

4  AND  5 

BETWEEN 

5  AND  5 

BETWEEN 

6  AND  7 

BETWEEN 

7  AND  3 

BETWEEN 

8  AND  9 

BETWEEN 
9  AND   10 

1            

1^       1 

^ 

" t:::::::_:V: 

Vi            -  -           -                                    '         \ 

'- :::::;::::: \. ±— 

\ 

" ""                   5 

in                                           ;                               -       -             i. 

10                                            t-                                                  \          -p 



' ::t::::: i 

„               t  V 

^                                 _         __^L 

'                    '                                                                          ^i~~- 

6 — ~J :::::::::::::::::::::::::::::s:::::: 

'       1      s  T__ 

/                                             \ 

5              /                                                                                                                    -V- 

T                              ~                                                                                ' 

4_ 

3  7 :""":::::: 

t                          -                                -r-                      - 

Showing  age  incidence  of  scarlet  fever  based  on  7470  cases,  and  representing  the  combined 
statistics  of  Whitelegge,  Ballard,  and  Keen. 


The  breath  of  the  patient  and  the  air  of  the  bed-room  are  probably  incapable 
of  transmitting  the  infection,  unless  the  latter  is  laden  with  the  dust  containing 
the  microorganism.  It  is  noteworthy  that  nurslings  are  not  as  susceptible  as 
children  of  from  two  to  five  years,  at  which  period  of  life  the  disease  most  often 
occurs.     The  age  incidence  is  well  shown  in  Fig.  23. 

A  patient  who  is  a  sufferer  from  the  infection  of  scarlet  fever  is  not  capable 

of  transmitting  the  disease  until  the  rash  develops.     At  the  fourth  or  fifth  day  of 

the  disease  the  infectiousness  of  the  case  is  perhaps  at  its  height,  and  the  ability 

to  transmit  the  malady  exists  as  long  as  there  is  the  slightest  discharge  from  the 

G 


82  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

nose,  which  is  often  for  as  long  a  period  as  six  weeks.  It  is  important  to  remember 
that  not  only  the  nasal  mucus  but  the  discharge  from  a  purulent  otitis  media  or 
from  a  chronic  consecutive  scarlatinal  pharyngitis  are  also  active  sources  of  infec- 
tion, and  until  all  these  parts  arc  entirely  healtliy  the  danger  of  spreading  the 
disease  exists.  Indeed,  numerous  instances  are  recorded  in  which  children  with 
such  mild  consecutive  pharyngitis  as  to  escape  notice  have  conveyed  the  disease 
several  weeks  after  apparent  complete  recovery  from  scarlet  fever. 

Many  investigators  have  endeavored  to  isolate  the  specific  microorganism 
of  scarlet  fever,  but  without  success.  LoefHer,  Fraenkel,  and  other  German 
physicians  first  demonstrated  the  presence  of  streptococci  in  cultures  prepared 
from  secretion  taken  from  the  throats  of  scarlet  fever  patients,  but  their  observations 
were  limited  to  a  small  number  of  cases  and  are  of  interest  from  an  historical  rather 
than  a  practical  stand-point.  The  same  statement  may  be  made  concerning  the 
researches  of  Klein  in  connection  with  an  epidemic  of  scarlet  fever  (1SS5)  caused 
by  contaminated  milk  from  a  farm  at  Hendon,  in  England,  for  although  Klein 
cultivated  a  microorganism  from  lesions  on  the  udders  and  teats  of  cows  on  this 
farm,  which  apparently  was  identical  with  one  he  found  in  the  blood  of  scarlet 
fever  patients,  and  although  this  latter  organism  when  injected  into  calves  produced 
a  lesion  resembling  the  one  with  which  the  Hendon  cows  were  affected,  the  inquiry 
instituted  by  the  Medical  Society  of  Edinburgh  and  the  investigation  of  Dr.  Crook- 
shank,  of  London,  proved  that  the  disease  from  which  the  cows  suffered  was  a 
modified  form  of  cow-pox,  and,  moreover,  that  the  persons  who  milked  the  cows 
did  not  contract  scarlet  fever.  A  similar  history  as  to  cows  and  patients  has  more 
recently  been  recorded  in  Lincoln,  England.  In  1891  Kurth  found  in  the  throats 
of  scarlet  fever  patients,  in  pus  from  the  cervical  abscesses  and  in  the  viscera  of 
persons  who  had  died  from  scarlet  fever,  a  streptococcus  which  formed  a  twisted, 
gelatinous  mass  when  grown  in  broth.  This  organism,  called  by  Kurth  Strepto- 
coccus conglomeratus,  was  subsequently  studied  by  Mervyn  Gordon,  who  found  it 
present  in  the  throats  of  twenty  out  of  twenty-seven  scarlet  fever  patients,  in  the 
internal  organs  of  most  patients  who  died  from  the  disease,  and  in  the  fluid  of  a 
scarlatinal  pleural  effusion.  Baginsky  and  Sommerfield,  who  published  the  results 
of  their  investigations  at  about  the  same  time  as  Gordon,  found  a  streptococcus, 
having  virulent  properties  and  generating  a  toxin,  in  all  cases  of  scarlatinal  angina, 
and  in  cultures  made  from  the  viscera,  bone-marrow,  and  blood  of  one  hundred 
and  forty-two  children  in  whom  the  disease  terminated  fatally.  This  streptococcus 
they  considered  to  be  the  specific  organism  of  scarlet  fever. 

Of  the  work  done  by  American  bacteriologists  that  of  Class,  of  Chicago,  should 
be  mentioned.  In  1899  Class  noticed  the  frequent  presence  of  a  diplococcus  in 
cultures  made  from  the  throats  of  patients  having  different  forms  of  angina,  and 
upon  further  investigation  he  found  that  the  organism  in^•a^iably  occurred  in 
cases  of  scarlatinal  angina.  He  then  made  cultures  from  the  blood  of  scarlet 
fever  patients  and  from  desquamated  epidermal  scales,  and  found  the  same  diplo- 
coccus. Gradwohl,  of  St.  Louis,  and  Calvin  Page,  of  Boston,  have  also  found  an 
organism  identical  with  the  one  described  by  Class,  but  their  observations  were 
confined  to  a  small  number  of  cases. 

From  this  brief  resume  of  the  bacteriology  of  scarlet  fever,  it  is  apparent  that 
streptococci  are  generally  present  in  the  throat  of  scarlet  fever  patients,  and  that 
they  are  often  found  in  the  blood  and  internal  organs;  but  when  wc  come  to  consider 
that  streptococci  have  been  found  in  healthy  throats,  that  cases  of  streptococci 
angina  exist  independent  of  scarlet  fever,  and  tliat  streptococci  are  found  in  the 
blood  in  other  diseases,  it  is  not  justifiable  to  assume  that  any  one  of  the  forms 
thus  far  described  is  the  specific  organism  of  scarlet  fever.  Closely  associated 
with  the  specific  germ  of  scarlet  fever,  whatever  it  may  be,  we  always  find  a  variety 
of  the  streptococcus,  and  it  has  been  claimed  by  some  that  this  is  the  cause  of  the 


SCARLET  FEVER  83 

disease.  There  can  be  no  doubt  that  it  is  responsit)ie  for  a  large  nuinlKT  of  tlie 
symptoms  and  comphcations  of  the  disease. 

Prevention  or  Prophylaxis. — Every  case  of  scarlet  fever  should  be  promptly 
isolated  and  every  attendant  of  the  patient  should  also  be  prevented  from  mingling 
freely  with  the  inmates  of  the  house.  The  food  should  if  possible  be  placed  in  an 
outer  room  and  from  there  oljtained  by  the  nurse  for  the  patient.  If  the  nurse 
is  to  leave  the  room  her  clothes  should  be  changed.  Before  she  lea\-es  the  con- 
valescent patient  to  take  care  of  other  cases  she  should  take  a  hot  bath  and  have 
her  hair  shampooed.  Her  nasopharynx  should  be  well  cleansed  by  an  antiseptic 
spray  or  douche.  The  clothing  she  has  worn  in  the  sick-room  should  be  steril- 
ized by  boiling.  The  physician  should  always  change  his  clothes  on  entering  and 
leaving  the  room,  or  at  least  wear  over  his  street  dress  a  long  operating  gown  to 
protect  him  from  the  infection.  If  he  is  attending,  or  about  to  attend,  a  case  of 
confinement  he  should  refuse  to  take  charge  of  a  case  of  scarlet  fever.  The  same 
rule  holds  true  as  to  operative  cases. 

All  clothing  and  bedclothing  should  be  immersed  in  boiling  water,  or  in  a  disin- 
fectant solution,  before  they  are  taken -from  the  sick-room,  and  books  and  cards 
which  have  been  in  the  patient's  room  should  be  burned.  If  possible  it  is  better  to 
burn  the  pillows  and  mattress  than  to  attempt  to  disinfect  them.  If  they  are 
disinfected,  steam  under  pressure  should  be  used  for  this  purpose.  The  hanging  of 
sheets  saturated  with  disinfectant  fluids  over  doorways  and  the  placing  of  pans  of  dis- 
infectants about  the  house  are  utterly  useless  except  that  their  presence  constantly 
reminds  the  inmates  or  visitors  that  an  infectious  disease  is  present  and  so  aids  in  the 
maintenance  of  caution.  An  amount  of  disinfectant  in  the  air  sufficient  to  destroy 
the  contagion  will  destroy  the  patient  and  nurse.  After  the  illness  is  over  and  the 
patient  has  left  the  room,  it  should  be  carefully  disinfected  by  an  adequate  formal- 
dehyde generator,  the  floors  and  walls  being  first  moistened  with  water  to  aid  in 
the  efficiency  of  this  gas.  Afterward  the  floors  and  walls  should  be  scrubbed  with 
1  to  2000  bichloride  solution  or  one  of  chlorinated  lime. 

No  case  should  be  isolated  less  than  five  weeks,  and  no  case  should  be  allowed 
to  mingle  with  other  persons  as  long  as  nasal,  aural,  or  pharyngeal  discharges 
exist  even  if  they  persist  for  months.  There  is  no  proof  that  infection  is  transmitted 
by  scales.  Before  the  patient  is  discharged  he  should  receive  at  least  three  hot 
baths.  Particular  attention  should  be  paid  to  the  scalp  and  hair.  Sleeping  with 
other  children  is  to  be  prohibited  for  several  months. 

After  exposure,  a  child  should  be  placed  in  quarantine  for  at  least  a  week  to 
discover  if  the  disease  is  to  develop.  When  an  epidemic  is  present  all  schools 
should  be  closed. 

Pathology  and  Morbid  Anatomy. — A  point  of  primary  importance  to  be  borne 
in  mind  in  considering  the  pathology  of  scarlet  fever  is  that  the  organs  of  the  body 
suffer  from  a  multiple,  not  a  single  infection.  Whether  a  special  form  of  strepto- 
coccus is  the  cause  of  the  disease,  or  whether  an  entirely  distinct  organism  is  the 
cause,  the  fact  is  that  the  disease  is  accompanied  by  streptococcus  infection  in  all 
cases  and  not  rarely  by  other  forms  of  infection  as  well. 

The  organic  changes  produced  in  the  body  by  an  attack  of  scarlet  fever  are 
marked,  but  none  of  them  can  be  said  to  be  characteristic  of  the  disease.  Altera- 
tions in  the  skin  and  inflammation  of  the  mucous  membrane  of  the  mouth  and 
pharyixx  are  the  most  constant  changes,  but  even  these  may  escape  notice.  The 
skin  is  the  seat  of  a  very  acute  inflammatory  process  involving  to  a  varying  degree 
all  its  layers  and  terminating,  even  in  mild  cases,  in  exfoliation  of  the  superficial 
cells,  often  in  large  flakes.  The  pharyngeal  mucosa  is  inflamed,  the  inflammation 
varying  in  degree  from  a  mild  acute  pharyngitis  to  extensive  necrosis  involving 
the  deeper  strata  of  the  uvula  and  tonsils.  This  inflammation  in  a  modified  form 
extends  at  times  all  the  way  down  the  esophagus  and  by  way  of  the  Eustachian 


84  DISEASES  DUE  TO  A   SI'ECIFIC  IXFECTIO.X 

tiihe  into  the  middle  car,  where  it  not  infreqnentiy  causes  so  destructive  a  change 
as  to  produce  permanent  deafness;  or  if  the  infection  be  severe  and  no  vent  for 
the  pus  is  afforded  the  mastoid  cells  become  involved  and,  finally,  a  secondary 
meningitis,  or  abscess  of  the  brain,  is  produced.  This  is  a  rare  sequel.  In  still 
other  instances  the  inflammatory  process  extends  into  the  nasal  cavities  and  from 
them  proceeds  to  an  infection  of  the  antrum  of  Ilighmore  or  even  the  frontal 
sinus.  Extension  of  the  pharyngeal  lesions  to  the  lymphatics  of  the  submucosa 
may  cause  infection  of  the  cervical  and  submaxillary  lymph  nodes,  so  that  there 
is  developed  great  swelling  under  the  jaw,  and  in  some  instances  sup])urati(iii, 
the  so-called  "collar  of  brawn." 

Equal  in  frequency  with  these  changes,  and  of  more  importaiu'c,  are  tlmse  wliich 
take  place  in  the  kidneys.  These  changes  not  only  endanger  the  life  of  the  |)aticnt 
during  the  illness,  but  occasionally  leave  him  with  kidneys  structurally  so  impaired 
that  complete  restoration  to  health  may  never  take  place.  The  renal  changes 
are  primarily  those  of  an  acute  diffuse  nephritis  involving  the  whole  texture  of  the 
kidney,  particularly-  the  cortex,  and  accompanied  by  marked  albuminuria,  inter- 
tubular  cellular  infiltration  and  necrosis,  and  desquamation  of  the  epithelium  lining 
the  tubes.  Areas  of  necrosis  and  infarction  and  even  acute  suppurative  nephritis 
occur,  although  infrequently. 

When  the  infection  with  the  streptococcus  is  particularly  severe  and  the  evidences 
of  toxemia  are  profound  the  autopsy  reveals  degenerative  changes  in  the  heart 
muscle,  areas  of  necrosis  in  the  liver,  and  bronchopneumonia  with  swelling  and 
softening  of  the  brt)nchial  nodes.  I)egenerati\-e  or  necrotic  changes  in  the  myo- 
cardium and  endocarditis,  vegetative  or  ulcerative,  may  l)e  present.  Pericarditis 
may  be  marked.  As  in  all  septic  infections  arthritis  may  be  found  in  numerous 
joints.     Pleurisy,  if  present,  often  results  in  empyema. 

With  the  onset  of  scarlet  fever  there  develops  a  hyperleukocytosis  amounting, 
according  to  Tileston  and  Locke,  to  from  18,000,  to  40,000.  After  the  eighth 
day,  if  there  are  no  complications  of  an  inflammator>-  nature,  there  is  a  gradual 
decline  to  the  normal,  somewhere  about  GOOO  to  8000.  The  increase  is  chiefly 
in  the  polymorphonuclear  cells. 

Schick  and  von  Pirquet  have  advanced  the  \iew  that  the  eru])tive  stage  of 
all  the  exanthematous  fevers  is  a  manifestation  of  anai)hylaxis,  the  time  between 
infection  and  the  appearance  of  the  rash  being  that  required  for  anajjliylactie 
bodies  or  ergins  to  de\'elop.  This  view  is  not  unix'ersally  accepted,  i)Ut  both 
Schick  and  Cederberg  liave  i)retty  clearly  shown  that  the  late  symptoms  or  sequela% 
particularly  po.st.scarlatinal  nephritis  are  due  to  this  cause,  at  least  in  part,  in 
that  a  state  of  hypersensitiveness  is  developed  as  the  result  of  the  jjresence  of 
reaction  or  anaphylactic  bodies  which,  if  the  system  has  not  succeeded  in  eliminating 
or  destroying  all  the  germs,  sensitize  it  to  the  toxic  substance  which  the  germs 
develop.  As  the  kidneys  are  the  organs  actively  engaged  in  excreting  germs  and 
toxins,  these  germs  or  poisons  are  present  in  the  renal  tissues  in  great  abundance 
and  this,  perhaps,  explains  the  frequency  with  which  postscarlatinal  nephritis 
develops.  In  those  cases  which  escape  such  complications,  the  germs  are  elimi- 
nated or  destroyed  before  the  reaction  bodies  de\elo]).  The  i)rimary  rasii  is  toxic 
while  the  secondary  rashes  and  comi)lications  are  probably  ana])hyla(tic. 

Incubation. — The  period  of  incubation  of  scarlet  fever  is  about  two  to  six  days, 
but  cases  are  recorded  in  which  it  has  been  as  l)rief  as  twenty-four  hours  and  as 
long  as  twenty-one  days.  Reimer  gives  the  following  figures:  1  day,  379  cases; 
2  days,  928  cases;  3  days,  751  eases.  The  perioil  of  incubation  is,  therefore,  the 
siiortcst  of  all  the  acute  exanthematous  fevers. 

Symptoms. — The  symptoms  of  an  ordinary  case  of  scarlet  fever  consi.st  chiefly 
in  soir  throat,  a  modrnitrli/  hiqh  fever,  a  scarlet  rash  first  aj^jjearing  on  the  chest, 
albumhiiiria  of  moderate  degree,  and  a  tendency  to  middle-car  iujlaminatiun. 


SCARLET  FEVER  85 

The  onset  of  the  symptoms  in  scarlet  fever  is  usually  abrupt  and  the  se\x'rity 
and  abruptness  of  these  symptoms  is  often  indicative  of  the  severity  of  the  attack 
which  is  to  follow.  A  child  api)arently  in  good  health  in  the  evenin}<  i)asses  a 
restless  night,  and  in  the  morning  suddenly,  without  apparent  cause  and  perhaps 
without  preliminary  nausea,  vomits  actively  as  soon  as  its  breakfast  is  swalUnved. 
Often  this  vomiting  is  almost  malignant  in  its  severity.  If  the  iemperuture  is 
taken,  it  will  usually  be  found  to  be  101°  or  \0'.'°,  the  skin  feels  hot  aiifl  dry,  the 
pulse  is  quick,  the  eyes  bright,  the  expression  listless,  and  the  tongue  and  mucous 
membrane  of  the  mouth  distinctly  reddened.  Sometimes  the  first  complaint 
on  the  part  of  the  patient  is  one  of  sore  throat,  in  other  cases  no  such  discomfort 
is  mentioned;  but  if  the  mouth  he  opened  the  ])haryngeal  mucous  meml)rane 
is  seen  to  be  angry  and  inflamed,  and  perhaps  unduly  dry.  The  child  is  manifestly 
ailing,  is  peevish,  and  is  anxious  to  lie  down.  In  from  twelve  to  twenty-four 
hours  from  the  manifestation  of  the  preliminary  symptoms  just  detailed,  and  in 
some  cases  in  even  less  time  than  this,  the  eruption,  or  rash,  develops,  beginning 
on  the  neck  and  upper  part  of  the  chest,  as  a  rule. 

No  one  of  the  eruptive  diseases  is  so  characteristic  in  its  appearance  as  is  scarlet 
fever,  the  skin  of  the  patient  being,  as  the  name  of  the  disease  indicates,  actually 
scarlet  or  as  bright  a  red  as  is  the  shell  of  a  boiled  lobster.  Again,  in  no  other 
one  of  the  eruptive  diseases  does  the  rash  appear  over  so  wide  a  surface  in  the 
first  hours  of  its  appearance  as  in  scarlet  fever.  Not  rarely  the  entire  body  and 
extremities  are  involved  in  four  or  five  hours. 

There  are  four  peculiarities  about  this  rash  which  are  worthy  of  note:  first, 
it  is  punctate — that  is,  about  each  hair  follicle  in  the  skin  the  color  is  slightly 
deeper  than  elsewhere;  second,  the  rash  is  often  most  marked  in  the  folds  of  the 
joints,  as  about  the  groins;  third,  the  skin  of  the  face  about  the  moutli  or  in  the 
nasolabial  line  is  pallid,  forming  a  marked  contrast  to  the  scarlet  hue  elsewhere; 
and  fourth,  the  rash  on  the  upper  part  of  the  thorax  is  often  very  profuse. 

When  the  rash  is  developed,  the  sense  of  heat  conveyed  to  the  hand  and  com- 
plained of  by  the  child  is  notable.  The  eruption  persists  from  three  to  seven 
days  in  the  majority  of  cases.  Desquamation  of  the  epiderm,  which  comes  away 
in  large  flakes,  rather  than  in  fine  bran-like  scales,  begins  at  the  twelfth  day  but 
sometimes  not  until  the  twentieth  day.  The  skin  may  literally  peel  off  the  hands 
and  feet.  In  rare  instances  it  may  be  shed  from  the  hand  in  the  shape  of  an  old 
glove.  This  desquamation  lasts  from  a  week  to  three  weeks,  beginning  about 
the  neck  and  continuing  longest  on  the  palmar  and  plantar  surfaces,  where  the 
skin  is  thick.  Indeed,  I  have  seen  it  continue- between  the  toes  for  six  or  eight 
weeks.  The  period  of  desquamation  is,  however,  greatly  shortened,  as  a  rule, 
if  during  the  illness  the  child  has  been  anointed  by  some  oily  substance  to  allay 
dermal  irritation,  or  if  during  convalescence  it  is  frequently  bathed. 

The  stage  of  invasion,  already  described,  varies  in  certain  cases  to  a  considerable 
degree.  It  may  be  so  mild  as  to  lead  to  a  belief  that  the  rash  is  due  to  indigestion, 
and  it  may  be  so  severe  that  the  patient  is  first  convulsed,  and  then  speedily  over- 
whelmed by  toxemia.  The  eruption  may  not  be  widely  diffused,  but  appear  for 
a  short  time  on  the  chest  and  abdomen,  in  the  groin,  or  about  the  buttocks  before 
it  spreads  elsewhere.  It  may  not  spread  farther  than  these  areas,  and  may  last 
only  one  day.  Such  cases  are  often  given  the  unfortunate  name  of  "scarlet  rash." 
They  are  just  as  capable  of  giving  scarlet  fever  to  another  child  as  a  more  severe 
attack.  In  other  cases,  of  a  malignant  type,  the  rash  seems  to  be  suppressed, 
the  skin  is  mottled,  but  the  true  rash  fails  to  appear,  or  it  may  appear  in  blotches, 
which  may  seem  to  be  macular,  as  in  measles.  When  doubt  exists  in  such  cases, 
the  patient  will  be  benefited  and  the  diagnosis  cleared  by  a  warm  bath  or  warm 
pack  to  stimulate  the  peripheral  circulation  and  bring  out  the  rash. 

The  temperature  in  scarlet  fever  runs  its  course  side  by  side  with  the  severity 


86  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

of  tlio  disease.  It  reaches  its  acme  within  a  few  hours  from  tlie  onset,  and  is  often 
as  high  as  105°  within  twelve  hours.  As  a  rule,  this  height  is  not  maintained, 
but  after  twenty-four  hours  to  three  days  it  falls  gradually  to  alwut  10.3°,  and  then 
gradually  decreases  daily  by  lysis,  reaching  normal,  as  desquamation  l)egins, 
about  the  eighth  or  ninth  day  (Fig.  24).  If  it  remains  high  or  if  a  recrudescence 
occurs,  some  secondary  trouble,  such  as  middle-ear  disease  or  bronchopneumonia, 
is  to  be  sought  for. 


Fig. 

24 

Slhf^ 

. 

2 

9 

4 

.-, 

(1 

8 

» 

10 

11 

12 

I!! 

14 

1.-. 

los' 
104'- 
103' 
102' 
loi' 

99" 

M  E 

ME 

ME 

M  E 

ME 

ME 

M  E 

ME 

ME 

M  E 

ME 

M  E 

M  E 

M  E 

ME 

f\ 

A 

1 

J 

1/ 

A 

/ 

^  1 

* 

/ 

V 

/ 

/ 

/ 

/ 

/ 

/ 

/^ 

A 

11 

\b 

ib 

\b 

\L 

b 

Chart  of  scarlet  fever. 


In  the  stage  in  which  the  disease  is  fully  developed  the  clinical  picture  presents 
very  great  variations  in  different  cases.  In  some  children  with  a  well-developed 
rash,  the  systemic  symptoms  are  so  mild  that  it  is  difficult  to  keep  the  patient 
in  bed,  and  all  the  manifestations  seem  of  little  moment.  In  others  the  general 
symptoms  are  sufficient  to  show  that  the  child  is  seriously  ill,  and  in  still  others 
of  a  severe  type  the  systemic  state  may  be  one  of  deep  toxemia,  so  that  the  child 
seems  overwhelmed  by  the  infection.  The  cases  in  which  toxemia  is  marked  are 
not  necessarily  those  in  which  great  glandular  involvement  is  present,  although 
both  sets  of  symptoms  may  occur  simultaneously. 

Sometimes  the  throat  symptoms  by  their  severity  mask  all  others.  Not  only 
may  the  pharyngeal  and  tonsillar  surfaces  be  ulcerated,  but  they  may  be  covered 
by  a  false  membrane,  which,  in  some  cases,  is  due  to  a  concurrent  diphtheria,  but 
which  may  also  be  due  to  the  streptococcus,  and  is  always  polymicrobic  in  nature. 
Such  cases  often  present  a  horrid  type  of  the  disease,  for  the  lips  and  teeth  are 
covered  with  sordes,  the  tissues  of  the  neck  are  infiltrated  and  swollen,  and  the 
head  thrown  far  back  to  diminish  pressure  on  the  air-passages  prodnccil  by  the 
swelling.  In  such  cases  the  general  infection  extends  rapidly  into  the  chest,  and 
bronchial  or  pulmonary  symptoms  develop  with  great  rapidity,  thereby  causing  a 
fatal  issue,  although  even  with  these  grave  complications  recoverj-  sometimes 
takes  place.     (See  Complications.) 

If  to  these  malignant  manifestations  are  added  a  tendency  to  suppression  of 
urine,  because  of  the  intense  nephritis  which  has  been  produced,  the  signs  of  toxemia 
deepen  into  stupor  and  death  ensues.  Cases  of  this  type  rarely  die  before  the 
sixth  day,  since  this  time  is  required  to  develop  the  contlition  described.  There 
is,  however,  a  fulminant  form  of  the  disease  in  which  the  malady,  after  being  ushered 
in  by  severe  convulsions,  speedily  develops  into  deep  stupor,  with  hypcrinrexia 
and  death.  In  some  of  these  cases,  however,  the  infection  is  so  profound  that  a 
high  temperature  does  not  occur,  the  temperature  never  rising  above  101°.  These 
cases  are  very  rare  and  are  described  more  frequently  by  French  clinicians  than 
they  are  seen  by  Anglo-Saxon  practitioners. 

A  few  cases  are  on  record  in  which  no  fever  has  developed,  and  others  in  which 
no  rash  has  been  seen. 

Under  the  name  "surgical  scarlet  fever"  is  described  a  febrile  affection  which 
attacks  persons,  usually  children,  after  surgical  operations  or  injuries.     The  term 


SCARLET  FEVER  87 

is  an  unfortunate  one,  for  no  such  malady  exists  as  a  distinct  disease.  The  con- 
dition is  an  erythema  due  to  sepsis  or  else  it  is  an  attack  of  scarlet  fever  coming 
on  during  convalescence  from  the  operation. 

Complications  and  Sequelae. — Scarlet  fever  depends  very  largely  for  its  gravity 
upon  its  complications  and  sequeliK,  which  are  not  rarely  met  with.  The  most 
constant  of  these  is  a  certain  degree  of  renal  irritation  or  inflammation.  The  con- 
dition of  the  kidneys  from  a  time  very  early  in  the  attack  is  such  that  slight  albumin- 
uria may  be  considered  a  fairly  constant  symptom.  In  some  instances  this  febrile 
albuminuria  is  the  only  evidence  that  the  kidneys  are  aft'ected,  but  in  others  the 
character  of  the  urine  and  the  general  systemic  condition  render  it  very  plain  that 
a  true  nephritis  is  present.  Not  only  does  the  urine  of  such  patients  show  consider- 
able quantities  of  albumin  and  casts,  but  there  is  distinct  puffiness  of  the  eyelids 
and  edema  of  the  ankles,  or  even  a  generalized  anasarca.  In  such  patients,  if 
this  state  persists,  transudation  may  take  place  into  the  serous  cavities  of  the 
body,  and  the  patient  suffers  from  the  pressure  produced  by  the  fluid  upon  the 
heart  and  lungs.  He  may  develop  uremic  symptoms,  and  these  in  turn  may  cause 
death.  In  manj^  of  these  cases,  however,  the  acute  nephritis,  responsible  for 
these  manifestations,  speedily  diminishes  with  the  subsidence  of  the  disease  itself, 
and  recovery  follows  with  a  rapidity  which  is  extraordinary.  I  have  seen  recovery 
take  place,  even  after  the  anasarca  was  so  marked  as  to  almost  close  the  eyes  and 
after  repeated  severe  uremic  convulsions. 

There  is  still  another  type  of  renal  disorder  met  with  in  a  few  cases  of  scarlet 
fever  in  which  the  infection  seems  so  intense  that  the  kidneys  are  completelj'  sup- 
pressed in  their  functional  power  very  early  in  the  attack,  and  in  which  we  find 
great  diminution  of  urinary  flow,  hematuria,  and  copious  amounts  of  albumin 
and  casts.  In  these  cases  the  toxemia  of  the  disease  and  that  resulting  from  the 
renal  lesions  produces  death  in  a  very  short  time. 

Suppression  of  urine  may  be  the  first  symptom. 

The  renal  changes  of  scarlet  fever  are,  therefore,  to  be  carefully  watched,  and 
the  greatest  care  must  be  taken  that  the  kidneys  are  not  permitted  to  be  additionally 
congested  by  the  patient  being  chilled.  Exposure  during  and  soon  after  scarlet 
fever  may  change  a  mild  renal  state  into  a  most  desperate  condition. 

A  very  considerable  number  of  cases  of  scarlet  fever  give  positive  cultures  of 
the  Bacillus  diphtherias  during  convalescence  as  well  as  during  the  attack.  Higgins 
states  he  found  this  organism  in  the  nose  and  pharynx  of  no  less  than  25  per  cent, 
of  the  children  sent  home  as  cured  of  scarlet  fever.  As  long  ago  as  1898  Todd 
reported  such  a  result  in  five  cases  out  of  365  patients  suffering  from  this  disease. 
This  is  far  in  excess  of  the  percentage  of  positive  cultures  in  supposedly  healthy 
persons.  Thus  in  3096  persons  in  communities  in  Massachusetts,  practically  free 
of  the  disease,  the  bacillus  was  found  in  only  1.4  per  cent. 

As  a  sequel,  rather  than  a  complication  of  scarlet  fever,  inflammations  of  the 
joints  sometimes  occur.  This  is  not  acute  rheumatism,  but  of  the  nature  of  a 
sejjtic  arthritis.  Rarely  the  joint  suppurates.  The  swelling  does  not  persist,  as 
a  rule,  if  the  effusion  be  simply  serous.  Another  very  rare  sequel  of  scarlet  fever 
is  dislocation  of  the  hip-joint.  In  1804  J.  Franck  reported  a  case  of  dislocation  of 
the  hip  occurring  in  an  attack  of  scarlet  fever.  In  1894  Champenois  published 
an  account  of  three  other  cases,  which  were  all  he  could  collect  from  the  literature. 
Since  1894  H.  Stanfield  Collier  has  reported  two  cases.  Robert  Jones,  of  Liverpool, 
states  that  one  such  case  has  come  under  his  observation. 

Much  more  common  that  arthritic  changes  during  or  after  scarlet  fever  are 
those  which  are  met  with  in  the  ears,  due  to  an  extension  of  the  septic  inflammation 
from  the  throat  through  the  Eustachian  tube  to  the  middle  ear.  These  have 
already  been  referred  to  when  considering  the  pathology  of  the  disease.  The 
physician  should  always  be  on  his  guard  for  aural  inflammation  in  the  course  of 


88  DISEASES-  DUE  TO  A   SPECIFIC  IXFECTIOX 

tliis  malady  and  after  it  has  run  its  course.  I'ermanent  deafiii's.s  not  rarely  results 
from  the  otitis  media  due  to  this  cause. 

Parotitis  sometimes  occurs  as  a  complication. 

Next  to  acute  articular  rheumatism,  scarlet  fever  stands  as  the  most  common 
of  all  the  acute  infections  in  producing  vnlviilnr  disease  of  the  heart.  Tliese  changes 
are  in  the  endocardium  and  myocardium,  and  may  be  acute  and  transient  or  become 
permanent.  Very  rarely  does  the  endocarditis  become  severe  enough  to  be  called 
ulcerative.  Great  responsibility  rests  upon  the  physician  in  regard  to  the  cardiac 
changes  in  this  disease,  because,  while  it  is  true  that  lie  cannot  ]jrevent  them,  lie 
can  often,  by  insisting  on  rest  during  the  attack  and  during  convalescence,  to  a  large 
extent,  limit  their  severity,  both  as  to  their  temporary  and  permanent  character. 
This  is  the  more  important,  since,  as  in  all  acute  infections,  the  heart  is  often  the 
seat  of  a  myocardial  change. 

Bronchopnemnonia  develops  in  a  small  proportion  of  cases.  EDipi/enin  ma\'  be 
a  secpiel  to  scarlet  fever,  and  is  usually  insidious  in  onset. 

The  induration  of  the  cervical  (/lands,  which  may  suppurate,  has  already  been 
referred  to. 

Nervous  complications  of  scarlet  fever,  aside  from  delirium  and  convulsions 
due  to  the  toxemia,  are  rare.  As  a  sequel,  chorea  may  develop,  or  hemiplegia 
arise,  caused  by  an  embolus  lodging  in  a  cerebral  vessel,  ^'ery  rarel\-  an  acute 
ascending  paralysis,  which  is  the  result  of  neuritis,  may  develop  in  the  lower 
limbs. 

An  exceedingly  rare  complication  of  scarlet  fever  is  perito7iitis,  due  in  all  proba- 
bility to  a  streptococcus  infection  of  the  peritoneum.  McColIom  and  Blake,  of 
Boston,  have  reported  two  such  cases  in  the  Boston  City  Hospital  Reports. 

Diagnosis. — While  scarlet  fever  in  its  typical  development  is  not  difficult  of 
diagnosis,  it  not  infrequently  happens  that  mild  attacks  render  a  decision  as  to  the 
exact  nature  of  the  illness  most  difficult  to  determine.  The  chief  reason  for  this 
is  that  children  very  commonly,  and  adults  more  rarely,  develop  a  roseola  or  rose 
rash  as  a  result  of  many  different  causes,  and  if  the  manifestation  of  scarlet  fever 
be  mild,  or  the  rose  rash  be  severe,  the  skin  lesions  may  not  only  not  aid  in  diagnosis, 
but  greatly  impede  the  physician  in  reaching  a  decision.  The  most  common  of 
these  rose  rashes  is  that  produced  by  certain  types  of  indigestion,  and  particularly 
that  which  follows  eating  fish,  shell-fish  seeming  especially  prone  to  cause  it.  As 
active  vomiting  and  diarrhea  and  even  fever  may  be  present  in  such  cases,  the 
patient  at  first  sight  quite  markedly  resembles  one  suffering  from  scarlet  fever; 
but  the  absence  of  sore  throat,  of  enlarged  tonsils,  of  enlarged  cervical  glands,  and 
a  history  of  no  exposure  to  the  specific  fever,  all  aid  in  excluding  scarlatina, 
particularly  if  it  can  be  discovered  that  indigestible  food  has  been  ingested.  Then, 
too,  the  rose  rash  of  indigestion  does  not,  as  a  rule,  appear  first  on  the  chest.  In 
some  persons,  with  a  very  sensitive  skin,  contact  with  nettles  or  other  irritants 
may  cause  a  roseola.  In  all  such  cases  the  physician  should  not  be  hasty  in  making 
a  diagnosis,  but  insist  that  enough  time  be  given  to  permit  him  to  make  a  careful 
study  of  the  case  for  several  Hays  before  expressing  an  opinion.  In  such  instances 
the  patient  should  be  isolated  until  the  diagnosis  is  decided. 

The  rose  rash  sometimes  met  with  in  German  measles  is  never  as  scarlet  as  it 
is  in  true  scarlet  fever  and  is  distinctly  maculated.  Further,  it  appears  on  the 
face  before  it  is  seen  on  the  chest,  the  punctation  of  the  rash  of  scarlet  fever  is 
absent,  the  fever  is  slight  and  lasts  but  two  or  three  days,  and  flaky  desquamation 
does  not  occur. 

Roseola  due  to  vaccination  and  that  due  to  the  use  of  diphtheria  antitoxin  are 
easily  diagnosticated  by  the  history  of  the  patient. 

Should  a  rose  rash  with  fever  develop  in  an  adult  there  is  much  more  likelihood 
of  its  being  due  to  early  secondary  syi)hilis  than  to  scarlet  fever.     The  rose  rash 


SCARLET  FEVER     ■  89 

of  syphilis  is  not,  however,  so  bright  a  red  as  that  of  scarlatina.  Such  a  rash, 
when  due  to  syphihs,  disappears  and  reappears,  becomes  dusky,  and,  finally,  it  is 
apt  to  be  circinate. 

Sometimes  in  acute  and  chronic  nephritis  n<jt  due  to  scarlet  fever  a  rose  rash 
develops.  The  absence  of  throat  symptoms  and  the  signs  of  nephritis  revealed 
by  the  urine  aid  in  the  differentiation. 

A  condition  called  "erythema  scarlatiniform"  has  a  sudden  onset  with  fever, 
and  is  characterized  by  a  rash  which  develops  rapidly  over  the  whole  body,  lasts 
for  several  days,  and  ends  in  desquamation.  The  absence  of  throat  symjitoms 
in  these  cases  is  once  more  an  important  differential  point.  Further,  the  other 
symptoms  are  by  no  means  so  severe  as  the  rash  would  lead  one  to  exj^ect.  Such 
patients,  too,  usually  have  a  history  of  repeated  attacks. 

A  factor  of  very  great  value  in  diagnosis  is  the  peculiar  appearance  of  the  tongue 
in  many  cases  of  scarlet  fever.  At  the  time  of  onset  it  may  have  a  heavy  white 
coating,  which  soon  diminishes  in  degree  and  becomes  dotted  with  red  and  enlarged 
papillae.     This  has  been  called  the  "strawberry  tongue"  of  scarlet  fever. 

Another  point  of  some  importance  is  the  time  at  which  desquamation  appears, 
for  the  mere  occurrence  of  desquamation  is  by  no  means  peculiar  to  scarlet  hver. 
In  this  disease  this  symptom  usually  develops  about  the  sixth  day  on  the  face  and 
neck,  and  about  the  eighth  day  on  the  chest  and  back.  The  hands  do  not  begin  to 
desquamate  until  as  late  as  the  twelfth  day,  and  the  feet  some  days  later  than  this. 
Other  eruptions  which  resemble  scarlet  fever  and  desquamate,  usually  begin  to 
shed  the  skin  in  these  areas  earlier  than  the  days  just  named. 

In  the  cases  of  scarlet  rash  due  to  sepsis  it  is  noteworthy  that  the  progress  of 
the  malady  is  always  aberrant  or  irregular,  for  the  throat  symptoms  are  often 
absent,  the  temperature  is  rather  that  of  sepsis  than  scarlatina,  and  the  septic 
symptoms  may  be  severe.  These  cases  are  particularly  interesting  and  worthy 
of  the  most  careful  study,  because  antiseptics,  when  absorbed,  sometimes  produce 
a  scarlatiniform  rash,  and  because  if  the  case  be  one  of  true  scarlet  fever  it  is  a 
menace  to  all  other  children,  sick  or  well.  As  the  differential  diagnosis  of  such 
cases  cannot  be  made  in  some  instances  till  the  disease  has  lasted  for  some  days, 
or  until  desquamation  has  begun,  all  patients  with  such  symptoms  should  be 
promptly  isolated.     A  focus  of  septic  infection  is  to  be  carefully  sought  for. 

Under  the  name  Df  the  Rumpel-Leede  test  the  following  test  to  determine  that 
scarlet  fever  is  the  cause  of  an  illness  may  be  resorted  to,  particularly  in  the  period 
between  the  fading  of  the  eruption  and  the  beginning  of  desquamation,  when  the 
case  is  very  infectious.  A  bandage  like  that  used  as  a  cuff  in  the  Tycos  sphygmo- 
manometer is  placed  around  the  arm  and  pressure  is  applied  to  the  point  of 
extinguishing  the  radial  pulse.  When  it  is  removed  there  may  be  found  in  scarlet 
fever  on  the  flexor  surface  just  above  the  elbow  several  well-marked  petechise  not 
there  before. 

Dohle  found  in  the  polymorphonuclear  leukocytes  of  scarlet  fever  certain  so-called 
"inclusion  bodies"  which  have  been  proved  not  to  be  pathognomonic  of  the  disease 
although  they  occur  with  great  constancy  during  the  first  five  or  six  days  of  its 
onset.  In  some  cases  they  fail  to  appear  at  any  time.  If  antitoxic  serum  has 
been  used  or  sepsis  or  streptococcic  sore  throat  is  present,  their  presence  possesses 
no  special  diagnostic  value  as  to  scarlet  fever.  They  occur  in  a  small  proportion 
of  cases  of  measles.  Boltenstern,  who  has  exhaustively  considered  their  value 
in  diagnosis  believes  that  they  are  a  distinct  aid,  but  Ker,  who  is  a  Medical  Superin- 
tendent of  the  Edinburgh  City  Hospital,  believes  that  this  aid  to  diagnosis  "is 
hardly  worth  the  trouble  entailed."  He  believes  that  it  is  of  most  value  in  separat- 
ing serum  rashes  from  true  scarlet  fever.  These  "inclusion  bodies"  occur  as 
round  or  oval  granules,  of  which  one  or  two  may  be  found  in  the  protoplasm  of 
the  cell.     They  stain  well  with  Hanson's  stain  or  with  carbol-methyl  blue.     In 


90  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

addition  to  tliese  granules  other  shapes  whicli  arc  spiral  or  rod-like  in  ai^pearance 
also  occur. 

Prognosis. — This  varies  greatly  in  different  epidemics  and  depends  largely  upon 
the  severity  of  the  sjTnptoms  in  a  given  case.  The  malady  is  always  to  be  con- 
sidered a  grave  one.  The  actual  mortality  is  shown  in  the  following  statistics. 
Of  26,921  cases  of  scarlet  fever,  3216,  or  11.9  per  cent.,  were  fatal.  Holt  states 
that  the  average  mortality  is  from  10  to  14  per  cent.,  but  for  children  under  five 
years  of  age  the  mortality  varies  from  20  to  30  per  cent.  (See  Fig.  2.5.)  The 
diminution  of  mortality  after  the  first  decade  of  life  is  noteworthy. 

Treatment. — In  the  treatment  of  scarlet  fever  the  fact  must  never  be  lost  sight 
of  that  the  disease  is  self-limited,  that  it  is  bound  to  run  its  course,  and  the  most 
the  physician  can  do  is  to  guide  his  patient  through  the  illness  with  the  hope  that 
complications  may  be  avoided  and  that  severe  symptoms  may  be  modified. 

First  and  foremost  in  the  treatment  of  this  malady,  it  is  essential  that  the  patient 
have  hygienic  surroundings,  with  plenty  of  fresh  air  and  careful  avoidance  of 
draughts  and  exposure  to  sudden  changes  of  temperature,  since  such  exposures 
by  chilling  the  surface  of  the  bodj^  are  almost  certain  to  exaggerate  the  renal  con- 
gestion or  inflammation  which  is  practically  always  present  during  the  acute 
stages  of  this  disease.  Indeed,  it  may  be  said  that  the  prime  object  of  the  physician 
and  nurse,  from  the  beginning  to  the  end  of  the  attack,  is  to  use  every  eft'ort  to 
avoid  sources  of  irritation  to  the  kidneys,  for  it  cannot  be  doubted  that  many 
cases  of  serious  renal  difficulty  which  arise  in  connection  with  scarlet  fever  depend 
upon  carelessness  in  this  respect.  It  is  also  important  to  remember  that  these 
precautions  in  regard  to  exposure  are  not  only  necessary  during  the  acute  attack, 
but  until  convalescence  has  been  thoroughly  completed  and  until  the  urine  no 
longer  shows  any  evidence  whatever  of  renal  irritation.  As  these  lines  are  written 
I  have  seen  in  consultation  a  boy,  aged  fourteen  years,  who  apparently  liad  reco\'ered 
entirely  from  an  attack  of  scarlet  fever,  except  that  there  was  still  some  descjuama- 
tion  in  the  palms  of  his  hands.  He  was  allowed  to  play  ball  out-of-doors,  became 
overheated  and  then  chilled,  and  within  forty-eight  hours  sufl'ered  violent  uremic 
convulsions,  which  nearly  cost  him  his  life. 

Medicinally,  it  is  usually  well  in  cases  of  scarlet  fever  to  prescribe  from  the  first 
a  mild  alkaline  diuretic,  of  which,  perhaps,  the  best  is  5  grains  of  citrate  of  potassium 
with  20  drops  of  sweet  spirit  of  nitre  in  water  three  or  four  times  a  day  to  a  child 
of  eight  years,  giving  at  the  same  time  copious  ciuantitics  of  such  pure  water  as 
the  non-sparkling  water  from  Poland  Springs,  or  any  other  spring-water  which 
contains  a  very  small  amount  of  organic  and  inorganic  matter.  By  these  means 
we  flush  the  kidneys  of  toxic  substances  which  in  a  concentrated  form  might  produce 
serious  renal  irritation. 

The  second  point  of  therapeutic  importance  is  the  condition  of  the  throat.  If 
the  child  is  old  enough  to  gargle  its  throat  with  a  weak  solution  of  chlorate  of 
potash  (3  or  5  grains  to  the  ounce)  four  or  five  times  a  day,  such  a  gargle  is  useful 
from  the  very  beginning  to  the  end  of  the  attack.  When  the  inflammatory  changes 
in  the  pharynx  are  severe,  the  part  may  be  cleansed  with  a  spray  of  i)eroxide  of 
hydrogen,  or  this  drug  may  be  applied  by  means  of  a  cotton  applicator,  the  throat 
being  afterward  cleansed  by  a  spray  of  Dobell's  solution.  For  the  pseudomem- 
branous pharyngitis  which  sometimes  develops,  a  similar  local  treatment  is  advisable, 
and,  combined  with  this,  both  diphtheria  antitoxin  and  antistreptococcic  serum 
should  be  given.  If  the  false  membrane  be  due  to  the  Klebs-Loeffler  bacillus, 
diphtheria  antitoxin  is  certainly  indicated,  and,  as  the  streptococcus  is  always 
present  in  scarlet  fever,  and  is  probably  responsible  for  the  formation  of  false 
membranes  in  some  cases,  the  use  of  serums  designed  to  antagonize  both  of  these 
poisons  is  manifestly  rational. 

For  the  relief  of  the  intense  burning  and  itching  of  the  skin  which  is  ]jrescnt  in 


SCARLET  FEVER 


91 


some  cases,  the  child  may  be  anointed  with  oHve  oil  containing  0.5  to  1  per  cent, 
of  carbolic  acid,  or  weak  carbolized  vaselin  may  be  used.  Sometimes  a  very 
distinct  fall  in  temperature  can  be  produced  by 
allaying  irritation  of  the  skin  in  this  manner. 

Should  the  fever  become  high  enough  to  deserve 
attention — that  is,  if  it  persistently  remains  above 
103°  or  if  it  occasionally  rises  as  high  as  105° — 
the  patient  should  be  sponged  with  tepid  water 
and  alcohol,  a  small  ice-bag  being  simultaneously 
applied  to  the  head.  Such  a  sponging,  given  early 
in  the  evening,  will,  by  diminishing  the  irritation 
of  the  skin  and  quieting  the  peripheral  sensory 
nerves,  often  cause  the  child  to  pass  a  comfortable 
night.  The  antipyretic  coal-tar  drugs  are  contra- 
indicated  in  these  cases,  except  under  extraordin- 
ary circumstances. 

If  intense  nervous  irritation  is  present,  5  or  10 
grains  of  the  bromide  of  strontium  or  sodium  may 
be  given  several  times  a  day.  Full  doses  of  cliloral 
have  been  highly  recommended,  but  they  are  often 
contra-indicated  because  of  the  irritant  effects 
upon  the  kidneys  and  the  depressant  influence 
upon  the  heart.  Should  evidence  of  circulatory 
failure  develop,  small  doses  of  an  old  brandy 
poured  over  shaved  ice,  or  given  in  cool  water, 
may  be  administered  every  two  or  three  hours 
with  advantage.  Or,  small  doses,  frequently  re- 
peated, of  aromatic  spirit  of  ammonia  may  be 
used  in  the  same  manner.  If  the  circulatory 
failure  is  acute  or  sudden,  either  the  aromatic 
spirit  of  ammonia  or  Hoffmann's  anodyne  should 
be  used  as  rapidly  acting  diffusible  stimulants. 

Pain  in  the  ear  should  be  relieved  by  irriga- 
ting the  external  auditory  canal  with  normal 
salt  solution  as  hot  as  the  child  can  bear  it.  In 
all  these  cases  a  careful  examination  of  the  ear- 
drum should  be  made  twice  a  day  to  see  whether 
there  is  any  bulging  due  to  acciunulated  secretion 
or  suppuration  in  the  middle  ear,  and  if  this  is 
present  paracentesis  of  the  tjmipanum  should  be 
performed  at  once  to  relieve  the  pain  and  avoid 
danger  of  infection  of  the  mastoid  cells. 

If  evidences  of  septicemia  are  present  and  the 
patient  seems  anemic,  either  during  the  later  stages 
of  the  attack  or  during  convalescence,  the  tincture 
of  the  chloride  of  iron,  in  the  dose  of  5  drops  three 
or  four  times  a  day,  is  advantageous,  since  it  tends 
to  combat  the  anemia  and  the  infection  and  also 
exercises  a  slight  stimulant  influence  upon  the 
kidneys.  For  the  relief  of  persistent  albuminuria 
after  the  attack  is  passed,  the  child  should  be 
prevented  from  taking  excessive  exercise,  but, 
nevertheless,  should  live  in  the  sunshine  as  much  as  possible,  and  may  take 
either  small  doses  of  the  tincture  of  chloride  of  iron  or  a  very  minute  dose  of 


Fia.  2.5 

UNDER 
1  YEAR 

BETWEEN 
1  AND  5 

BETWEEN 
SAND  10 

BETWEEN 
10  AND  15 

BETWEEN 
15  AND  20 

68 

^' :::::::] :::::::::::    ::: 

»_ 

■■'■''.                   i  I 

SI     i                                                 i 

63      1    i        1    1    1                   1                              1 

02      '    .       ,                 :       '    1       1           1       1 

61     i    i       ,    1    :           ,    1    ;                     \       \   ' 

6u    i  i     1  1  ,  ;     1  1                   1 

«'''':       j    ■    ^         ll    t                               i 

.8     ,  i      ■   1   '            1                                   ;      1 

17    1  ,            :  ■      1  ,  1                        1  1  ! 

16      '                   '    <            1    1    1                                      1 

»    :  .        ,     :       1  1                          1 

"   -■    -    !  aL T± 

"   i  :    ;  :        i  1                     1 

1=     :  1      1                                 .             1 

10             1  1  !          1 

3-'          ^           i             1 

3S                     i    i    1           1 

■■'-                     \\\        \\ 

M     \    '  '  '.  ;    1  '\\  I        1      III 

25          1                                1                     1            1    1    1 

31      , 

33                                                                                             1 

32                                                                                             i 

31                  ■   !   1          1       '       :   ;   i   ■                      1 

30       ■    •             ;                          1    1         .    ;    ;    :         1    1 

29      1    1                               IJ                            1 

28      1                                       t 

27      1                                        1 

26                                              1 

25                                              1 

21                                               1 

23                                         T 

22                                            1 

21                                            1 

20 

VJ                 \ 

is   1       ;  i  ;  i 

17      1                       1                        \ 

IC      1    i                                            I 

15      1                                                 \ 

H       :                                                        \      ' 

13             (1                                            \ 

'-            1                                              \ 

11            j                                              \ 

J"  i::::::::::::^::::::::: 

s                                                f 

7 

6 

^                                    -                                            L... 

*__ T.,^  \ 

3 \ 

2                                                                           \ 

1                          ""^                                              i"" 

Showing  the  mortality  of  scarlet 
fever  according  to  age,  based  on  Johan- 
nessen's  9855  cases. 


92  DISEASES  DUE  TO  A  SPECIFIC  IXFECTIOX 

the  tincture  of  cantharides — say,  |  to  1  drop  twice  or  thrice  a  day,  well  (Hhitcd; 
but  the  cantharides  is  contra-indicated  if  the  microscope  shows  in  the  urine  the 
presence  of  red  blood  cells,  indicating  that  the  kidneys  are  still  acutely  inflamed. 

In  those  cases  of  scarlet  fever  in  which  the  rash  fails  to  develoi)  its  full  efflorescence 
promptly,  and  particularly  in  those  cases  in  which  the  skin  is  mottled  and  marbled, 
indicatint;  poor  capillary  circulation,  it  is  exceedingly  useful  to  innnerse  the  child 
in  a  hot  l)ath.  In  other  cases  the  cool-warm  pack  may  be  used.  This  consists 
in  strijjijing  the  child  of  its  night-clothing  and  rolling  it  in  a  sheet  which  has  been 
dipped  in  warm  water,  which,  by  the  time  it  is  wrapped  around  the  child,  has 
become  considerably  cooled  by  evaporation.  As  soon  as  the  sheet  is  wraj^ped  about 
the  child,  an  ice-bag  being  in  the  meantime  applied  to  the  head,  it  is  wrajjpcd  in  a 
blanket,  and  in  a  few  moments  the  heat  of  the  child's  body  transforms  the  cool 
sheet  into  a  warm  pack.  The  primary  effect  of  the  cool  sheet  is  to  drive  the  stagnant 
blood  out  of  the  peripheral  capillaries,  and  the  effect  of  the  warm  sheet  is  to  bring 
new  blood  into  these  vessels.  By  these  means  we  are  very  frequently  enabled 
not  only  to  improve  the  circulation  and  develop  the  rash,  but  to  diminish  the  toxic 
symptoms  and  relieve  nervous  stress.  It  is  hardly  necessary  to  add  that  exposure 
for  any  length  of  time  to  the  cool  sheet  is  to  be  a\'oided.  The  blanket  is  to  be 
placed  tightly  about  the  child  at  the  earliest  possible  moment  after  the  cool  sheet 
comes  in  contact  with  its  body,  so  that  the  chilling  of  the  surface  will  be  only 
instantaneous.  French  therapeutists,  and  some  other  practitioners,  have  advised 
that  in  those  cases  in  which  cerebral  symptoms  are  very  marked  and  toxemia 
is  evidently  profound,  the  child  should  be  placed  in  a  warm  bath,  and  that  cool 
water  should  be  poured  over  its  head,  neck,  and  chest  for  a  moment,  in  order  to 
produce  a  certain  amount  of  shock  and  rouse  the  flagging  powers  of  the  body. 
This  method  has  been  so  highly  endorsed  by  excellent  practitioners  that  it  cannot 
be  condemned  for  theoretical  reasons,  but  the  author  has  ne\-er  been  bra\e  enough 
to  employ  it. 

Within  the  last  few  j'ears  several  attempts  have  been  made  to  produce  an  anti- 
scarlatinal  serum  without  very  satisfactory  therapeutic  results.  In  the  cases 
in  which  the  author  has  directed  its  use,  it  has  seemed  to  modify  the  throat  syni]i- 
toms,  but  otherwise  it  has  not  affected  the  progress  of  the  tliseasc. 

MEASLES. 

Defiiiition. — Measles  is  an  acute  infectious  disease,  usually  epidemic,  which 
most  commonly  attacks  children  and  rarely  occurs  after  the  second  decade  of 
life.  The  skin  during  an  attack  is  covered  more  or  less  profusely  by  a  dusky  red 
eruption  of  a  maculopajiular  type.  The  eyes  are  congested  and  lachrymose,  and 
the  nasal  and  pharyngeal  mucous  membranes  swollen  and  red.  One  attack  usually 
confers  immunity.     Measles  is  sometimes  called  " Morbilli." 

Distribution. — INIeasles  is  met  with  in  all  parts  of  the  civilized  world.  If  by 
chance  it  is  carried  to  a  people  who,  by  reason  of  isolation,  have  not  lieen  exjjosefl 
in  i)revious  generations  to  its  eli'ects,  it  often  (le\elo])s  a  malignant  form  and 
causes  a  great  mortality.  Perhaps  the  most  noteworthy  example  of  this  is  the 
case  of  the  inhabitants  of  certain  of  the  Fiji  Islands,  who,  being  exposed  to  the 
infection,  fell  ill  and  died  by  thousands,  .so  that  it  is  estimated  that  2(),()()0  deaths 
occurred  in  four  months.  The  epidemic  ceased  only  after  every  person  on  the 
islands  had  been  infected. 

The  susceptibility  of  children  in  the  first  ten  years  of  life  to  the  infection  is 
cjuite  remarkable.  If  a  large  number  who  have  not  l)een  rendered  immune  by  a 
previous  attack  are  exposed  to  the  infection,  nearly  all  fall  sick.  Smith  and  I  )abuey 
report  an  instance  in  which  110  children  between  eight  and  eighti'cn  years  of  age 
were  exposed,  and  only  2  were  not  taken  ill. 


MEASLES  93 

Measles  is  much  more  prevalent  in  the  spring  and  winter  months  than  in  the 
summer  months,  probably  because  the  open-air  life  and  free  ventilation  of  the 
warmer  season  aids  in  preventing  the  exposure  of  susceptible  persons  to  a  concen- 
trated form  of  the  contagion. 

Etiology. — Measles  is  in  all  probability  due  to  a  distinct  microorganism  but 
so  far  it  has  not  been  isolated.  It  belongs  to  the  ultramicroscopic  group  and  passes 
through  a  Berkefeld  filter.     It  resists  freezing  twenty-four  hours. 

Hektoen  first  transmitted  the  disease  from  man  to  man  by  means  of  the  blood 
in  1905,  and  Anderson  and  Goldberger  have  produced  the  disease  in  monkeys 
when  using  blood  obtained  less  than  fourteen  hours  after  the  onset  of  the  eruption. 
They  also  showed  that  discharges  from  the  mouth  and  nose  in  the  first  twenty- 
four  hours  transmitted  the  disease.  The  desquamated  skin  failed  to  transmit  the 
malady. 

The  disease  spreads  with  great  readiness  through  the  air  and  contact  with  the 
patient  or  his  garments  is  not  necessary  for  its  transmission,  although  such  contact, 
of  course,  provides  the  infection  in  more  concentrated  form.  There  is  no  doubt 
that  the  breath  of  a  patient  suffering  from  measles  carries  the  infection,  and  so 
does  the  nasal  and  pharyngeal  mucus,  so  that  the  expulsion  of  these  secretions 
by  coughing  or  sneezing  may  result  in  nurses  or  visitors  becoming  a  means  of 
transmitting  the  disease  by  their  garments  becoming  contaminated  in  this  manner. 

Very  short  exposure  to  infected  air  is  sufficient  for  infection,  and  even  when 
careful  precautions  are  taken  to  prevent  the  spread  of  the  disease  it  not  infrequently 
happens  that  all  the  other  children  in  a  house  develop  the  malady,  partly  because 
it  is  infectious  from  the  earliest  period  of  invasion  before  its  presence  is  recognized, 
but  largely  because  of  the  ease  with  which  it  is  conveyed  by  the  air.  This  great 
diffusibility  of  the  virus  of  measles  is  quite  in  contrast  with  the  limited  diffusibility 
of  the  poison  of  scarlet  fe\'er. 

Although  it  is  true  that  the  diffusibility  and  activity  of  the  infection  of  measles 
is  exceedingly  active  while  the  disease  lasts,  it  is  also  a  fact  that  it  speedily  disappears 
after  convalescence  is  established.  Three  weeks  after  the  attack  begins,  the  patient 
rarely  transmits  the  disease,  and  by  this  time,  with  ordinary  ventilation,  the  room 
and  surroundings  of  the  patient  are  usually  innocuous.  x\ny  condition  of  ill-health 
which  diminishes  vital  resistance  very  distinctly  increases  the  susceptibility  of  an 
individual  to  infection,  and  in  these  instances  the  disease  is  prone  to  be  severe. 

The  period  of  incubation  of  measles  is  usually  from  eleven  to  fifteen  days  but 
cases  are  recorded  in  which  the  disease  began  one  week  after  exposure. 

Prevention. — Measles  is  to  be  prevented  by  complete  isolation  of  the  patient, 
by  the  disinfection  of  all  garments  of  the  patient  and  nurse  before  they  leave  the 
sick-room,  and  by  free  ventilation,  so  arranged  that  the  other  rooms  in  the  house 
are  not  exposed  to  a  draught  from  the  sick-room.  After  the  attack  has  passed 
the  patient  should  be  given  several  hot  baths  to  rid  the  body  of  all  desquamating 
skin,  and  the  scalp  should  be  cleansed  with  special  care.  The  period  of  isolation 
should  be  15  days. 

Frequency. — Measles  is  one  of  the  most  common  of  the  acute  exanthemata 
and  affects  nearly  all  persons  living  in  cities  before  they  reach  adult  life.  Indeed, 
it  may  be  said  to  be  the  most  common  of  all  diseases  in  childhood. 

Pathology  and  Morbid  Anatomy. — There  are  no  noteworthy  changes  produced 
in  the  various  viscera  by  measles,  if  we  exclude  those  ordinarily  considered  as 
complications  and  the  changes  in  the  mucous  membranes  of  the  respiratory  and 
digestive  tract,  consisting  of  acute  irritation  and  catarrh.  With  the  onset  of  the 
disease  these  membranes  become  hyperemic,  and,  it  may  be,  dotted  with  an  eruption 
much  like  that  which  is  seen  on  the  skin. 

The  pathological  changes  due  to  complications  are  chiefly  those  of  bronchitis 
and   bronchopneumonia,   conditions   which   are   exceedingly   common   in   young 


94 


DISEASES  DUE  TO  A  SPECIFIC  INFECTION 


children,  and  in  patients  wlio  are  poorly  nursed  and  badly  nourished,  when  sufl'erint; 
from  aeute  infectious  diseases. 

Symptoms. — Measles  is  usually  ushered  in  by  the  symptoms  of  an  ordinary 
cold  or  attack  of  coryza.  There  may  be  an  initial  chill,  but  this  is  often  absent, 
the  fever  being  the  first  additional  s,>anptom  which  becomes  manifest.  The  patient's 
face  looks  lluslicd  and,  it  may  be  slightly  swollen  about  the  eyes  and  nose,  and  the 
eonjunctivie  are  injected,  the  general  expression  of  the  face  being  tearful.  At 
this  time,  and  later,  in  the  disease  photophobia  may  be  marked.  Sneezing  may 
be  noticeably  frequent,  and  an  examination  of  the  phar.ynx  will  reveal  the  fact 
that  its  mucous  membrane  is  reddened  and  the  hard  palate  dotted  with  a  measles- 
like rash,  which  often  appears  here  before  it  develops  on  the  skin.  Some  cough 
may  be  present  in  the  stage  of  onset  as  the  result  of  the  pharyngeal  and  laryngeal 
irritation,  and  headache  may  be  complained  of. 


Showing  initial  fever  with  the  subsequent  fall  and  then  a  rise  when  the  rash  is  well  developed 
in  a  case  of  measles.     Also  shows  an  ending  of  the  fever  by  crisis. 


There  are  present  in  many  cases  upon  the  buccal  mucous  membrane  before  the 
rash  develops  a  nvmiber  of  small,  white-tipped,  reddish  spots  first  described  by 
Filaton,  but  more  commonly  called  "Koplik's  spots."  (See  Plate  III.)  When 
present  they  are  pathognomonic  of  measles,  but  their  absence  does  not  negative 
the  diagnosis  of  the  presence  of  this  disease. 

The  fever  usually  begins  to  rise  with  the  onset  of  the  catarrhal  symptoms,  increas- 
ing day  by  day  till  it  reaches  its  acme  of  103°  to  105°  on  the  fourth  or  fifth  day 
from  invasion,  and  remains  fairly  constant  at  about  this  level  until  the  rash  begins 
to  fade,  on  the  fifth  to  the  seventh  day,  when  the  fever  ceases  abruptly  or  by  lysis, 
reaching  normal  in  a  few  hours  or  by  the  end  of  two  or  three  days  (Fig.  2H). 

The  eruption  of  measles  develops  on  the  third  or  fourth  day  of  the  disease,  and 
at  first  is  most  marked  back  of  the  ears  and  about  the  roots  of  the  hair  or  on  the 
forehead.  The  individual  spots  look  like  a  fiea-bite  and  are  rather  dusky  red  in 
appearance.  By  the  end  of  twenty-four  hours  or  at  the  expiration  of  the  fifth 
day  this  rash  is  usually  pretty  well  diffused  all  over  the  body,  and  the  macular 
appearance  of  the  eruption  begins  to  become  papular,  so  that  it  can  be  distinctly 
felt  by  the  finger-tip  of  the  phj'sician.  This  rash  varies  greatly  in  its  degree. 
Sometimes  it  is  so  profuse  that  every  part  of  the  body  is  covered;  in  other  instances 
very  considerable  spaces  of  unafl'eeted  skin  can  be  found  between  the  groups  of 
papules.     It  has  been  generally  stated  that  the  erescentic  arrangement  or  grouping 


PLATE    III 


Fiy.  2 


Fig. 


Fig.   8 


The  Pathognomonic  Sign  of  Measles  (KopUk's  Spots). 

Fig.  1.— The  discrete  measles  spots  on  the  buccal  or  labial  mucous  membrane,  showing  the  isolated 
rose-red  spot,  with  the  minute  bluish-white  centre,  on  the  normally  colored  mucous  membrane. 

Pig.  2.— Shows  the  partially  diffuse  eruption  on  the  mucous  membrane  of  the  cheeks  and  Ups;  patches 
of  pale  pink  interspersed  among  rose-red  patches,  the  latter  showing  numerous  pale  bluish-white  spots. 

Fig.  3.— The  appearance  of  the  buccal  or  labial  mucous  membrane  when  the  measles  spots  completely 
coalesce  and  give  a  diffuse  redness,  with  the  mjTiads  of  bluish-white  specks.  The  exanthema  on  the  skin 
is  at  this  time  generally  fuUy  developed. 

F'°-  4.— Aphthous  stomatitis  apt  to  be  mistaken  for  measles  spots.  Mucous  membrane  normal  m  hue. 
Minute  yellow  points  are  surrounded  by  a  red  area.     Always  discrete. 


MEASLES  95 

of  the  rash  is  diagnostic  of  measles.  That  this  is  erroneous  the  author  is  conviiiecd, 
as  he  has  frequently  seen  it  occur  in  other  morbilliform  eruptions.  ^Vhen  the 
disease  is  in  its  fully  developed  stage  the  skin  of  the  face  may  be  quite  swollen 
and  that  of  the  neck  and  chest  well  covered  by  the  eruption;  but  as  the  lower  part 
of  the  trunk  and  the  lower  limbs  become  involved  the  rash  on  the  face  usually 
begins  to  diminish  and  slowly  fades/leaving  for  several  days  after  it  has  entirely 
disappeared,  a  faint  mottling  of  the  skin  with  the  desquamation  of  branny  scales, 
which  is  scanty  in  some  cases,  but  profuse  in  those  who  have  had  an  intense 
eruption.  The  entire  duration  of  the  rash  is  from  five  days  to  one  week,  and  the 
period  of  desquamation  lasts  for  about  the  same  length  of  time.  Occasionally  the 
patient  suffers  from  prodromal  rashes  such  as  a  punctate  erythema  which  begins 
on  the  trunk  instead  of  the  face.  Sometimes  it  develops  on  the  limbs.  Sucii  a 
rash  may  at  first  be  thought  due  to  scarlet  fever.  In  other  cases  a  papular 
erj'thema  may  be  present. 

Hecker  and  others  have  proved  that  during  the  last  few  days  of  incubation  and 
dm-ing  the  course  of  the  eruption  in  measles  there  is  constantly  present  a  distinct 
leukopenia.  It  is  so  constant  that  he  proposes  to  use  it  as  a  diagnostic  aid,  asserting 
that  the  leukopenia  is  present  four  and  a  half  days  before  the  outbreak,  and  three 
and  a  half  days  before  the  appearance  of  Koplik's  spots.  Two  or  three  days  before 
the  eruption  there  may  be  a  temporary  increase  ia  leukoc\-tes.  The  decrease 
is  almost  solely  in  lymphocytes,  the  neutrophiles  being  relatively  in  excess.  Indeed 
a  diminution  of  l\Tnphoc}i;es  may  be  present  six  days  before  the  eruption. 

Diu-ing  the  well-developed  stage  of  the  disease  the  patient  nearly  always  presents 
some  symptoms  of  hronchitis.  These  may  be  so  mild  as  to  be  undemonstrable, 
or  so  severe  as  to  threaten  life.  The  thorax  should  be  frequently  examined,  in 
order  that  the  development  of  this  complication  may  be  recognized  and  its  severe 
effects,  as  far  as  possible,  avoided. 

Variations. — It  must  not  be  thought,  however,  that  measles  always  follows  the 
course  just  described.  All  the  acute  infections  present  widely  different  sjTnptoms 
in  different  epidemics  and  in  different  persons,  and  measles  is  no  exception  to 
this  rule,  for  in  some  cases  the  systemic  or  constitutional  distiu-bance  is  so  slight 
as  to  be  of  no  importance,  whereas  in  others  it  is  exceedingly  severe.  In  strong, 
hearty  children  the  course  of  measles  is  rarely  grave  if  they  are  protected  from  cold 
and  exposure,  whereas  in  puny,  badly  nourished  infants  it  is  one  of  the  most  fatal 
maladies. 

The  following  variations  from  the  ordinary  course  of  measles  are  met  with: 

A  mild  type,  with  a  scanty  rash  and  almost  no  constitutional  disturbance, 
which  runs  its  course  without  complications  if  ordinary  care  is  exercised. 

A  severe  t\-pe,  in  which  nervous  and  constitutional  sjTnptoms  predominate, 
in  which  the  eruption  may  be  exceedingly  profuse,  but  is  more  commonly  indistinct 
or  poorly  developed,  perhaps  because  of  poor  circulation  in  the  skin  by  reason  of 
toxemia. 

Another  severe  tj'pe  is  known  as  hemorrhagic  or  "black"  measles,  because 
of  the  tendency  to  the  occurrence  of  hemorrhages  in  the  skin.  Still  another  form 
is  a  respiratory  tj-pe,  in  which  the  patient  may  suffer  from  great  laryngeal  and 
tracheal  distress  or  from  a  serious  bronchopneumonia.  It  is  often  said  of  these 
cases  by  the  laitj'  that  the  rash  has  been  driven  in  by  exposiu-e  to  cold  and  is  exerting 
its  deleterious  influence  on  the  lungs.  This  is  not  exactly  true,  but  it  is,  neverthe- 
less, a  fact  that  when  we  can,  by  means  of  a  hot  pack,  restore  the  peripheral  circula- 
tion and  so  indirectly  cause  the  rash  to  be  manifest,  the  sjTnptoms  of  toxemia 
and  respiratory  disorder  often  become  decidedly  less. 

Rare  cases  are  met  with  in  which,  after  vomiting,  purging,  convulsions,  and 
coma,  death  speedily  occurs,  even  before  the  rash  has  had  time  to  become  well 
marked. 


96  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

Complications  and  Sequelae. — It  has  already  been  intimated  that  measles  in 
itself  is  a  disease  which,  in  most  indi\'idiials,  with  ordinary  care,  pursues  a  safe 
course  and  ends  in  recovery.  While  this  is  undoubtedly  true,  it  is  also  a  fact  that 
it  takes  high  rank  among  the  acute  infectious  diseases  which  produce  death,  by 
reason  of  the  complications  which  are  prone  to  occur. 

Of  all  these  by  far  the  most  frequent  and  deadly  is  bronchoptieiimonia,  a  complica- 
tion which  is  often  severe  in  its  course  and  which  causes  a  great  number  of  deaths 
when  measles  attacks  young  infants.  The  physical  signs  and  symptoms  are 
describcfl  in  full  in  the  article  on  that  disease,  but  it  is  important  to  remember 
that  in  measles  the  disease  is  insidious  and  speedy  in  its  onset,  so  that  a  pneumonia 
may  be  developed  before  the  physician  discovers  it,  unless  he  be  on  his  guard  and 
resorts  to  frequent  examinations  of  the  chest.  Bronchopneumonia  during  an 
attack  of  measles  in  a  child  under  one  year  of  age  is  an  exceedingly  common  and 
very  grave  complication  of  the  disease.  In  children  of  five  years  or  more  this 
complication  usually  does  not  occur  if  the  primary  state  of  the  health  is  fairly  good 
and  if  careful  nursing  prevents  exposure  to  "catching  cold." 

A  second  complication  of  far  less  importance  than  bronchopneumonia,  both 
as  to  frequency  and  results,  is  diarrhea  and  vomitinq  due  to  a  catarrhal  state  of 
the  bowels  and  stomach.  It  also  is  a  complication  which  is  due  in  a  considerable 
proportion  of  cases  to  bad  nursing  and  can  generally  be  avoided  by  proper  feeding 
and  the  avoidance  of  draughts.  It  not  infrequently  hajjpens  that  these  digestive 
disturbances  are  mild  during  the  acute  illness,  while  the  patient  is  required  to  be 
prudent  and  quiet,  and  become  pronounced  when  the  acute  illness  is  past  and  the 
attendants  become  careless  as  to  exposure  and  feeding.  This  gastro-intestinal 
disorder  varies  from  a  mild  catarrh  to  a  severe  enterocolitis. 

Another  complication  seen  in  many  cases  is  a  mild  degree  of  xtomatUis,  which 
in  poorly  nourished  children  may  become  ulcerative.  Even  so  severe  aufl  fatal 
a  lesion  as  noma  may  develop  in  cases  with  very  low  vitality,  ^"ery  rarely  gangren- 
ous nlceration  of  the  ear,  the  labije,  or  the  prepuce  takes  place. 

So  far  as  the  nervous  system  is  concerned,  it  may  be  said  that  it  is  rarely  affected. 
In  the  stage  of  onset  in  very  young  children  with  poor  resistance  and  an  unstable 
nervous  system  there  may  be  con\'ulsions,  but  they  are  exceedingly  rare.  Meningi- 
tis as  a  sequel  to  measles  is  also  very  rare.  Even  meningitis  due  to  middle-ear 
disease  is  rarely  met  with,  for  the  otitis  of  measles,  while  not  macommon,  is  usually 
mild  and  rarely  causes  secondary  lesions. 

The  eyes  are  usually  inflamed  and  there  may  be  a  mucopurvlent  conjunctivitis, 
or,  if  the  general  health  be  i)oor,  keratitis  may  prove  troublesome.  So  rarely  are 
the  heart  and  kidneys  affected  to  any  serious  degree  that  these  organs  may  be 
considered  almost  immune.  A  feebleness  of  the  heart  due  to  the  infection  and 
fever  may  be  present  for  a  time,  and  a  transient  albuminuria  is  often  manifested, 
but  both  of  these  symptoms  usually  rapidly  disappear  if  the  patient  is  kept  at  rest. 

Measles  is  an  infection  which  is  not  rarely  complicated  by  other  acute  infections. 
Diphtheria  may  develop  during  its  course,  and  whooping-cough  is  so  exceedingly 
frequent  that  some  relation  between  the  two  diseases  has  been  thought  to  exist. 
When  whooj^ing-cough  does  occur  as  a  complication  the  danger  of  hrochopneu- 
monia  is  greatly  increased.  Still  another  sequel  of  measles  is  tuberculosis,  probably 
because  the  catarrhal  state  of  the  mucous  membranes  offers  a  path  for  infection 
by  the  tubercle  bacillus  or  because  the  devitalizing  influence  of  measles -permits 
an  old  focus  of  tuberculous  infection  to  become  active. 

The  persistence  of  a  felirile  movement  in  a  case  of  measles  after  seven  days 
should  always  arouse  the  suspicion  of  some  inflammatory  complication  which 
should  be  most  carefully  searched  for.  Neumark  calls  attention  to  the  value  of 
leukocytosis  as  indicating  a  complication,  the  leukocytes  being  about  in  number 
normal  in  uncomplicated  measles. 


MEASLES 


97 


Diagnosis. — Measles  must  be  carefully  separated  from  a  large  number  of  cou- 
ditious  which  somewhat  resemble  it.  Many  kinds  of  food,  particularly  shell-fish, 
produce  a  rash  which  looks  remarkably  like  measles,  but  which  usually  lasts  only 
a  few  hours,  but  the  watering  and  hypercmic  eyes  and  swollen  visage  of  measles 
are  not  present.  Antipyretic  or  other  coal-tar  products  do  likewise  in  some  persons, 
and  the  physician  should  always  inquire  as  to  the  use  cjf  these  foods  or  drugs 
before  stating  that  measles  is  present.  Sometimes  a  morbilliform  rash  follows 
vaccination  or  precedes  smallpox.  The  use  of  antidiphtheritic  serum  may  also 
cause  such  an  eruption.  The  contact  of  a  cater- 
pillar with  the  skin  in  some  persons  may  cause  ^^^-  27 
a  measles-like  eruption  which  lasts  only  a  few 
hours.  None  of  these  states,  however,  are  ac- 
companied by  the  appearance  of  Koplik's  spots, 
hy  marked  coryza,  nor  by  the  appearance  of 
the  rash  on  the  mucous  membrane  of  the  soft 
palate.  Fever,  too,  is  usually  absent.  (For 
the  diagnosis  from  Rotheln,  see  Rubella.) 

Prognosis.  —  From  what  has  already  been 
said  it  is  evident  that  the  prognosis  in  a  case 
of  measles  is  dependent  not  on  the  fact  that 
measles  has  developed,  but  rather  upon  the 
age  of  the  patient,  the  vital  resistance  or  the 
general  condition  of  the  system,  and  the  sur- 
roundings as  to  sanitation  and  nursing.  Given 
a  poorly  nourished  infant  in  bad  surroundings 
and  with  inefficient  care,  measles  becomes  one 
of  the  most  fatal  diseases  to  be  met  with, 
whereas  in  a  case  where  these  conditions  are 
good  the  prognosis  is  fairly  favorable.  AVe 
find,  too,  that  the  danger  of  the  disease  de- 
creases greatly  with  each  year  of  life;  so  that 
children  near  puberty  rarely  die  from  this 
malady  unless  poorly  nourished  or  badly  ne- 
glected (Fig.  27).  If  bronchopneumonia  de- 
velops, the  prognosis  must  be  guarded  in  direct 
proportion  to  the  youth  of  the  child.  Thus, 
out  of  a  series  of  408  cases  of  measles  complica- 
ted in  this  manner,  290,  or  71  per  cent.,  died. 
This,  however,  is  an  exceedingly  high  figure 
and  by  no  means  represents  the  death  rate  in  a 
general  run  of  cases  in  which  all  ages  and 
conditions  of  patients  are  considered.  Under 
these  conditions  the  death  rate  for  all  cases 
is  probably  about  35  per  cent.  Thus,  Holt 
speaks  of  an  epidemic  in  the  Nursery  and 
Child's  Hospital  in  New  York  in  1892,  in  which 
the  mortality  was  .3.5  per  cent.,  and  in  9239  cases  of  measles  occurring  in  France, 
principally  in  hospitals  of  Paris,  there  were  3096  deaths,  or  a  mortality  of  33.5 
per  cent.  It  is,  moreover,  to  be  carefully  borne  in  mind  that  hospital  or  asylum 
statistics  are  utterly  worthless  in  determining  the  death  rate  for  ordinary  private 
practice,  because  most  of  these  hospital  cases  are  primarily  in  bad  health  or  are 
brought  to  the  hospital  desperately  ill  from  neglect.  Including  all  cases  in  private 
practice  the  mortality  should  not  be  over  5  to  10  per  cent.,  and  in  many  epi- 
demics it  is  much  lower,  even  in  institutions  and  where  good  nursing  is  not  to  be 


PERCENTAGE 

UNDER 
1   YEAR 

BETWEEN 
I  AND  2 

BETWEEN 

2  AND  3 

BETWEEN 

3  AND  4 

BETWEEN 

4  AND  5 

40      1          _M_ 

Mil 

39   1      jy 

1    III 

38        1             j\ 

i     ;  :  1 

3T        1              /  \ 

1     '  !  1 

30       1  !         ;/;   \ 

i  i 

a5   1  1  i  !    7i  \ 

34           1     / :     \ 

*J            jT  T 

1 

33        Ir    1 

31                  fl 

(ill 

30              I       M i 

ill             _L  •'  1    1 

ii9              Ml 

il  '  i            1    (      i 

as          i     J  i 

V  I  i 

ar          ./ 

\ 

as   1  _J    MJ 

i\  i 

■^.^JLITT 

j\i_ 

■24         /;     i; 

;  \ 

^-_X    1 

\-          ~i~ 

j  i\           ( } 

21                        1 

1 1\ 

20           !                1 

1  \            i 

19. J 

,   1   l\                      ;    ,    I 

18 

"7t\"  "     _n± 

IT 

1     '                    11 

16 

\ L     ,  [  ,1 

IS 

\ 

14 

—        { 

13 

-y-T— 

12 

L 

11 

^ 

10            ^ 

::::""   \ 

9  j^ 

\ii 

S 

\m 

T 

\ 

6 

5 

4 

1 

3 

1 

Showing  the  mortality  of  measles 
according  to  age,  based  on  29,464  cases 
collected  by  H.  Courtenay  Fox. 


98  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

had.  Thus,  in  an  epidemic  in  the  Faroe  Islands  only  S  cases  out  of  1123  cases 
died,  and  at  the  Boston  City  Hospital  only  5  were  fatal  out  of  3GG. 

Treatment. — When  measles  runs  a  natural  course,  little  or  no  medication  is 
required;  for,  as  it  is  a  self-limited  disease,  it  cannot  be  jugulated.  The  therapeutics 
of  an  attack  of  measles,  therefore,  consists  in  the  prevention  of  comjilications  and 
the  relief  of  symptoms  which  are  so  prominent  as  to  be  distressing  or  |)crhaps  even 
dangerous.  In  order  to  avoid  irritation  of  the  eyes  and  to  lessen  the  suffering 
due  to  photophobia  the  sick-room  should  be  kept  dark.  Light  bed-covering  should 
be  employed,  and  heavy  cjuilts  which  cause  the  child  to  perspire  unnecessarily 
are  to  be  tabooed.  As  a  mild  gastro-intestinal  catarrh  is  often  present  with  the 
fever,  food  should  be  light,  given  at  frequent  intervals,  and  should  consist  chiefly 
of  nutritious  fluids,  such  as  the  various  broths,  milk,  an  egg  boiled  only  one  minute, 
and  similar  substances. 

If  the  irritation  of  the  conjunctivae  is  marked,  eye  drops,  composed  of  4  grains 
of  common  salt  and  4  grains  of  boric  acid  to  an  ounce  of  water,  may  be  used  several 
times  a  day;  and  if  the  cough  is  sufficiently  constant  to  prevent  sleep,  it  may  be 
controlled  by  small  doses  of  codeine,  .rV  of  a  grain  once,  twice,  or  thrice  in  twenty- 
four  hours,  to  a  child  of  two  years,  or  heroin  may  be  used.  Should  the  fever  reach 
105°  there  is  usually  no  necessity  of  reducing  it  owing  to  its  short  duration,  but  the 
child's  comfort  can  be  much  increased  by  sponging  it  with  tepid  water  and  alcohol, 
or  even  with  water  at  70°,  using  active  friction  at  the  same  time.  These  cases  do 
not  need  an  immersion  bath  and  it  is  not  wise  to  give  it  to  them.  If  the  circulation 
has  a  tendency  to  fail,  carbonate  of  ammonium  in  the  dose  of  2  grains  four  or 
five  times  a  day  may  be  given  in  syrup  of  acacia.  For  the  relief  of  headache  a 
small  ice-bag  may  be  applied  to  the  head,  provided  that  a  nurse  is  at  hand  to 
prevent  it  from  slipping  down  upon  the  neck,  or  about  the  ears,  and  also  to  prevent 
it  from  wetting  the  pillow.  It  should  usually  be  wrapped  in  a  towel  to  prevent 
the  accumulation  of  moisture,  and  also  to  protect  the  head  from  too  great  cold. 

In  cases  in  which  the  rash  is  not  well  developed  and  the  skin  is  dusky  in  hue, 
the  brief  use  of  a  hot  pack  is  very  useful. 

Should  diphtheria  arise  as  a  complication  antitoxin  should  be  given. 

After  the  disease  has  run  its  course,  convalescence  should  be  aided  by  the  use 
of  simple  bitter  tonics,  the  hypophosphites,  iron,  and  arsenic,  and,  if  malnutrition 
is  present,  cod-liver  oil  proves  itself  an  exceedingly  valuable  remedy,  since  it  im- 
proves the  nutrition  of  the  patient  and  exercises  a  most  beneficial  efl'ect  upon  the 
mucous  membranes.  If  the  bronchitis  is  persistent  and  a  considerable  quantity 
of  mucus  is  in  the  bronchial  tubes,  3  grains  of  chloride  of  ammonium  may  be  given 
in  a  teaspoonful  of  fluid  extract  of  liquorice  and  a  teaspoonful  of  water  three  or 
four  times  a  day,  and  gentle  counter-irritation  in  the  form  of  chloroform  liniment 
or  ammonia  liniment  may  be  applied  to  the  chest.  After  the  eruption  has  dis- 
appeared and  desquamation  has  begun,  the  child  should  be  bathed  daily  in  order 
that  the  skin  may  be  thoroughly  rid  of  dead  epithelium;  and  before  the  patient 
plays  with  other  children  the  scalp  should  be  shampooed  several  times,  since  not 
infrequently  desquamation  continues  upon  the  head  long  after  it  has  ceased  upon 
the  trunk. 

For  a  long  time  after  the  rash  of  measles  has  disappeared  the  greatest  care  should 
be  exercised  that  the  patient  is  protected  from  exposure,  as  acute  and  chronic 
catarrhs  of  any  or  all  the  mucous  membranes  are  very  prone  to  develop  under  very 
slight  provocation. 

RUBELLA. 

Defiiiition. — Rubella  is  sometimes  caWed" Rothcln" or  "German  measles," " R2ibeola 
7uiiha,"  "Epidemic  Roseola,"  and  "Hybrid  Scarlet  Fever."  It  is  a  disease  distinct 
from  measles  and  scarlet  fever,  and  is  one  of  the  mild  acute  infectious  eruptive 


MUMPS  99 

diseases  of  childhood.  It  rarely  affects  adults.  Johann  Seitz  studied  an  epidemic 
involving  21  families  and  comprising  111  cases,  and  found  that  4  per  cent,  of  all 
adults  were  attacked.  The  ratio  for  children  was  much  higher,  being  04  per  cent. 
Rubella  occurs  as  a  rule  in  epidemics,  but  sporadic  cases  are  met  with. 

Etiology. — The  microorganism  of  this  affection  has  not  been  isolated,  but  the 
disease  is  distinctly  infectious  and  is  contracted  by  one  patient  from  another,  not 
only  by  contact,  but  also  by  clothing  and  through  the  air. 

Symptoms. — After  a  period  of  ijinbation  lasting  from  ten  to  twelve  days  the 
stage  of  onset  manifests  itself  by  chilliness,  general  malaise,  some  running  of  the 
eyes  and  nose,  but  there  is  not  marked  reddening  of  the  conjunctiva.  As  early 
as  the  first  day  of  the  illness  the  rash  appears  as  a  macular  eruption  which  is  red 
in  hue,  but  is  not  scarlet.  This  is  a  so-called  "rose  rash."  In  some  cases,  however, 
this  rash  does  not  develop  till  the  third  day.  The  rash  shows  itself  first  on  the 
face,  then  on  the  anterior  surface  of  the  thorax,  and  speedily  covers  the  entire 
body.  It  is  not  as  scarlet  as  in  scarlet  fever  nor  so  dusky  as  in  measles.  It  can 
often  be  seen  on  the  soft  palate  before  it  appears  on  the  skin,  in  the  form  of  bright 
rosy-red  spots  (ForcWieimer's  spots).  The  individual  macules  may  remain  separate; 
or  coalesce.  In  some  instances,  however,  the  skin  has  a  diffuse  redness  like  that  of 
scarlet  fever,  but  it  is  less  scarlet.  The  macules  last  about  tliree  days  and  then 
fade  gradually,  being  usually,  but  not  always,  followed  by  slight  scaly  desquamation. 
As  a  rule  the  rash  on  the  face  fades  at  about  the  time  it  becomes  well  developed 
on  the  lower  part  of  the  trunk.  The  skin  is  rarely  as  much  stained  after  the  rash 
disappears  as  it  is  after  measles. 

A  noteworthy  sign  to  be  sought  for  is  the  enlargement  of  the  lymph  nodes.  They 
feel  like  a  string  of  beads  below  the  ears,  in  the  lateral  cervical  region,  and  at  the 
back  of  the  neck.     Sometimes  the  inguinal  glands  are  also  affected. 

The  febrile  movement  is  usually  \ery  moderate,  the  temperature  often  not  rising 
above  100°.  The  general  symptoms  may  be  so  mild  that  the  attention  of  the 
nurse  is  first  called  to  the  illness  by  the  rash. 

If  the  child  is  carefully  nursed  and  clothed  and  properly  fed,  the  malady  pursues 
a  rapid  course  of  recovery.  If,  on  the  other  hand,  the  child  be  feeble  and  exliausted, 
this  disease  may  be  severe  in  its  manifestation  and  be  accompanied  by  otitis  media, 
catarrhal  pneumonia,  or  even  albuminuria  and  jaundice.  Isolation  should  be 
kept  up  for  ten  days. 

Diagnosis. — Rubella  is  to  be  separated  from  true  measles  by  the  moderate 
character  of  the  coryza,  by  the  absence  of  Koplik's  spots,  the  early  swelling  of 
the  glands  in  the  neck,  and  by  the  absence  of  bronchial  irritation.  From  scarlet 
fever  it  is  separated  by  the  absence  of  high  fever  and  of  the  well-diffused  scarlet 
rash,  which  is  not  macular,  and  by  the  absence  of  the  sore  tliroat  of  that  affection. 
Vomiting  in  onset  is  rare  in  rubella  but  very  common  in  scarlet  fever.  While 
these  differential  points  are  of  value  in  many  cases,  it  is  a  fact  that  in  some  instances 
a  diagnosis  is  most  difficult  until  the  case  has  been  studied  for  some  days,  when  the 
mildness  of  the  symptoms  and  the  brevity  of  the  attack  aid  in  deciding  that  neither 
measles  nor  scarlatina  are  present.  For  this  reason  careful  isolation  should  be 
practised.  If  the  rash  lasts  more  than  three  days  it  is  probably  not  German 
measles.     The  presence  of  albuminuria  and  nephritis  points  to  scarlet  fever. 

Treatment. — The  treatment  of  rotheln  consists  in  rest  in  bed  and  the  use  of 
spirit  of  nitrous  ether  and  citrate  of  potash  as  diuretics,  and  in  attention  to  the 
bowels  and  kidneys.     Exposure  to  cold  should,  of  course,  be  avoided. 

MUMPS. 

Definition. — Mumps,  or  epidemic  parotitis,  is  an  acute  infectious  disease  affecting 
the  parotid  gland  and  accompanied  by  mild  systemic  symptoms  which  may  not 


100  DISICASI'JS  Dl'H  TO  .1    SPECIFIC  ISFECTION 

l)c  severe  enough  to  demand  notice.  It  oecurs  in  the  great  majority  of  instances 
during  childhood,  lietween  the  fourth  year  and  puberty,  and  one  attack  protects 
the  ])atient  from  a  second. 

Etiology. — Mumps  is  usually  conveyed  hy  contact  from  one  patient  to  another, 
hut  it  may  be  carried  by  a  third  person  or  by  garments  to  a  susceptible  indixidual. 
It  is  contagious  from  the  Ijcginning  to  the  end  of  the  attack,  and  it  is  probable 
that  ])crsons\vho  have  so  far  recovered  as  toha\-e  no  \'isil)le  swelling  of  the  ])arotids 
can  still  transmit  the  disease.  For  this  rciison  the  jjatient  should  be  kcjit  sei)arate 
from  other  children  for  a  period  of  three  weeks  after  the  swelling  disappears.  It 
is,  however,  a  noteworthy  fact  that  mumps  is  by  no  means  so  infectious  as  are  the 
eruptive  fevers,  and  many  children  escape  the  disease  even  when  thoroughly 
exposed  to  it. 

The  period  of  incubation  is  uncertain.  Sometimes  it  is  brief,  in  other  cases 
surprisingly  prolonged.  Holt,  in  42  cases  collected  from  literature,  found  it  varied 
from  three  to  twenty-five  days.  In  all  probability  it  is  about  fifteen  days  in  the 
average  case. 

Pathology. — The  chief  change  in  mumps,  and,  indeed,  the  only  one  which  is 
characteristic,  is  the  swelling  of  one  or  both  parotid  glands.  The  swelling  is  d"ue 
to  a  i)rimary  parenchymatous  inflammation,  followed  by  involvement  of  the 
connective  tissue  of  the  gland  as  well.  Rarely  the  other  salivary  glands  become 
swollen,  and  still  more  rarely  the  parotids  suppurate.  This  result  occurs  only 
in  children  who  are  impoverished  by  other  diseases,  and  is  due  to  an  invasion  of  the 
gland,  through  the  duct  of  Steno,  by  pyogenic  organisms. 

Symptoms. — The  chief  symptoms  of  mumps,  aside  from  the  swcHiiki  nf  llir  gldiids, 
is  pain  in  the  parotid  region,  which  is  greatly  increased  by  moving  the  jaw  or  by 
taking  any  sour  material  into  the  mouth.  In  susceptible  persons  there  may  be 
some  feeling  of  malaise  or  wretchedness  and  the  fever  may  reach  103°  or  104° 
on  the  first  day,  although  a  temperature  of  102°  is  more  commonly  met  with. 

The  swelling  of  the  gland  is  usually  at  its  height  by  the  third  da\-  and  remains 
at  this  stage  for  two  or  three  days  more,  when  it  begins  to  decrease  and  then  grad- 
ually disappears.  In  some  cases  the  degree  of  swelling  is  so  marked  that  the  tissues 
of  tiie  face  and  neck  share  in  it  to  such  an  extent  that  the  patient  is  unrecognizable. 
The  swelling  is  bilateral  in  the  vast  majority  of  instances,  but  it  often  begins  in  a 
single  gland. 

Complications  and  Sequelae. — While  mumps  is  a  very  mild  disease  in  many  cases, 
it  at  times  becomes  severe,  chiefly  because  of  the  complications  which  arise.  These 
are  more  frequently  met  with  in  adults  than  in  children.  The  most  common  of 
them  is  orchitis,  which  may  be  bilateral  and  severe  enough  to  cause  the  patient 
intense  suffering  and- force  him  to  remain  in  bed. 

Before  the  age  of  puberty  the  testicles  are  rarely  involved,  but  after  puberty 
orchitis  is  a  frecpient  complication.  Bich  collected  statistics  on  .S62  cases  of  mumps 
occurring  in  young  men  between  the  ages  of  eighteen  and  twenty-five  years,  and 
founfl  that  29  per  cent,  of  the  number  were  affected  with  orchitis.  Granvier's 
record  of  cases  occurring  in  the  French  army  gives  a  percentage  of  23.  Usually 
only  one  testicle  is  involved.  Thus,  of  159  cases  collected  from  various  sources 
152  were  unilateral.  The  combined  statistics  of  Granvier  and  Bich,  based  on 
309  cases  of  orchitis,  showed  that  atrophy  of  the  testicle  resulted  in  17()  cases,  or 
57  per  cent.  Active  exercise  seems  to  predispose  to  this  complication,  and  it 
is  much  more  frecpient  in  some  epidemics  than  in  others.  Some  years  ago 
mumps  ai)peared  in  an  epidemic  among  the  students  of  the  Jefl'erson  Medical 
College,  and  a  \-ery  large  proportion  of  those  attacked  developed  metastasis  to  a 
testicle.  The  development  of  the  orchitis  is  usually  associated  with  a  second 
rise  of  tem])erature  and  a  general  .sense  of  illness  which  is  in  excess  of  that  present 
at  the  onset  of  the  primary  illness.     The  swelling  of  the  testicle  lasts  about  a 


WHOOPING-COUGH  101 

week,  and  after  the  acute  iiifliiininiition  has  passed  the  f^hmd  may  be  enlarged  for  a 
long  period  of  time. 

Cases  have  been  recorded  in  vvliich  coiiotilsiDns,  inetiiiKjUls,  and  nrllinlis  liave 
developed  as  compHcations  of  mumps. 

In  young  girls  who  have  mumps,  secondary  swelling  of  the  mammary  gUmds, 
of  the  ovaries,  or  of  the  labite  may  develop,  but  secondary  changes  are  far  more 
rare  among  females  than  are  those  detailed  as  occurring  in  males. 

Simonin,  a  French  surgeon,  has  reported  10  cases  of  pancreatitis  which  occurred 
among  652  cases  of  mumps.  The  symptoms  of  pancreatitis  appeared  from  the 
first  to  the  twelfth  day  of  the  disease,  but  usually  from  the  third  to  the  sixth  day, 
and  lasted  from  two  to  seven  days.  The  chief  symptoms  were  ejjigastric  pain 
and  vomiting,  but  no  glycosuria.  Cuche  has  stated  that  he  found  epigastric 
tenderness  present  in  20  out  of  26  cases  of  mumps. 

Treatment. — The  treatment  of  mumps  consists  in  the  use  of  mild  alkaline  diuretics 
and  rest,  for  if  the  patient  can  be  persuaded  to  avoid  exercise  and  to  use  a  light 
diet  active  medication  is  never  needed.  Sour  foods  and  acid  drinks  are  to  be 
avoided,  for  when  they  are  taken  into  the  mouth  they  cause  severe  pain.  If  the 
febrile  movement  is  marked  and  the  pulse  is  quick  3  minims  of  tincture  of  aconite 
every  two  hours  is  useful  for  the  first  twenty-four  hours  of  the  malady.  By  decreas- 
ing the  congestion  in  the  gland  the  aconite  not  only  moderates  the  inflammation, 
but  also  diminishes  the  pain.  Local  applications  to  the  swollen  parotids  are  usually 
not  needful,  but  if  any  are  employed  they  should  be  hot  rather  than  cold.  Should 
metastasis  to  the  testicle  occur,  rest  in  bed  is  imperative,  since  taking  exercise 
at  such  a  time  causes  great  increase  in  the  swelling  and  pain.  The  scrotum  should 
be  supported  by  a  bandage.  Aconite  in  full  doses  and  citrate  of  potassium  are 
useful  remedies  when  the  swelling  of  the  scrotal  contents  is  severe. 


WHOOPING  COUGH. 

Definition. — Whooping-cough  is  sometimes  called  Pertussis,  and  is  an  infectious 
disease  chiefly  met  with  in  childhood.  It  consists,  as  its  name  implies,  in  a  respira- 
tory disorder  which  is  peculiar  in  two  particulars.  The  patient  in  the  well-de^'eloped 
stage  of  the  disease  is  seized  at  varying  intervals  by  a  paroxysm  of  coughing  which 
is  so  constant  and  violent  that  in  a  few  seconds  the  quantity  of  residual  air  in  the 
thorax  is  greatly  decreased  below  the  normal  amount,  producing  in  this  way  a 
sense  of  suffocation  and  flushing  of  the  face  or  cyanosis.  Immediately  after  the 
cough  ceases  the  patient  endeavors  to  take  a  deep  inspiration  to  compensate  for 
the  excessive  expiratory  effort,  when  there  is  developed  a  narrowing  of  the  glottic 
opening  so  that  it  is  very  difficult  for  the  air  to  enter  the  larynx.  This  violent 
effort  to  draw  air  through  a  narrow  opening  produces  a  peculiar  "whoop,"  which 
gives  the  disease  its  name.  The  name  "whooping-cough"  does  not  signify  that 
the  cough  is  whooping  in  character,  but  that  there  is  a  cough  followed  by  a  whooping 
sovmd. 

History. — The  first  recorded  epidemic  of  whooping-cough  appeared  in  Paris 
in  1573. 

Distribution  and  Frequency. — Whooping-cough  is  a  disease  which  is  found  in 
all  parts  of  the  world,  and  is  apt  to  occur  in  epidemic  form,  particularly  during  the 
months  of  March  and  April.  It  is  least  prevalent  in  September  and  October.  It 
is  rare  and  mild  in  the  Tropics,  severe  in  colder  climates.  Ceylon  has  17  cases 
per  1000,  England  347  per  1000  population.  As  already  stated,  it  is  particularly 
prone  to  attack  children;  so  that  few  persons  reach  adult  years  without  suffering 
from  an  attack.  If  they  do  escape  during  childhood,  they  may  suffer  from  it 
even  in  advanced  old  age.     Even  sucklings  are  attacked  by  it,  and  in  this  class 


102  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

of  cases  it  is  an  exceedingly  fatal  malady.  Two-thirds  of  its  deaths  occur  in  patients 
under  one  year  of  age.     It  is  also  a  grave  disease  in  old  age. 

Whooping-cough  attacks  both  sexes  with  about  equal  frequency.  Rosen  col- 
lected 43,393  cases,  of  which  21,850  occurred  in  boys  and  21,543  in  girls.  If  the 
statistics  of  Goodhart,  Comly,  and  Rilliet  and  Barthez  are  combined,  it  is  found 
that  in  4157  cases  1868  occurred  in  boys  and  2289  in  girls. 

Etiology. — The  baccillus  of  pertussis  was  discovered  by  Bordet  and  Gengou  in 
1900  and  obtained  in  pure  culture  in  1906.  It  is  a  minute  ovoid  Gram-negative 
cocco-bacillus  about  the  size  of  the  influenza  bacillus. 

Whooping-cough  so  often  occurs  in  close  connection  with  an  attack  of  measles 
that  the  two  diseases  must  be  regarded  as  nearly  related. 

The  exact  period  of  incubation  is  unknown.  It  proliably  varies  greatly  in 
different  persons  and  in  different  epidemics.  Sometimes  it  seems  to  be  as  short 
as  two  days;  in  others  it  apparently  takes  ten  days,  or  even  longer  than  this.  The 
infection  is  perhaps  conveyed  by  the  air  and  certainly  is  transmitted  by  the  sputum, 
either  by  the  direct  expulsion  of  particles  of  it  into  the  face  and  air-passages  of  the 
child  not  as  yet  affected,  or  upon  clothing  or  the  food,  so  that  it  gains  access  to  the 
respiratory  tract.  The  infection  is  most  marked  during  the  acme  of  the  malady, 
but  is  active  at  all  times  during  the  attack,  and  probably  for  a  week  or  more  after 
the  cough  has  lost  all  characteristics  of  the  disease.  Children  who  have  suffered 
from  this  disease  should  not  come  in  contact  with  those  who  have  not  had  it,  for 
three  or  four  weeks  after  the  last  whoop  is  heard. 

Pathology  and  Morbid  Anatomy. — Mallory,  of  Boston,  has  shown  that  in  pertussis 
the  bacillus  pertussis  is  found  packed  in  large  numbers  about  the  cilia  of  the  epithe- 
lial cells  lining  the  trachea  and  bronchi.  The  organisms  interfere  mechanically 
with  the  movements  of  the  cilia.  This  condition  is  peculiar  to  this  malady.  Pri- 
marily the  only  noteworthy  change  present  in  the  thoracic  organs  during  whooping- 
cough  is  a  mild  catarrhal  state  of  the  mucous  membranes  of  the  \vhole  respiratory 
tract.  Secondarily,  the  pathological  results  are  far  more  serious  in  that  the  bron- 
chitis and  the  great  strain  thrown  ujjon  the  heart  by  asphyxia  result  in  conditions 
which  may  destroy  the  patient,  death  usually  ensuing  in  fatal  cases  from  exhaustion 
due  to  excessive  cough,  lack  of  food,  and  lack  of  rest  combined  with  bronchopneu- 
monia, which  in  turn  is  also  due  to  several  causes,  of  which  lowered  ^utal  resistance 
and  a  feeble  heart  are  important  factors.  Then,  too,  in  the  violent  inspiratory 
efforts  of  the  patient  small  particles  of  food  or  infected  mucus  may  be  drawn  into 
the  smaller  bronchi  and  so  produce  local  infection.  As  stated  in  the  article  on 
Bronchiectasis,  this  condition  in  its  cylindrical  form  may  be  caused  by  pertussis. 
(For  further  pathological  changes  see  Complications.) 

Symptoms. — The  symptoms  of  whooping-cough  have  already  been  described 
to  some  extent.  Usually  the  patient  develops  what  is  apparently  a  slight  cold 
in  the  head  and  thorax,  followed  by  a  cough,  which  may  be  described  as  nervous 
or  spasmodic.  Perhaps  the  word  "sudden"  can  best  be  applied  to  it  in  the  sense 
that  each  coughing  spell  is  sudden  in  onset.  At  first  there  may  be  only  one  or 
two  coughs,  but  soon  they  come  in  series,  which  day  by  day  increase  in  frequency 
and  violence.  Sometimes  the  ^cJioop,  which  occurs  at  the  end  of  the  series  of  short, 
sharp  coughs,  does  not  appear  for  several  days.  It  may  never  appear  in  the  mild 
type  of  case,  the  patient  sufl'ering  only  from  the  paroxysms  of  cough  which  exhaust 
the  chest  of  air  to  a  considerable  degree.  When  the  whoop  does  come  on  it  appears 
at  the  end  of  the  repeated  coughs,  and  is  caused  by  the  attempt  to  inspire  air 
suddenly  and  forcibly  through  the  narrowed  glottis.  The  whole  paro.xysm,  there- 
fore, consists,  first,  of  a  series  of  coughs  which  increase  in  rapidity  as  one  would 
count  1,  2,  3,  4,  5,  6,  7,  8,  9,  10,  11,  12  with  increasing  speed,  and,  secondly,  in 
the  long-drawn  inspiratory  whoop.  Owing  to  the  violence  of  the  cough  the  face 
becomes  suH'used,  the  tears  run,  and  the  patient  may  even  seem  more  or  less  con- 


WHOOPING-COUGH  103 

vulsed.  The  frequency  of  the  paroxysms  varies  very  greatly  in  different  cases 
and  at  different  times  in  the  twenty-four  hours.  Some  patients  cough  but  once 
or  twice  a  day,  while  others  are  seized  every  few  minutes.  Usually  the  child  is 
greatly  frightened  if  the  attack  is  severe,  and  often  it  soon  learns  to  recognize  the 
early  signs  of  an  approaching  seizure  and  runs  to  its  mother  or  nurse  for  help. 
The  attacks  are  provoked  by  crying,  laughing,  eating  or  drinking,  and  by  inhalation 
of  dust-laden  air.  Between  the  paroxysms  perfect  quiet  and  respiratory  comfort 
may  be  present  unless  complications  arise.  In  the  severe  cases  nose-bleed  and 
ecchymoses  of  the  conjunctiva  may  occur  and  blood  may  come  from  the  ears  and 
mouth.  The  convulsive  efforts  during  the  cough  very  frequently  cause  vomiting, 
and  at  times  the  urine  or  feces  may  be  forcibly  expelled,  or  they  escape  after  an 
attack  because  of  profound  exhaustion  and  the  relaxation  produced  by  the  asphyxia. 
A  nodular  infiltration,  or  an  ulcer,  at  the  frenum  of  the  tongue  is  often  produced 
by  irritation  of  the  projecting  organ  upon  the  lower  incisor  teeth.  The  circulation 
is  usually  not  much  affected  save  during  the  paroxysm,  when  it  is  labored,  owing 
to  the  asphyxia.  Between  the  paroxysms  it  may  be  rapid  and  feeble  if  the  attacks 
are  frequent  and  severe  enough  to  strain  and  dilate  the  heart.  Some  clinicians  assert 
that  permanent  cardiac  feebleness  and  dilatation  may  result  from  this  disease. 

In  severe  cases  in  young  children  and  in  feeble  individuals  great  asthenia  may  be 
produced  by  the  violence  of  the  spasm,  the  loss  of  sleep,  and  the  loss  of  food  from 
vomiting,  which  may  occur  at  every  paroxysm. 

Inspection  of  the  bared  chest  during  the  inspiratory  part  of  each  attack  reveals 
in  the  stage  of  inspiration  deep  retraction  of  the  intercostal  spaces,  of  the  episternal 
notch,  and  of  the  epiclavicular  areas.  The  epigastrium  is  also  retracted,  for  all 
the  auxiliary  muscles  of  respiration  endeavor  to  aid  in  the  drawing  in  of  air.  Auscul- 
tation of  the  chest,  particularly  over  the  posterior  surface,  almost  always  reveals 
bronchial  rales,  due  to  the  bronchitis  which  is  present  in  all  cases,  even  if  they  be 
mild.  Care  should  always  be  exercised  that  this  bronchitis  is  not  increased  by 
exposure  to  cold  and  dampness,  since  it  is  exceedingly  prone  to  develop  into  broncho- 
pneumonia, particularly  in  young  children  and  old  persons.  Indeed,  it  may  be 
said  that  the  high  mortality  of  the  disease  is  due  almost  entirely  to  this  complication. 

A  number  of  clinicians,  particularly  Cima  and  Meunier,  have  shown  that  even 
in  the  very  early  stages  of  pertussis  there  is  present  a  very  extraordinary  leukocy- 
tosis. This  is  accompanied  by  an  increase  in  the  percentage  of  large  and  small 
lymphocytes,  both  increasing  until  the  height  of  the  disease  is  reached.  Eosinophiles 
are  found  during  convalescence.  The  lymphocytosis  is  of  distinct  diagnostic  value 
in  uncomplicated  cases,  Kolmer  diagnosing  81  per  cent,  of  a  series  of  cases  by 
the  blood  examination  alone.  As  in  most  infectious  diseases,  a  small  amount  of 
albumin  is  found  in  the  urine  in  the  majority  of  cases. 

The  duration  of  whooping-cough  varies  from  sLx  to  eight  weeks,  more  commonly 
the  latter  than  the  former. 

Complications. — The  complications  of  whooping-cough  are  chiefly  connected 
with  the  respiratory  tract.  Bronchopneumonia,  as  just  stated,  is  very  common, 
and  follows  the  bronchitis  which  usually  is  developed  in  the  earlier  stages  of  the 
disease.  It  is  particularly  apt  to  attack  young  children  and  to  occur  in  the  winter 
months.     Somtimes  a  true  lobar  pneumonia  develops. 

In  nearly  all  cases  of  whooping-cough  a  moderate  degree  of  compensatory  emphy- 
sema comes  on  because  of  the  violent  respiratory  efforts  of  the  patient,  and  rarelj^ 
this  strain  on  the  tissues  of  the  lungs  results  in  the  rupture  of  an  air  vesicle  and  the 
development  of  interstitial  or  interlobular  emphysema.  In  other  instances  the 
quantity  of  air  which  escapes  in  this  way  is  very  large  and  infiltrates  the  tissues 
of  the  mediastinum,  the  subcutaneous  tissues  of  the  chest,  and  in  extreme  cases 
those  of  the  entire  body.  Instances  of  thig  condition  have  been  reported  by  Gelmo, 
Ferreil,  and  Bierbaum,  and  have  usually  proved  fatal.     Cases  are  also  recorded  in 


104  DISEASES  DVK  TO  A   SPECIFIC  l.XFECTIOX 

wliich  pneumothorax  has  been  produced.  Another  complication  of  iini)ort:iiice, 
although  it  has  been  descril)ed  as  a  sym])tom,  is  voinitinfi,  wliicli  if  it  Ix'conies 
constant  is  a. serious  condition,  ])articuiarly  in  infants,  since  it  may  cause  death 
from  asthenia. 

The  bronchial  glands  are  nearly  ahvays  enlarged  and  may  be  so  much  increased 
in  size  as  to  cause  dulness  on  percussion  over  the  sternum.  The  area  of  cardiac 
dulness  is  increased  by  reason  of  the  dilatation  of  the  heart  due  to  the  strain  tlirown 
upon  it  in  the  attack  of  coughing.  Brick  found  clianges  in  tiic  hearts  of  all  of 
14  cases  coming  to  autopsy.  There  was  in  most  instances  an  excentric  hyp(Ttroi)hy 
of  the  right  ventricle,  less  often  sim])le  hypertrophy  or  dilatation.  Tiic  heart 
muscle  was  often  fatty,  particularly  on  the  right  side. 

Measles  and  whooping-cough  are,  as  already  stated,  very  commonly  associated, 
but  the  whooping-cough  complicates  the  measles  more  frecpiently  than  the  measles 
complicates  the  pertussis.  Sometimes  in  very  young  children  the  disease  becomes 
so  severe  that  the  spasm  of  the  cough  seems  to  spread  to  all  the  muscles  of  the  body 
and  produce  general  convulsions.     These  cases  are  nearly  always  fatal. 

Paralysis  complicating  whooping-cough  is  not  common.  It  is  nsuall\  in  the 
form  of  a  hemijjiegia,  and  occurs  either  during  the  acute  period  of  the  disease  or 
as  a  sequel.  When  it  takes  place  during  the  paroxysmal  period  it  is  due  in  the 
majority  of  instances  to  meningeal  or  cerebral  hemorrhage  in  all  probal)ility, 
although  statistics  as  to  this  question  are  scanty.  Twelve  cases  of  cerebral  hemor- 
rhage due  to  whooping-cough  have  been  collected  by  Townsend,  of  which  se\en 
recovered,  and  Brown  has  reported  a  case  in  which  he  operated  for  the  relief  of 
cerebral  compression  due  to  this  cause,  with  excellent  results  to  the  patient.  The 
literature  of  this  subject  has  recently  been  analyzed  by  W.  G.  A.  Robertson.  Some- 
times paraplegia  or  monoplegia  has  occurred  during  the  stage  of  convalescence. 
The  prognosis  seems  to  be  fairly  favorable,  indicating  that  the  lesion  producing 
these  conditions  cannot  be  permanent.  Small  conjunciiral  hemorrhacjc.i  are  not 
infrequent,  and  more  rarely  large  extravasations  of  blood  into  the  conjnncti\al 
tissues  take  place,  amounting  to  ecchymoses.  Still  more  rarely  temporary  anilili/opia 
develops  as  a  result  of  disordered  circulation  in  the  retina  or  possibly  of  an  actual 
retinal  hemorrhage. 

Diagnosis. — The  important  points  in  the  diagnosis  of  whooping-cough  are  the 
repeated  and  rai)id  coughs  in  series  until  the  chest  is  almost  emptied  of  air,  followed 
l\y  a  sudden  inspiration  through  the  narrowed  glottic  opening.  Some  cases  develop 
only  the  series  of  short  coughs,  and  present  no  whoop  afterward.  The  only  cough 
resembling  it  is  one  due  to  enlarged  bronchial  lymph  nodes,  and  in  adults  that  due 
to  a  laryngeal  crisis  in  ataxia. 

Prognosis  and  Mortality. — The  prognosis  in  whooping-cough,  as  in  most  infectious 
diseases,  depends  ui)on  the  age  of  the  child,  its  general  nutrition  and  \-ital  resistance, 
and  upon  the  care  the  child  can  receive.  In  general  terms  it  may  also  be  stated  that 
the  prognosis  is  not  so  good  in  winter  as  in  summer,  as  fresh  air  is  not  so  readily 
obtained  and  there  is  greater  danger  of  exposure  to  cold  in  the  winter  months. 
In  itself  wlioo])ing-cough  is  not  a  fatal  disease.  Death  is  due  to  the  comjilications 
which  ensue,  and  if  these  can  be  ])revente(l  the  ])atient  always  gets  well.  In  very 
young  children,  however,  it  is  almost  imjjossible  to  ])revent  the  development  of 
bronchopneumonia,  and  this  is  a  dangerous  condition  in  projiortion  to  the  youth 
of  the  child.  In  London  whooping-cough  stands  second  as  a  cause  of  death  from 
the  infectious  diseases  in  children  under  two  years  of  age. 

Ilagenbach,  of  Basle,  gives  the  following  mortality  statistics,  which  are  based 
on  the  cases  that  came  under  his  observation  during  a  period  of  eleven  years: 
Under  one  year,  26.8  per  cent.;  between  one  and  two  years,  13.8  per  cent.;  between 
two  and  five  years,  3  per  cent.;  between  five  and  fifteen  years,  1  .S  per  cent. 

Holt  states  that  the  mortality  for  children  under  one  year  of  age  is  25  ])cr  cent. 


WHOOPING-COUGH  105 

Treatment. — It  is  vitally  important  that  children  who  have  whooijing-cough 
should  he  put  under  the  most  favorable  hygienic  conditions  as  to  sunlight,  fresh 
air,  and  equable  temperature.  In  the  summer  they  do  best  out-of-doors  when 
the  weather  is  not  too  cool,  if  they  are  prevented  from  acting  imprudentls-,  as,  for 
example,  getting  the  feet  wet.  In  winter  they  should  be  kept  in  a  warm  room, 
the  temperature  of  which  should  be  70°  night  and  day.  The  air  of  tiiis  room  should 
also  be  moistened  by  liberating  in  it  small  ciuantities  of  steam  obtained  from  a 
kettle  of  .boiling  water,  from  a  croup  kettle,  or  by  dropping  pieces  of  unslaked  lime 
in  a  bucket  of  water.  This  is  an  exceedingly  important  measure  if  the  room  is 
heated  by  a  furnace,  since  the  air  from  the  ordinary  furnace  is  exceptionally  dry 
and  often  laden  with  dust,  and  these  two  causes  act  as  an  irritant  to  the  already 
irritated  respiratory  tract.  When  it  is  not  possible  to  confine  the  child  to  a  rooni 
which  is  heated  evenly,  a  most  excellent  method  of  treatment,  particularly  in 
those  cases  where  the  paroxysms  are  frequent  at  night,  is  to  place  the  child  in  a 
bronchitis  tent.  A  bronchitis  tent  consists  in  throwing  over  a  bed  a  large  sheet 
which  is  supported  several  feet  above  the  head  of  the  child  by  means  of  broom- 
sticks or  poles,  which  are  tied  at  each  corner  of  the  bed.  This  tent  can  be  made 
quite  attractive  for  children  by  decorating  it.  Into  this  tent,  at  the  foot  of  the 
bed,  may  be  discharged  a  small  quantity  of  steam  such  as  is  given  off  from  an 
ordinary  kettle  of  water  when  it  is  kept  constantly  boiling.  In  this  way  the  child's 
mucous  membranes  are  not  irritated  by  dry  or  cold  air,  but  on  the  contrary  are 
greatly  soothed,  and  I  have  frequently  diminished  the  number  of  paroxysms  per 
day  at  least  one-half  by  the  institution  of  this  plan  of  treatment,  which  has  the 
additional  advantage  that  it  is  prophylactic,  and  prevents  the  development  of 
those  serious  complications  like  vomiting  and  bronchopneumonia,  which  are 
much  aided  in  their  development  by  repeated  and  violent  paroxysms  of  cough. 
With  a  little  attention  a  child  may  be  kept  in  such  a  bronchitis  tent  night  and  day 
through  the  entire  attack. 

In  the  way  of  drugs  there  is  no  remedy  so  efficacious  in  diminishing  the  severity 
of  the  attack  as  small  doses  of  antipyrin;  that  is  to  say,  4  to  1  grain  of  antipyrin 
every  three  or  four  hours  to  a  child  of  one  or  two  years,  or  2  grains  every  three  or 
four  hours  to  a  child  of  five  or  six  years,  care  being  taken  that  the  drug  does  not 
too  greatly  relax  the  skin  or  depress  the  circulation.  There  is  a  widespread  belief 
among  the  laity  that  quinine  in  small  doses  is  not  only  a  prophylactic  against 
whooping-cough  for  other  children  in  the  family  who  have  not  as  yet  contracted  the 
disease,  but  that  it  is  also  of  curative  value.  Some  physicians  have  used  a  spray 
of  a  weak  solution  of  quinine  in  the  throat  with  asserted  advantageous  results, 
but  its  value  is  doubtful,  and  its  bitter  taste  makes  its  use  impossible  in  a  large 
proportion  of  cases.  Vaccine  treatment  using  50,000,000  of  the  Bacillus  pertussis 
has  given  excellent  results,  the  dose  being  repeated  about  every  five  days. 

The  development  of  complications,  such  as  bronchopneumonia,  necessitates  the 
institution  of  those  lines  of  treatment  which  will  be  found  suggested  for  that  disease. 
For  the  relief  of  the  individual  paroxysms  of  cough  several  remedies  may  be  employed, 
of  which  the  best  is  probably  chloroform.  It  is  needless  to  say  that  this  drug 
should  be  used  with  great  caution,  and  the  patient's  parents  and  the  nurse  should 
be  instructed  never  to  use  it  on  a  cloth,  but,  when  the  paroxysm  is  threatened, 
to  pour  the  remedy  over  the  back  of  the  hand  and  place  the  hand  under  the  child's 
nose.  Under  these  circumstances  a  sufficient  quantity  of  the  chloroform  is  often 
inhaled  to  relax  the  spasm,  without  producing  any  of  the  marked  physiological 
effects  which  would  certainly  be  obtained  to  an  undesirable  degree  if  the  drug  were 
poured  on  to  a  napkin.  This  method  also  prevents  an  overdose  of  chloroform 
being  given,  since  the  excess  of  the  drug  rapidly  runs  off  the  hand  or  evaporates. 
As  the  hurry  of  an  approaching  paroxysm  often  makes  the  attendant  careless  as 
to  the  quantity  which  is  poured  out  of  the  bottle,  the  physician  should  insist  that 


106  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

the  chloroform  be  used  in  no  other  way  than  that  which  has  just  been  described. 
If  the  parosysms  are  too  severe  to  be  controlled  in  this  way,  nitrite  of  amyl  may 
be  occasionally  employed. 

An  innumerable  array  of  drugs  have  been  recommended  for  the  palliation  and 
cure  of  whooping-cough.  Suffice  it  to  say  that  most  of  them  are  entirely  useless. 
Even  such  powerful  nervous  sedatives  as  the  bromides  cannot  act  advantageously 
in  many  of  these  cases,  and  the  use  of  more  powerful  ones  such  as  chloral  and  opium 
are  contra-indicated  for  evident  reasons.  The  physician  should  always  remember 
that  whooping-cough  is  a  disease  which  is  bound  to  run  its  course,  uninfluenced 
in  its  duration  by  any  treatment  which  he  can  employ.  The  most  that  the  physician 
can  do  is  to  prevent  complications,  treat  them  if  they  arise,  and  endeavor  to  modify 
the  frequency  and  severity  of  the  individual  parosysms,  being  careful  in  so  doing 
that  the  remedy  is  not  worse  than  the  disease,  in  the  sense  that  it  produces  digestive 
or  circulatory  disorders  which  are  distinctly  disadvantageous. 


INFLUENZA. 

Definition. — Influenza  is  sometimes  called  la  Grippe.  It  is  a  pandemic  disease; 
that  is,  one  which  appears  in  widely  separated  parts  of  the  world  simultaneously. 
It  is  also  highly  infectious,  and  the  infection  is  produced  by  the  bacillus  of  Pfeiffer. 
Influenza  of  this  type  is  to  be  separated,  theoretically  at  least,  from  that  condition 
sometimes  called  "common  cold"  or  "coryza,"  which  often  causes  somewhat 
similar  symptoms  in  a  milder  form,  although  during  the  presence  of  an  epidemic 
of  la  Grippe  the  difi'erential  diagnosis  may  be  impossible.  At  the  present  time 
the  term  "influenza"  is  often  employed  when  the  physician  is  unable  to  reach  a 
diagnosis,  and  as  a  consequence  is  greatly  abused,  particularly  in  the  early  stages 
of  typhoid  fever  and  tuberculosis. 

Leichtenstern  has  divided  the  disease  into  two  varieties,  namely,  true  epideujic 
influenza  {influenza  vera)  due  to  the  bacillus  of  Pfeift'er,  and  endemic  influenza 
due  to  the  same  cause  and  occurring  for  some  years  after  an  epidemic  has  been 
present.  Both  of  these  forms  are  to  be  separated  from  ordinary  pseudo-epidemic 
influenza  or  an  attack  of  ordinary  cold  in  the  head.  A  peculiarity-  of  true  influenza 
in  its  epidemic  form  is  the  large  percentage  of  persons  which  it  attacks  within  a 
short  space  of  time,  more  than  any  other  epidemic  disease  except  dengue. 

History. — At  various  times  in  the  past  great  epidemics  ha\'e  broken  out  and 
raged  over  the  entire  world,  and  have  been  followed  by  long  periods  of  immunity. 
Thus,  when  the  great  epidemic  of  1889  occurred,  only  a  few  ph>sicians,  and  they 
of  advanced  years,  had  ever  seen  a  case,  for  the  previous  epidemic  had  occurred 
in  1847  and  1848. 

Pandemics  have  occurred  during  the  last  century  in  1830-33,  1836-37,  1847-48, 
and  1889-90.  In  1889  the  disease  began  in  remote  parts  of  Russia  in  October, 
reached  Moscow  in  November,  ten  weeks  later  it  got  to  Berlin,  a  month  later  to 
London,  and  soon  after  to  New  York  and  Philadelphia,  and  thence  it  spread  all 
over  the  continent  of  North  America.  Within  t\\e  next  few  months  nearly  the 
whole  civilized  world  was  affected  by  it.  Since  the  last  outbreak  the  disease  has 
been  endemic,  but  it  is  an  attenuated  form  of  the  infection.  An  individual  locality 
is  rarely  subject  to  an  epidemic  for  more  than  two  months,  but  sporadic  outbreaks 
occur  for  a  long  period  afterward. 

Etiology. — It  is  interesting  to  note  that  the  word  influenza  is  derived  from  the 
Latin  sentence  ah  cocli  occultes  quadam  influentia — from  some  hidden  influence 
in  the  sky.  Influenza,  if  entirely  dependent  upon  a  microorganism  for  its  infectious 
character,  must  also  be  dependent  upon  certain  telluric  influences,  at  present 
unknown,  which  render  the  human  race  more  susceptible  to  the  ett'ects  of  the  germ 


INFLUENZA  107 

at  certain  times  or  which  render  the  germ  more  capable  of  producing  infection 
at  certain  periods. 

There  are  two  chief  factors  involved  in  the  production  of  an  attack  of  influenza, 
namely,  the  presence  of  the  bacillus,  usually  received  directly  from  another  patient 
by  contact,  or  through  the  air;  and,  second,  atmospheric  states  which  are  favorable 
to  the  growth  of  the  germ  or  to  the  production  of  individual  susceptibility.  A 
third  factor,  always  of  importance  in  connection  with  infectious  diseases,  is  the 
presence  of  preexisting  disease  which  decreases  the  general  vital  resistance  of 
the  patient. 

The  bacillus  of  Pfeiffer  was  first  isolated  by  that  investigator  in  1892.  The 
organism  is  small  and  non-motile,  and  can  be  well  stained  by  Loeffler's  methylene 
blue  or  by  well-diluted  watery  solutions  of  carbol-fuchsin.  It  develops  in  myriads 
on  the  nasal  and  bronchial  mucous  membranes  and  in  the  secretions  of  those  parts. 
A  number  of  observers,  and  more  particularly  Ricciardi,  have  shown  that  the 
bacillus  is  readily  distributed  and  spreads  most  actively  by  droplets  of  mucus. 
Even  after  the  patient  has  recovered  from  an  attack  his  nasal  secretions  may 
reinfect  himself  or  other  persons  for  a  period  of  weeks,  and  therefore  all  handker- 
chiefs, towels,  and  pillowcases  used  by  him  should  be  boiled  before  being  used  by 
others.  The  room  occupied  by  the  patient  should  be  fumigated  with  formaldehyde 
after  his  recovery  occurs  and  before  anyone  else  occupies  it. 

It  is  a  noteworthy  fact  that  during  an  epidemic  of  influenza  other  infectious 
diseases  seem  to  be  less  common.  This  is  particularly  true  of  malarial  fevers, 
if  the  statistics  collected  by  Anders,  of  Philadelphia,  are  correctly  interpreted. 
On  the  other  hand  it  is  very  common,  and  indeed  it  is  almost  constantly  the  case, 
to  find  that  the  illness  is  due  quite  as  much  to  associated  infection  with  the  pneu- 
mococcus  and  pyogenic  cocci  as  to  the  influenza  bacillus.  That  is  to  say  the 
infection  is  usually  compound  or  complex  and  not  single.  Thursfield  reports 
two  cases  of  influenzal  septicemia,  with  recovery  of  both.  He  believes  that  the 
organisms  described  as  the  B.  infliienzw  are  not  identical  but  form  a  group,  like 
the  typhoid-colon  family,  with  different  pathogenic  powers.  Lesions  produced 
by  the  various  members  of  the  group  include  influenza,  endocarditis,  a  septicemic 
form  of  cerebrospinal  meningitis,  septicemia,  pertussis,  and  suppuration  in  the 
middle  ear  and  nasal  sinuses. 

Incubation. — ^The  period  of  incubation  is  probably  from  twenty-four  to  seventy- 
two  hours,  but  in  some  cases  it  seems  to  be  longer  than  this. 

Symptoms. — The  onset  of  symptoms  of  epidemic  influenza  is  nearly  always 
sudden.  A  person  feeling  perfectly  well  may  suddenly  be  seized  by  a  sense  of 
chilliness  or  a  severe  rigor,  followed  by  severe  aching  pains  in  the  back  and  in  the 
legs.  There  is  usually  congestion  of  the  nasal  mucous  membrane,  so  that  the  patient 
seems  to  have  a  severe  cold  in  the  head.  The  chill  is  quickly  followed  by  fever 
which  may  rapidly  rise  to  a  point  as  high  as  105°,  although  as  a  rule  103°  is  the 
more  common  acme.  Associated,  with  these  early  symptoms  there  is  usually  a 
sense  of  severe  illness  and  a  feeling  of  great  wretchedness,  so  that  the  patient  not 
only  expresses  himself  as  feeling  very  ill,  but  seems  so  to  the  physician. 

About  this  time  the  symptoms  are  wont  to  be  associated  with  additional  ones 
indicating  involvement  of  certain  viscera.  Most  frequently  the  respiratory  system 
is  affected,  and,  in  addition  to  more  or  less  intense  congestion  of  the  nasal  mucous 
membrane,  an  acute  bronchitis  develops;  the  physical  signs  in  the  chest  being 
typically  those  of  acute  bronchitis  with  excessive,  unproductive  cough  and  a 
sense  of  thoracic  soreness.  When  the  nasal  mucus  is  examined  it  is  seen  to  be 
unusually  thin,  excoriating  to  the  nose  and  upper  lip,  and  if  any  bronchial  mucus 
is  expelled  it  is  also  of  this  character.  As  the  disease  progresses  the  sputum  becomes 
greenish-yellow  and  thick. 

The  general  state  of  the  patient  at  this  time  is  often  one  of  profoimd  depression, 


108  DISEASES  DUE  TO  A  SPECIFIC  I.XFECTIOX 

far  in  excess  of  that  which  usually  accompanies  sudi  sifjns  of  hronciiitis.  Tiie 
action  of  the  heart  may  he  frchic  and  tin-  skin  is  relaxed  and  clannn.v,  or  it  tna\-  he 
very  hot  and  dry. 

If  convalescence  is  not  soon  estahlishcd  tlic  disease  often  de\elo|).s  into  a  peenliar 
form  of  piilinonari/  conyestidn  or  pneiiiiionni,  in  wliich  tiie  sputum  may  he  hlood- 
tinged  ami  frothy  or  in  which  no  sputum  may  appear.  A  peculiarity  of  this  pul- 
monary invohement,  in  one  of  its  forms,  is  the  fact  that  it  moves  from  ])lace  to 
place  with  remarkahle  rajjidity.  An  area  of  imijaired  resonance  which  existe(i 
yesterday  is  clear  today,  and  still  another  area  of  congestion  develops  elscwhen — 
a  form  of  wandering  congestion.  When  true  pneumonia  fle\elops  it  may  he 
croupous  in  type  and  be  due  to  mixed  infection  hy  the  bacillus  of  I'feiH'cT  and  1)\- 
that  of  true  pneumonia,  or  it  may  be  in  the  form  of  bronchopneumonia.  The 
latter  type  is  the  more  common,  but  both  forms  are  apt  to  be  .serious  and  j)articularly 
so  in  the  feeble,  the  aged,  the  very  young,  and  in  alcoholic  or  renal  cases.  Pneu- 
monia and  heart-failure  due  to  an  action  of  the  toxin  of  the  disease  on  the  heart 
muscle  are  the  chief  causes  of  death  in  all  epidemics. 

Pleurisy  followed  by  empyema  is  not  \-ery  rare. 

In  studying  a  case  of  influenza  accompanied  by  pulmonary  signs  the  physician 
must  always  bear  in  mind  the  possibility  of  the  presence  of  associated  tuberculous 
infection,  because  an  attack  of  influenza  not  onl,\'  often  predisposes  to  this  disease, 
but  in  addition  permits  unrecognized  foci  of  early  tuberculous  infection  to  become 
active. 

In  some  cases  of  influenza  the  Jwart  seems  to  bear  the  chief  brunt  of  the  attack 
so  that  repeated  attacks  of  syncope  ensue.  These  instances  arc  met  with  chiefly 
among  patients  who  have  persisted  in  remaining  at  work  during  the  early  stages 
of  the  disease,  or  who  have  had,  previous  to  the  attack,  an  impaired  heart  muscle. 
Thus,  a  heart  dilated  as  the  result  of  excessive  exercise  may  succumb  readily,  or 
one  in  which  early  but  hitherto  unrecognized  degenerative  changes  were  dtveloi)ing 
may  suddenly  fail.  Often  the  symptoms  of  influenza  are  chiefly  gastro-intcstiiial 
or  nervous. 

The  gasiro-iniedinal  form  of  the  disease  may  have  its  onset  in  severe  diarrhea 
and  vomiting,  with  collapse  and  violent  abdominal  pain.  In  some  cases  the 
pain  is  entirely  absent,  and  profuse  watery  stools  are  present.  Jaundice  may  be 
present,  due  to  an  extension  of  the  gastro-intestinal  eatarrh  to  the  common  biliary 
duct. 

In  the  nervous  form  the  symptoms  consist  of  profound  7iervoiis  and  mental 
depression,  or  in  severe  neuralgic  pain  which  may  or  may  not  be  due  to  neuritis. 
Mental  disturbances  in  the  course  of  an  attack  of  influenza  are  by  no  means  rare. 
Indeed,  it  may  be  said  that  no  other  acute  infectious  disease  is  so  commonly  com- 
plicated, or  followed,  by  such  a  condition.  Leichtenstern  states  that  he  met  with 
fewer  p.sychoses  among  2()()()  cases  of  typhoid  fever  and  .']()00  cases  of  pneumonia 
than  he  found  among  439  cases  of  influenza.  The.se  psychoses  may  be  of  the 
exhaustion  t\pe,  but  usually  are  due  to  a  toxic  state  induced  by  the  malady.  The 
mental  disturbance  may  develop  during  the  stage  of  onset,  the  febrile  stage,  or 
the  stage  of  decline  or  convalescence.  The  latter  cases  are  usually  of  the  exhaustion 
ty])e.  The  prognosis  in  these  cases  as  to  the  state  of  the  mind  is  usually  good 
unless  there  is  a  bad  history  as  to  heredity. 

Very  rarely  men'nujitis  develops,  and  still  more  rarely  true  cncciilialitis.  The 
meningitis  is  primarily  due  to  the  influenza  bacillus  but  other  secondary  organisms 
are  nearly  always  found  at  autopsy.  It  usually  occurs  in  children  under  one 
year  of  age  and  the  mortality  is  ninety  per  cent.  Lumbar  puncture  reveals  a 
turbid  fluid  under  high  pressure  with  many  leukocytes  and  an  excess  of  polynuclear 
cells.  In  some  instances,  however,  although  the  meningeal  symptoms  are  most 
marked  during  life  no  definite  lesions  can  be  fovmd  at  autopsy.     Particularly  is  this 


INFLUENZA  109 

true  in  young  children.  In  other  cases  extensive  hemorrhages  into  the  pia  mater 
may  be  produced  or  a  sharp  perivascularitis  in  the  vessels  of  the  brain  may  develop. 
In  still  others  there  may  develop  a  chronic  perivascularitis  which  induces  permanent 
palsies.  It  is  usually  met  with  in  infants.  Cases  of  cerebral  abscess  have  also  l)een 
ascribed  to  this  disease.  In  rare  cases  toxic  neuritli  develops,  and  this  may  be 
single  or  multiple.  Even  paraplegia  due  to  this  cause  may  arise.  Not  only  may 
this  type  of  influenza  affect  the  nerves  of  sensation  and  motion,  but  specialized 
nerves  such  as  the  vagus,  thereby  causing  disturbances  of  the  circulation  such  as 
paroxysms  of  tachycardia  and  bradycardia.  In  an  analysis  of  29,0(10  cases  Lee 
found  that  7000  were  of  the  nervous  type.  In  some  instances  the  disturbance  of 
circulation  is  due  more  to  an  influence  exercised  upon  the  vasomotor  nervous  system 
than  to  any  direct  aft'ect  upon  the  nerve  supply  of  the  heart,  so  that  attacks  of 
syncope  come  on  from  acute  vascular  relaxation. 

Complications  and  Sequelae. — It  is  difficult  to  separate  the  complications  of  in- 
fluenza from  the  ordinary  symptoms  of  the  disease  because  its  natural  course 
presents  such  diverse  manifestations  in  different  organs.  Without  doubt 
pulmonary,  cardiac,  and  renal  disorders  are  the  most  common  complications. 
In  many  cases  death  is  due  to  an  attack  of  pneumonia,  which  rapidly  carries  off 
the  patient  whose  vitality  is  already  sajjped  by  the  onset  of  ki  Grippe.  In  other 
instances  the  kidneys,  which  have  been  impaired  before  the  attack,  suffer  from  an 
acute  congestion  or  true  nephritis  superimposed  upon  a  subacute  or  chronic 
state,  and  so  uremia  speedily  comes  on,  with  its  helpmate,  pulmonary  edema. 

Patients  with  influenza  develop  cardiac  complications  in  three  chief  classes: 
either  they  already  have  mild  cardiovascular  degeneration  which  enables  the 
influenzal  toxin  to  work  havoc  with  the  cardiac  muscle,  or  they  ha\-e  dilated  feeble 
hearts,  or,  again,  as  already  stated,  they  persist  in  remaining  at  work  after  the 
attack  begins  and  refuse  to  go  to  bed.  These  patients  not  only  haxe  serious 
cardiac  difficulty  during  the  attack,  but  very  frequently  suft'er  from  cardiac  weak- 
ness and  distress  for  many  weeks  after  convalescence  should  be  well  established. 
The  man  who  persists  in  remaining  out  of  bed  when  attacked  by  this  disease, 
even  if  mildly  ill,  literally  "takes  his  life  in  his  hand." 

In  children,  as  well  as  adults,  severe  middle  ear  inflammation  is  a  very  common 
complication  even  in  mild  cases. 

The  German  collective  investigation  of  the  epidemic  of  1889-90,  based  on  an 
analysis  of  3185  cases,  gave  the  following  results  as  to  the  relative  frequency  of 
complications,  which  results,  however,  differ  materially  from  clinical  experience 
in  America  so  far  as  the  cardiac  complications  are  concerned: 

1.  Diseases  of  the  respiratory  organs,  exclusive  of  pneumonia,  48.76  per 
cent. 

Of  these  complications  pleurisy  was  the  most  frequent,  being  present  in  27  per 
cent,  of  the  entire  number  of  cases.  Pneumonia  was  present  in  from  6  to  8  per 
cent,  of  all  cases. 

2.  Diseases  of  the  nervous  system,  45.77  per  cent. 

3.  Diseases  of  the  ear,  37.95  per  cent. 

4.  Hemorrhages,  25.33  per  cent. 

5.  Diseases  of  the  heart  and  vascular  system,  14.09  per  cent. 

6.  Diseases  of  the  digestive  organs,  10.36  per  cent. 

7.  Polyarthritis,  7.28  per  cent. 

8.  Diseases  of  the  eye,  7.03  per  cent. 

9.  Albuminuria  and  nephritis,  4.52  per  cent. 

Diagnosis. — It  is  so  easy  to  make  a  diagnosis  of  influenza  during  the  presence 
of  an  e]jiflemic  that  physicians  are  wont  to  be  careless  in  examining  the  patient 
thoroughly,  and  so  may  overlook  complications  of  importance  or  decide  that  the 
case  is  one  of  influenza  when  in  reality  the  chills,  the  fever,  the  aching,  and  the 


110  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

prostration  are  due  to  an  oncoming  typhoid  fever  or  an  acute  tuberculosis  or  malaria. 
All  of  these  diseases,  and  also  ulcerative  endocarditis  and  sepsis,  should  be  carefully 
excluded  before  a  diagnosis  of  influenza  is  made. 

Treatment. — Above  all  other  things  in  the  treatment  of  influenza  is  rest  in  bed. 
This  is  as  true  of  mild  as  of  severe  eases  and  of  the  patient  who  is  stalwart  as  of 
the  patient  who  is  feeble.  A  robust  man  who  fails  to  rest  almost  always  suffers 
from  a  severe  attack  or  from  sequelte,  such  as  cardiac  disorder  and  giddiness,  which 
may  invalid  him  for  weeks.  Aside  from  rest  in  bed  little  medicine  is  needed  except 
for  the  purpose  of  relieving  symptoms  which  are  troublesome.  For  the  relief  of  the 
excessive  pain  in  the  back  and  limbs  the  coal-tar  antipyretics  have  been  employed 
by  the  ton.  Although  they  give  ease  they  are  harmful  if  the  doses  are  large,  and 
often  fail  if  they  are  used  in  moderate  amounts.  They  tend  to  increase  nervous 
and  circulatory  depression,  and  to  decrease  the  ability  of  the  patient  to  resist  the 
infection  from  which  he  is  suffering  and  the  possible  secondary  infections  which 
may  occur.  If  the  patient  will  rest  they  may  be  used  moderately;  if  he  will  not 
rest  they  should  not  be  used,  for  they  not  only  do  harm  directly,  but  by  diminishing 
discomfort  they  also  enable  and  encourage  him  to  remain  out  of  bed. 

A  very  useful  drug  for  the  relief  of  the  aching  and  pains  in  the  back  and  limbs 
is  salicin  in  5  grain  doses  every  five  hours  in  capsules.  Many  practitioners  believe 
that  this  drug  alone,  or  when  combined  with  .3  grains  of  cinchonidine,  acts  as  a 
specific  in  the  cure  of  the  affection.  Should  the  pain  in  the  back  be  intense  it  may  be 
relieved  by  the  application  of  hot  stupes  or  compresses,  or  by  rubbing  with  soothing 
liniments.  A  more  ancient  but  nevertheless  very  useful  remedy  for  this  condition, 
jiarticularly  in  the  early  stage  of  the  malady,  is  Dover's  powder  in  the  dose  of 
from  2  to  10  grains  once  or  twice  a  day.  At  one  time  used  as  a  matter  of  routine 
in  all  infections,  it  has  fallen  into  an  undeserved  disuse. 

Headache,  if  it  be  due  to  congestion,  may  be  modified  by  the  use  of  an  ice-bag, 
or  by  the  administration  of  1  to  2  grains  of  caffeine  with  10  grains  of  bromide  of 
sodium  or  potassium  every  few  hours.  This  formula  can  be  given  in  the  form  of 
an  effer-\-escent  granular  salt  without  the  use  of  the  coal-tar  products  often  added 
by  manufacturers  of  headache  cures.  Hot  foot-baths  also  decrease  headache. 
Menthol  pencils  may  be  used  locally  for  neuralgia  or  a  spray  of  chloride  of  ethyl 
may  be  used  for  the  same  purpose. 

As  in  all  infectious  maladies,  it  is  of  the  greatest  importance  that  the  organs  of 
elimination  be  kept  active.  The  bowels  may  be  first  moved  by  a  grain  or  two  of 
calomel,  followed  in  twelve  hours  by  a  Seidlitz  powder,  or,  if  constipation  has  been 
marked,  they  may  be  opened  at  once  by  citrate  of  magnesium.  For  the  purpose 
of  keeping  the  kidneys  active  5  grains  of  citrate  of  potassium  or  of  bicarbonate  of 
potassium  may  be  given  every  four  hours  in  copious  draughts  of  water  if  the  urine 
is  acid,  or  the  same  amount  of  benzoate  of  ammonium  if  the  urine  is  alkaline. 
The  latter  drug  is  best  given  in  konseals,  and  possesses  the  additional  advantage 
of  acting  favorably  upon  the  respiratory  mucous  membrane  and  upon  the  muscular 
pains.  A  hot  compress  or  poultice  applied  over  the  loins  will  often  establish  renal 
secretion  when  it  seems  scanty. 

Dryness  and  soreness  of  the  mucous  membrane  of  the  respiratory  tract,  in  the 
stage  of  onset,  may  be  much  relieved  by  telling  the  patient  to  inhale  steam  which 
may  be  medicated  by  the  addition  to  the  water  from  which  it  arises  of  a  few  grains 
of  menthol  or  of  equal  parts  of  menthol,  oil  of  eucalyptus,  and  oil  of  pine.  In 
other  instances  the  patient  may  add  to  the  boiling  water  a  tablcspoonful  of  com- 
pound tincture  of  benzoin.  The  medicated  steam  may  be  taken  directly  from  an 
inlialer  or  the  vapor  may  be  set  free  in  the  air  of  the  room  by  the  use  of  a  bronchitis 
kettle.  When  the  nasal  mucous  membrane  is  so  congested  and  occluded  that 
breathing  is  difficult  and  oppression  is  marked,  adrenalin  chloride,  1 :  5000,  with 
chloretone  may  be  sprayed  into  the  nostrils  or  applied  on  pledgets  of  cotton.     It 


ACUTE  POLIOMYELOENCEPHALITIS  111 

loses  its  effect  if  applied  too  often,  but  it  does  not  do  so  as  rapidly  as  does  cocaine, 
nor  is  it  dangerous  in  its  systemic  efl'ects. 

For  the  relief  of  the  congestion  of  the  respiratory  mucous  membrane,  when  the 
illness  has  lasted  for  several  days  and  the  secretion  is  thick  and  tenacious,  chloride 
of  ammonium  in  5  grain  doses  four  times  a  day  may  be  administered  combined  witii 
codeine  or  heroin  to  relieve  cough,  or  terpin  hydrate  may  be  used  with  the  same 
sedatives  in  the  form  of  the  well-known  elixir  of  terpin  hydrate  with  heroin.  For 
the  persistent  cough  of  convalescence,  oil  of  sandal-wood  in  5  minim  doses  four 
times  a  day  is  very  useful. 

Circulatory  and  nervous  stimulants  are  not  to  be  used  unless  there  is  distinct 
evidence  of  their  need.  Alcoholic  drinks  are  as  a  rule  to  be  excluded,  unless  the 
patient  uses  them  habitually  when  well,  when  they  have  to  be  given,  preferably 
in  the  form  of  an  old  brandy  or  good  whiskey.  Great  care  must  be  taken  that  the 
patient  does  not  overuse  them  in  his  endeavor  to  make  himself  feel  stronger.  For 
acute  circulatory  failure  aromatic  spirit  of  ammonia  or  Hoffmann's  anodyne  are 
the  remedies  of  choice.  When  the  failure  of  the  cirulation  is  associated  with 
nervous  depression  the  use  of  strychnine  is  indicated,  but  it  is  greatly  abused  and 
should  not  be  given  day  after  day  except  as  a  tonic  in  convalescence,  as  it  loses 
its  power,  is  not  a  true  stimulant  but  a  nervous  irritant,  and  often  causes  great 
irritability  if  not  employed  skilfully. 

As  influenza  is  a  disease  which  produces  great  prostration,  a  diet  which  is  easily 
digested  and  nutritious  is  essential  for  the  maintenance  of  strength,  particularly 
in  the  very  young,  very  feeble,  and  very  old.  Animal  broths,  oysters,  and  predi- 
gested  foods  are  useful,  and  they  may  be  fortified  with  advantage  by  barley-gruel, 
the  digestion  of  which  may  be  aided  by  the  use  of  taka-diastase.  Indeed,  the 
various  vegetable  gruels  with  taka-diastase  are  in  many  cases  better  than  the 
animal  broths.     Arrowroot  and  milk-toast  and  eggs  are  also  useful. 

Prophylaxis. — ^There  can  be  no  doubt  that  much  can  be  done  to  prevent  the 
spread  of  la  grippe  from  one  person  to  another  by  isolating  the  ill  and  by  forbidding 
healthy  persons  to  occupy  the  sick-room  after  it  is  vacated,  until  it  is  thoroughly 
disinfected.  This  is  particularly  advisable  when  the  old  and  feeble  are  about  the 
house  and  when  persons  who  are  still  weak  from  one  attack  are  exposed.  Every 
effort  should  be  made  to  keep  the  malady  out  of  the  non-medical  wards  of  hospitals, 
insane  asylums,  and  almshouses.  Patients  in  these  institutions  when  taken  ill 
should  be  isolated,  and  the  bedding,  napkins  and  handkerchiefs  be  promptly  disin- 
fected.    The  sputum  should  be  expelled    upon   pieces  of  rag  and  then  burned. 

All  rooms,  clothes,  and  books  used  by  patients  suffering  from  influenza  should 
be  disinfected  as  carefully  as  if  the  patient  had  suffered  from  some  more  fatal 
malady. 

ACUTE   POLIOMYELOENCEPHALITIS. 

Definition. — This  infectious  disease  is  sometimes  called  infantile  spinal  paralysis, 
because  it  most  commonly  presents  spinal  symptoms.  It  is  also  called  acute  infantile 
palsy,  and  acute  atrophic  paralysis.  In  its  spinal  form  it  is  characterized  by  fever 
and  sudden  loss  of  power  in  one  or  more  of  the  limbs,  most  commonly  the  lower 
extremities.  As  a  rule,  the  loss  of  power  is  complete,  but  occasionally  it  is  local- 
ized in  certain  groups  of  muscles.  Immediately  after  the  development  of  the 
paralysis,  wasting  of  the  muscles  begins  to  take  place  and  may  be  extreme.  There 
is  no  disturbance  of  sensation. 

Etiology. — Within  recent  years  it  has  become  more  and  more  evident  that  acute 
anterior  poliomyelitis  is  due  to  an  infection.  That  the  disease  at  times  occurs  in 
epidemic  form  was  noted  by  Colmar  more  than  sixty  years  ago.  Since  1907  out- 
breaks have  occurred  in  many  widely  separated  States  of  the  Union,  in  Canada, 


112 


DJSI'JASl'JS  DUE  TO  A  SPECIFIC  ISFECTKiS 
Fia.  28 


aooo 

8000 

roco 


cooos; 

o 

jOOOu. 

o 

4000  01 

s 
:j(iOoi 

21)00 

11)00 


^ 1SS1-1S93- 


-isoi-iaoi-*" 02  "Oi  '00  'OS  "10 


RuUitivu  prevalence  of  infantile  paralysis  in  the  United  States  and  Europe  and  Australia,  ISSl  -I'JIO. 
The  solid  black  line  refers  to  the  United  States;  the  dotted  line  to  the  following  countries:  Itiily, 
Sweden,  Norway,  Germany,  Austria,  France,  England,  and  Australia.  Part  of  this  increase  is  due  to 
better  recognition.     (Lovett.) 

Fig.  29 


B 

.  — .^ 

\\Vz\\':-:-^W-  z-  - x^. 

h----^P 

::::::::+:..                    ^  :-^ 

:^5i 

, ^ 

T.-T 

i 

"■^^■' 

■■  1 

:jxr 

■fl  iiiitB"ftii"i^"'*^ 

,_■■■ 

III 

PfWPPNri 

I  i 

i:      :      :      ^.     ^    .;     i;      ^      || 

^ 

'^'t 

i'  '■'     :        :■'        '     M     ''Uh'.r 

ving  graphically,  age  incidence  of  1076  cases  of  poliomyelitis  recorded  in  1910. 
(Department  of  Health  of  Pennsylvania.) 


ACUTE  POLIOMYELOENCEPHALiriS 


113 


Cuba,  Austria,  Germany,  and  Melanesia.  In  the  last  decade  its  occurrence  has 
greatly  increased  in  ail  parts  of  the  world. 

Flexner  and  Noguchi  have  grown  the  virus  outside  the  body  anaerobically. 
It  developed  in  minute  colonies  of  globoid  bodies  (0.15  to  0.3  microns  in  size). 
These  cultures  are  capable  of  causing  the  typical  disease  in  monkeys.  It  is  killed 
by  1  to  500  of  potassium  permanganate  or  1  per  cent,  of  menthol  in  oil. 

The  biting  stable-fly  (Siomoxys  calcitrans)  has  been  accused  of  transmitting 
the  disease  but  this  has  been  denied.  House  flies  undoubtedly  carry  the  infectious 
agent  on  their  bodies. 

The  disease  is  distinctly  one  of  early  child  life,  the  greatest  number  of  cases 
developing  in  the  first  three  years  of  life,  it  being  comparatively  rare  after  the 
tenth  year  (Fig.  29).  It  is  far  more  apt  to  develop  in  the  summer  than  in  winter, 
and  has  its  greatest  incidence  in  July  and  August.  After  this  season  it  is  most 
frequent  in  September  and  in  June.  The  period  of  incubation  may  vary  from  two 
days  to  tliree  weeks. 

One  attack  protects  to  some  extent  from  another.  The  infection  probably  is 
spread  by  the  nasal  secretions  of  those  who  are  convalescent  or  who  act  as  "carriers." 


a.  spin,  post 


a.  spill,  post 


Dots  show  chief  areas  of  disease  in  acute  poliomyelitis. 


Prevention. — Patients  in  the  acute  stages  should  be  isolated  and  their  nasal 
discharges  destroyed.  They  should  be  protected  from  flies  which  may  carry  the 
disease  for  at  least  two  weeks.  Kling  found  the  virus  in  the  nasal  discharges,  how- 
ever, six  months  after  the  illness.  Dust  should  be  avoided  and  the  tliroat  gargled 
with  a  1  or  2  per  cent,  solution  of  hydrogen  peroxide  or  treated  by  a  spray  of 
menthol  in  oil,  5  grains  to  the  ounce.  This  may  also  be  used  in  the  nose.  Urotropin 
may  be  given  in  5-grain  doses,  i.  e.,  as  a  prophylactic.  Patients  suffering  from  the 
disease  should  be  quarantined  for  three  weeks  after  the  acute  symptoms  cease. 

Pathology  and  Morbid  Anatomy. — As  Flexner  and  his  colaborers  have  well  put 
it,  epidemic  poliomyelitis  is  a  general  disease  of  the  nervous  system,  although 
the  most  prominent  and  important  symptoms  are  those  following  injury  to  the 
motor  neurones  of  the  spinal  cord  and  brain.  The  essential  lesion  of  this  disease 
is  an  acute  inflammatory  process  in  the  anterior  cornua  of  the  spinal  cord,  with 


114  I)/SKASr':S  DUE  TO  A  HI'Kcnnc  INFECTION 

associiitwl  liNpiTfiiiiu  of  tlie  inenihraiK's  cox criii};  tJio  anterior  .surface  of  the  cord. 
Tlie  branches  of  the  anterior  si)in:il  artery  (Ki}?.  130)  hear  the  brunt  of  the  attack 
and  are  intensely  engorfjed.  Their  finer  brandies  are  ruptured  so  tliat  extrava- 
sations of  blo(Kl  take  place  into  the  gray  matter.  As  a  result  of  these  changes 
the  typical  jjicture  of  tissues  suffering  from  an  acute  inflammatory  process  is 
presented,  for  serum,  leukocytes,  and  red  cells  crowd  the  nervous  protoplasm. 
The  ganglion  cells  of  the  gray  matter  in  the  anterior  horns  undergo  marked  degen- 
erative changes.  They  undergo  cloudy  swelling  and  the  nuclei  become  granular, 
or  if  the  change  is  still  more  severe  the  nuclei  disappear  and  the  neurones  lose  their 
dendrites  and  become  \-acuolated.  As  a  final  stage  the  cell  undergoes  shrinkage, 
becomes  a  small,  granular  mass,  and  finally  disappears.  The  damaged  areas,  in 
old  cases,  are  occupied  by  connective  tissue  and  are  much  shrunken,  so  that  the 
affected  gray  horn  is  much  smaller  than  its  fellow.  The  anterior  nerve  fibres,  which 
have  their  origin  in  this  part  of  the  cord,  also  atrophy.  Associated  with  these 
changes  in  the  anterior  cornua  of  the  cord  there  is  often  some  involvement  of 
fibres  in  the  anterolateral  tracts,  because,  it  will  be  recalled,  some  of  the  fibres, 
or  axones,  which  leave  the  anterior  horns  pass  upward  and  downward  in  these 
columns  to  enter  the  anterior  horns  above  and  below  to  associate  their  function, 
and  it  is  also  due  to  the  inflammatory  process  extending  into  the  white  columns. 

The  degree  of  the  inflammatory  process  in  the  gray  matter  ^•aries  very  greatly 
in  difl'erent  cases  and  may  involve  the  cells  supplying  but  a  few  muscles.  It  may 
affect  chiefly  that  part  of  the  gray  matter  which  is  most  anterior  or  that  nearer  the 
commissure.  In  rare  cases  it  would  seem  probable  that  no  true  inflammatory 
process  develops  in  the  cord,  but  that  simple  degenerative  changes  occur  in  the 
neurones  in  the  anterior  horns. 

Symptoms. — The  symptoms  of  acute  poliomyelitis  of  the  mild  form  usually 
take  the  following  course:  A  child  in  good  health  has  a  restless  und  fere  r  is  It  nKjhi, 
and  seems  on  the  next  day  to  be  somewhat  out-of-sorts.  In  the  course  of  twent\'- 
four  or  forty-eight  hours  it  not  infrequently  happens  that  the  parents  consider 
the  child  recovered  from  its  acute  illness,  and  it  may  be  some  days  or  weeks  before 
the  mother  notices  that  one  or  both  of  the  lower  limbs  are  lacking  in  power.  Xot 
rarely  it  is  found,  as  the  child  sits  in  its  mother's  lap,  that  one  leg  moves  while 
the  other  hangs  like  a  flail,  or  the  mother  notices  that  the  child  is  unable  to  push 
its  leg  into  its  clothing  as  efficiently  as  it  could  do  before  it  was  taken  ill.  These 
may  be  considered  as  the  symptoms  of  a  comparatively  moderate  case.  There 
is  usually  marked  leukocytosis  chiefly  of  the  lympliocytes.  Spinal  jjuncture  gives 
a  fluid  containing  an  excess  of  cells  nearly  all  of  which  are  lymphocytes.  In  the 
earlier  stages  the  mononuclear  cells  may  be  in  excess. 

In  instances  in  which  the  onset  and  course  of  the  malady  is  more  severe,  we  find 
that  fever  is  cjuite  marked,  often  rising  as  high  as  102.5°,  and  continuing  at  this 
point  for  several  days.  Occasionally,  at  onset,  it  may  reach  as  high  as  103°,  and 
with  this  febrile  movement  there  may  be  headache,  loss  of  appefite,  and  romitiini. 
Sometimes  diarrhea  occurs.  In  these  instances  the  manifestatioii  of  loss  of  power 
is  usually  so  marked  that  its  presence  is  recognized  within  a  few  hours  of  its  onset. 
Even  in  these  cases,  however,  it  not  infrequently  happens  that  the  child  is  supposed 
to  ha^•e  suffered  from  an  attack  of  acute  gastric  catarrh  or  indigestion  until  its 
inability  to  make  certain  movements  calls  attention  to  the  palsy.  Occasionally 
pain  is  a  symptom  of  some  importance,  if,  as  already  pointed  out,  the  lesions  in 
the  anterior  horns  extend  sufficiently  backward  to  involve  some  of  the  sensory 
fibres  beyond  the  commissures.  These  pains  are  usually  felt  about  the  joints. 
In  some  cases  they  come  on  not  as  a  symptom  of  onset,  but  as  a  sequel,  and  seem 
to  be  due  to  an  associated  neuritis.  At  times  a  fine  fibrillating  tlirill  is  seen  in 
the  muscles  about  to  be  chiefly  affected. 

The  degree  of  the  parlilysig  varies  greatly  in  different  cases.    In  some  instances 


ACUTE  POLIOM YELOENCEPHA  LITIS  1 1 5 

only  one  or  two  muscles  seem  to  he  affected.  In  others,  the  whole  linih  may  be 
paralyzed,  or  both  lower  limbs  and  one  upper  limb  may  manifest  loss  of  power. 
Even  when  the  paralysis  is  quite  widespread,  it  is  rare  for  the  cranial  ner\-es  to 
be  affected,  and  equally  rare  for  the  sphincter  muscles  to  lose  power. 

There  is  still  a  third  type  of  case  in  which  crmindsions  appear  at  the  time  of 
onset.  This  type  is  described  as  polioencephalitis.  These  convulsions  may  be 
cerebral  or  epileptiform  in  character,  and  may  be  followed  by  deep  coma  lasting  for 
many  hours.  A  fourth  type  presents  a  very  typical  picture  of  cerebrospinal  men- 
ingitis arising  from  the  diplococcus  of  Weichselman.  Paralysis  may  not  be  present, 
but  there  is  marked  headache,  \omiting,  pains  in  the  back,  rigidity,  and  Kernig's 
sign.    Later,  if  life  persists  the  paralysis  becomes  noticeable. 

In  other  instances  a  child  in  preA'iously  good  health  develops  fever  more  or  less 
severe.  There  may  be  headache  and  ^'omiting  without  the  onset  of  convulsions. 
In  some  cases  it  passes  into  stupor.  In  other  instances  it  is  delirious  and  exceed- 
ingly irritable  with  excessive  hyperesthesia.  Kernig's  sign  is  marked.  Ocular 
palsies  may  be  present,  even  with  or  without  facial  palsy,  unilateral  or  bilateral. 
If  the  patient  recovers  consciousness  returns,  the  signs  become  normal,  but  on 
attempting  to  let  the  child  stand  up  he  suffers  from  vertigo  and  ataxia.  In  some 
instances  marked  symptoms  of  hydrocephalus  develop.  Not  infrequently  in 
these  cases,  after  recovery  from  the  acute  illness  is  established,  there  remains 
strabismus  and  sometimes  tliere  is  dimness  of  vision  which  may  progress  to  com- 
plete blindness.  Very  remarkable  recovery  from  this  blindness,  howe\-er,  some- 
times ensues.  In  those  cases  of  the  cerebral  type  which  closely  resemble  tuber- 
culous meningitis,  facial  and  ocular  palsy,  without  Kernig's  sign,  accompanied 
by  complete  muscular  relaxation  and  Cheyne-Stokes  respiration,  occur,  ^^hile 
death  frequently  takes  place  in  these  cases  a  surprising  number  survive. 

In  some  instances  the  disease  seems  to  be  progressive  in  its  type,  the  full  degree 
of  paralysis  not  developing  at  once,  but  beginning  in  one  part  and  then  spreading 
to  adjacent  parts.  Rarely  one  attack  speedily  follows  another,  involving  a  dift'- 
erent  set  of  muscles. 

In  ^•e^y  rare  instances  the  paralysis  ma>'  de^'elop  without  any  history  of  the 
symptoms  of  onset  already  described.  Cases  are  on  record  in  which  the  paralysis 
has  been  almost  universal,  but  it  is  a  noteworthy  fact,  in  regard  to  the  paralysis 
of  acute  poliomj'elitis,  that  it  is  far  more  widespread  in  its  early  stages  than  later 
on,  this  being  due  to  the  fact  that  as  the  inflammation  subsides  certain  cells  which 
have  not  been  irreparably  damaged  regain  part  or  all  of  their  functions,  and  so 
adequately  supply  the  muscles  under  their  control,  or  collateral  muscles  supply 
the  power  needed. 

Occasionally  the  onset  of  the  symptoms  may  resemble  Landry's  paralysis,  since 
the  paralysis  starting  in  the  lower  extremities  speedily  travels  upward  and  may 
produce  grave  respiratory  difHculty  through  interference  with  the  diaphragm. 

The  bulbar  type  may  cause  rapid  death  and  paralysis  of  the  cranial  ner\-es. 
Rarely  the  symptoms  are  those  of  a  polyneuritis. 

Wickham  has  classified  the  type  as  follows: 

1.  Ordinary  spinal  paralysis,  anterior  poliomyelitis. 

2.  Progressive  paralysis,  usually  ascending,  less  often  descending;  Landry's 
paralysis. 

3.  Bulbar  paralysis;    polioencephalitis  of  pons. 

4.  Acute  encephalitis,  causing  spastic  mono-  or  hemiplegia. 

5.  Ataxic  form. 

6.  Polyneuritic  form. 

7.  Meningitis  form. 

8.  Abortive  form. 

The  period  of  recovery  usually  extends  from  one  to  three  months.    The  muscles 


116  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

wliicli  I'ail  to  recover  soon  lose  their  contractility  to  faradism  and  tlien  to  galvanic 
electricity.  Tlie  loss  of  faradic  responses  may  be  present  as  early  as  the  eighth 
or  ninth  day,  but  in  other  instances  some  response  is  maintained,  for  a  number 
of  weeks.  At  the  end  of  a  few  weeks  the  reactions  of  degeneration  are  observed. 
As  would  be  expected  from  the  lesions  already  mentioned  and  described  when 
discussing  the  pathology  of  the  aft'ection,  sensation  is  usually  unimpaired.  Keflex 
activity  is,  of  course,  diminished  or  lost  because  of  the  spinal  lesions  and  the  atrophy 
of  the  muscles.  As  secondary  lesions  to  the  paralysis  we  find  shortening  of  the 
muscles  with  consequent  contractures  and  deformities. 

The  legs  are  affected  more  frequently  than  the  arms  in  the  proportion  of  '.]  to  1 . 
The  muscles  below  the  knee  suffer  more  frequently  than  those  above  the  knee, 
and  the  tibial  and  peroneal  muscles  suffer  more  frequently  than  those  of  the  calf. 
Lovett  and  Richardson  found  the  proportion  to  be  one  leg,  27.97  per  cent.;  both 
legs,  2.3.48  per  cent.;  back,  23.29  per  cent.;  both  arms  and  both  legs,  11.13  per 
cent.;  one  arm  only,  7.25  per  cent.  In  the  forearms  the  supinators  usually  escape, 
but  the  deltoids  suffer  more  frequently  than  any  other  muscles  in  the  upi)er 
extremity. 

Diagnosis. — ^The  acute  poliomyelitis  of  childhood  is  usually  readily  diagnosed. 
Care  must  be  taken  that  the  muscular  pains  when  they  occur  are  not  thought  to 
be  due  to  rheumatism.  None  of  the  other  spinal  lesions  of  childhood  have  such  a 
characteristic  onset,  but  postdiphtheritic  paralysis  and  multiple  neuritis  due  to 
lead  or  arsenic  may  produce  similar  symptoms  although  their  onset  is  not  so  sudden 
and  there  is  no  fever.  The  meningeal  type  must  be  separated  from  cerebrospinal 
meningitis  by  an  examination  of  the  cerebrospinal  fluid  which  in  the  latter  disease 
is  turbid  and  contains  the  diplococcus  and  an  excess  of  polynuclear  cells.  From 
tuberculous  meningitis  it  is  differentiated  by  the  aid  of  the  von  Pirquct  and  Moro 
tests,  by  the  finding,  very  rarely,  of  the  tubercle  bacillus  in  the  fluid  and  by  the 
possible  disco\-ery  that  the  child  has  been  exposed  to  tuberculous  persons.  Pueu- 
mococcic  meningitis  must  also  be  considered. 

Prognosis. — This  is  usually  good  so  far  as  life  is  concerned,  although  if  the  at- 
tack has  been  severe,  vital  resistance  may  be  so  diminished  that  other  affections 
may  readily  cause  the  death  of  the  child.  The  degree  of  ultimate  paralysis  can 
be  determined  only  after  two  or  three  weeks  of  careful  observation,  when  some 
idea  as  to  the  number  of  muscles  which  may  recover  can  be  obtained,  particularly 
if  electricity  is  used  to  determine  the  electrical  contractility  of  the  aft'ected  muscles. 
The  percentage  of  complete  recovery  after  the  attack  is  usually  reckoned  at  about 
2.5  per  cent. 

Treatment. — In  the  treatment  of  acute  poliomyelitis  little  can  be  done  in  the 
way  of  directly  combating  the  disease.  The  ciiild  should  l)e  put  at  absolute  rest 
in  a  quiet  and  darkened  room.  Sweet  s])irit  of  nitre  and  citrate  of  potassium  should 
be  given  in  small  and  frequent  doses  to  diminish  fever  and  to  cause  mild  perspiration. 
The  use  of  as  large  doses  of  hexamethylcnamine  as  the  stomach  and  kidneys  will 
stand  (10  to  30  grains  a  day)  inhibits  the  growth  of  the  infection  in  the  nose  and 
tends  to  protect  others,  but  can  do  little  good  to  the  patient  already  stricken.  Hot 
applications  have  been  recommended  to  be  appliecl  to  the  back.  It  is  diflficult 
to  understand  how  they  can  be  of  much  \aluc.  Some  mild  counter-irritant  over 
the  spine,  such  as  a  spice  plaster,  or  a  ])epper  plaster,  may  be  advantageous.  The 
whole  object  of  the  physician  must  be  to  iiroduce  nervous  quiet  and  aid  in 
diminishing  the  inflammatory  process  in  the  cunl  by  avoiding  excitement  of  the 
nervous  system. 

After  the  acute  stage  of  onset  is  past,  and  the  paralysis  is  present,  that  is  to 
say,  after  sufficient  time  has  elapsed  for  the  acute  stage  of  the  inflammation  to  have 
passed  by,  or,  in  other  words,  in  three  or  four  weeks  after  onset,  moderately  large 
doses  of  strychnine  may  be  given,  but  care  must  be  taken  that  the  doses  are  not  so 


DENGUE  117 

large  as  to  produce  twitching  or  great  nervous  irritability.  At  this  time,  too,  tlie 
slowly  interrupted  faradic  current  may  he  applied  to  the  paralyzed  muscles,  and 
particularly  to  those  whicli  are  semiparalyzed,  in  the  hope  that  in  this  way  their 
nutrition  may  be  maintained.  It  must  not  be  forgotten,  however,  that  the  greatest 
care  must  be  exercised  that  the  muscles  are  not  overfatigued,  since  if  they  are 
exhausted  they  will  more  rapidly  atrophy  than  if  no  electricity  was  employed. 
If  electricity  is  used  before  the  spinal  cord  has  recovered  from  the  acute  stage  of 
the  inflammation,  it  will  make  the  condition  worse.  In  many  instances  it  is  advis- 
able to  use  electricity  on  one  day  and  careful,  gentle  massage  on  the  next.  The" 
electrical  current  should  never  be  employed  in  such  strength  as  to  give  the  child 
pain  or  distress. 

As  general  tonics  for  the  nervous  system  the  hypophosphites,  glycerophospjiates, 
cod-liver  oil,  and  iron  may  be  used. 

Should  any  tendency  to  deformity  take  place,  this  must  be  treated  by  the  methods 
commonly  resorted  to  by  orthopedic  surgeons.  Rapid  recovery  should  not  be 
expected  in  these  cases.  Careful  treatment  for  months  is  necessary  to  get  the  best 
results. 

DENGUE. 

Definition. — Dengue  is  an  acute  infectious,  but  non-contagious,  usually  epidemic 
fever,  which  is  probably  dependent  for  its  development  upon  the  presence  of  some 
specific  organism  the  exact  nature  of  which  is  still  obscure,  although  INIcLaughlin 
and  Graham  believe  that  they  have  succeeded  in  isolating  it.  The  disease  is 
characterized  by  two  febrile  attacks  with  severe  pains  in  the  muscles  and  joints. 
Because  of  these  latter  symptoms  it  is  often  called  "breakbone  fever,"  and  from 
the  peculiar  gait  caused  by  this  condition  "dandy  fever."  A  large  number  of 
other  popular  names  have  been  given  it,  such  as  "three-day  fever,"  "bouquet 
fever,"  or  sometimes,  as  a  corruption  of  the  last  name,  "bucket  fever." 

History  and  Distribution. — The  earliest  accurate  description  of  dengue  that  we 
possess  is  that  of  Brylon,  who  described  the  outbreak  of  1779;  later  the  celebrated 
epidemic  in  Philadelphia,  in  1780,  was  described  by  Rush.  Since  then  it  has 
occurred  in  a  considerable  number  of  epidemics  in  various  subtropical  parts  of  the 
world  such  as  Batavia,  Spain,  India,  Bermuda,  Brazil,  the  West  Indies,  and  in 
various  parts  of  the  Southern  United  States.  Within  twenty  years  it  has  also 
visited  Turkey,  Greece,  Fiji,  and  Tripoli.  It  is  distinctly  a  disease  of  warm 
climates,  and,  so  far  as  I  know,  has  never  been  met  with  north  of  Philadelphia. 
The  disease  spreads  from  point  to  point  along  lines  of  travel,  being  carried  by 
infected  individuals  and  perhaps  by  clothing. 

A  peculiarity  of  dengue  is  the  rapidity  of  its  spread  and  the  few  people  in  a  com- 
munity who  escape  its  attack.  In  this  respect  it  surpasses  epidemic  influenza. 
No  age,  sex,  or  race  escapes,  and  in  an  incredibly  short  time  after  the  first  case 
is  seen  a  multitude  may  be  down  with  it.  As  Manson  well  says,  it  "bursts"  upon 
a  place.  The  spread  of  an  epidemic  is  always  arrested  by  the  appearance  of  cold 
weather.     High  altitudes  are  also  unfavorable  to  its  spread. 

Etiology. — As  the  result  of  valuable  researches  carried  out  by  Ashburn  and  Craig 
and  by  Vedder  of  the  United  States  Army  in  the  Philippines,  in  which  they 
observed  over  six  hundred  cases,  they  conclude  that  the  disease  is  not  contagious. 
They  also  assert  that  no  organism,  either  bacterium  or  protozoon,  can  be  demon- 
strated in  either  fresh  or  stained  specimens  of  blood  with  the  microscope. 

The  red  blood  count  in  dengue  is  normal. 

There  occur  no  characteristic  morphological  changes  in  the  red  or  white  cor- 
puscles in  this  disease. 

Dengue  is  characterized  by  a  well-marked  leukopenia,  the  polymorphonuclear 


118  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

leukocytes  heiiij^  flecrcased,  as  a  rule,  while  tliere  is  a  inarkcii  increase  in  the  small 
lynipliocytes. 

The  intravenous  inf)culati(jn  of  unfiltercd  (lenj;iie  Mood  into  healtiiy  men  is 
followed  by  a  typical  attack  of  den<];ue. 

Graham,  of  Beyrouth,  believes  that  tiie  infection  is  conveyed  by  the  moseiuito, 
the  Ciller  fasliiiaii.i.  In  several  instances  (iraham  ])laccd  persons  sufl'erincc  from 
dengue  in  apartments  in  which  all  mosquitoes  liad  been  destroyed  by  chlorine  gas, 
and  allowed  healthy  individuals  to  associate  with  the  sick.  In  no  case  of  this  kind 
'was  the  disease  contracted.  In  addition  to  this  negative  evidence  Graham  offers 
positive  evidence,  which  he  obtained  by  allowing  mosquitoes  which  had  bitten 
affected  persons  to  bite  two  healthy  individuals  who  resided  in  a  district  where 
no  cases  of  dengue  were  present.  Both  of  these  men  developed  the  disease,  one 
on  the  fourth  and  the  other  on  the  fifth  da>'  after  they  were  bitten.  They  were 
kept  under  mosquito  nettings  until  they  had  completely  recovered  and  the  infected 
mosquitoes  were  all  killed.  No  other  cases  of  dengue  occurred  in  the  village  where 
these  experiments  were  made. 

That  mosquitoes  convey  the  disease  is  belie\'ed  by  Ashburn  and  Craig  from 
their  reseraches  in  the  Philippines. 

Symptoms. — Dengue  is  characterized  by  a  train  of  symptoms  which  is  quite 
remarkable.  In  the  first  place,  the  suddenness  of  its  onset  is  noteworthy.  A 
patient  may  be  in  perfect  health  at  one  hour  and  sick  in  bed  with  well-de\-eloped 
symptoms  the  next.  In  any  event  the  onset  is  sudden,  and  sometimes  it  is  ushered 
in  by  a  chill  or  by  pains  in  the  limbs.  Fever  rapidly  develops  and  may  reach  as 
high  as  106°  or  107°,  but  usually  the  acme  is  103°  to  105°.  There  is  intense  headache 
and  the  pains  in  the  limbs  are  so  excruciating  that  the  term  "breakbone  fever" 
is  well  applied.  The  discomfort  of  the  patient  is  increased  by  the  pain  caused  by 
moving  the  body.  The  tongue  is  usually  heavily  coated,  and  nausea  and  vomiting 
may  be  distressing  symptoms. 

With  the  onset  of  the  fever  there  develops  a  rash  which  is  of  the  nature  of  erythema. 
In  from  one  to  three  days,  usually  two  days,  the  fever  suddenly  ends  by  crisis  and 
simultaneously  the  patient  not  only  sweats  freely,  but  also  has  free  diuresis,  diarrhea, 
and  nosebleed.  This  nosebleed,  by  relie\ing  the  cerebral  congestion,  greatly 
decreases  the  headache,  and  the  rash  rapidly  fades. 

In  other  instances  the  fever  gradually  falls  by  lysis,  but  this  is  less  common 
than  crisis.  The  fever  having  fallen  to  normal  the  patient,  still  feeling  weak,  is 
able  to  be  about,  although  he  suffers  from  twinges  of  pain  in  the  joints  and  muscles, 
w'hich  impress  upon  his  mind  the  fact  that  he  is  as  yet  ill.  After  a  remission  of 
several  days,  usually  from  two  to  four,  the  fever  returns  with  some  violence,  but  it 
is  rarely  as  severe  as  in  the  primary  paroxysm,  and  it  usually  lasts  only  a  few  hours. 
With  the  appearance  of  this  secondary  fever  a  roseolous  rash  develops,  and  with 
its  development  the  patient  may  have  a  return  of  his  bone  and  joint  pains  to  a 
very  severe  degree.  Although  the  fever  soon  disappears  the  rash  lasts  for  several 
days  and  may  end  in  a  slight  desciuamation.  Taking  it  all  in  all,  the  secondary 
attack  is  usually  much  milder  than  the  first. 

The  rash  of  the  second  attack  is  roseolous,  and  is  peculiar  in  that  it  is  usually 
first  seen  on  the  hands,  both  in  palmar  and  extensor  surfaces,  and  thence  rapidly 
spreads  to  the  entire  body.  The  spots  are  as  large  as  a  pea,  circular  in  appearance, 
dusky  red,  and  ])erhaps  elevated.  As  the  disease  progresses  they  may  coalesce, 
leaving  patches  of  healthy  skin  between.  This  rash  is  more  apt  to  be  profuse  and 
to  coalesce  around  the  joints  than  elsewhere.  The  roseola  fades  as  it  begins,  first 
on  the  hands,  then  on  the  arms  and  body,  and  lastly  on  the  legs.  The  desquamation 
may  last  for  weeks,  but  it  is  so  fine  that  it  may  be  overlooked.  The  skin  never 
peels  as  after  scarlet  fever.  In  some  instances  the  patient  passes  on  to  rapid 
convalescence  after  the  terminal  or  roseolous  rash  fades,  but  in  others  he  remains 


DENGUE  119 

miserable  for  a  long  time  from  wandering  pains  in  his  joints  or  in  the  soles  of  his 
feet.  The  muscles  are  sore  on  pressure  and  stiff  on  moving  after  a  long  rest,  and 
(]el)ility  may  be  persistent.  In  some  instances  insomnia  or  furunfiilnsis  delays 
complete  recovery. 

In  certain  epidemics  there  is  sufficient  degree  of  swelling  and  redness  about  the 
joints  to  suggest  the  presence  of  acute  rheumatism. 

Relapses  of  dengue  occur  not  infrequently. 

Diagnosis. — Dengue  may  be  separated  from  rotheln,  which  it  resembles  during 
the  period  of  its  secondary  rash  by  the  lymphatic  swellings  of  the  latter  disease. 
The  differentiation  is  also  accomplished  by  the  sudden  severe  onset  and  the  pain 
in  the  joints.  It  is  distinguished  from  scarlet  fever  by  the  lack  of  sore  throat 
and  })y  the  peculiar  scarlet  hue  of  that  disease,  and  from  syphilitic  ro.seola  by  the 
absence  of  a  history  of  venereal  infection,  and  the  fact  that  associated  symptoms 
of  the  early  secondary  stage  of  syphilis  are  absent.  On  the  other  hand,  it  is  to  be 
recalled  that  many  syphilitics,  with  the  onset  of  the  roseola  of  that  disease,  suffer 
from  a  chill  and  general  wretchedness,  with  pains  in  the  bones.  Influenza  is  sepa- 
rated by  the  absence  of  catarrhal  symptoms  and  by  the  presence  of  the  rash  in 
dengue.  Acute  articular  rheumatism  and  malarial  infection  are  two  other  diseases 
which  must  be  borne  in  mind  when  the  diagnosis  of  an  individual  case  is  in  question. 

Prognosis. — The  prognosis  in  a  case  of  dengue  is  always  favorable  if  the  patient, 
prior  to  the  attack,  is  in  good  health,  and  not  debilitated  by  some  other  malady 
or  old  age.  Death  may  be  said  not  to  be  known  as  a  result  of  this  malady  in 
ordinarily  healthy  persons.  Convalescence,  after  a  se^-ere  attack,  is,  howe\-er, 
very  often  quite  slow,  and  if  the  patient  is  living  in  a  hot  climate  reco\'ery  may  not 
be  complete  until  a  change  of  residence  is  made. 

When  dengue  attacks  the  aged  and  feeble,  or  very  young  children,  it  sometimes 
indirectly  causes  se^-ere  illness  and  death  by  predisposing  the  patient  to  other 
infections  so  that  there  develops  a  severe  bronchitis  or  bronchopneumonia,  or  some 
other  cA-idence  of  another  acute  infection.  In  such  cases  the  prognosis  depends 
chiefly  upon  the  character  of  the  secondary  ailment. 

Treatment. — In  discussing  the  treatment  of  this  disease  it  is  to  be  recalled  that 
it  presents  very  different  degrees  of  severity  in  different  cases.  In  many  persons 
the  symptoms  are  so  mild  that  the  patient  seems  scarcely  at  all  ill,  and  in  others 
the  manifestations  are  so  severe  that  convulsions  and  unconsciousness  may  be 
present.  In  the  mild  cases  no  drugs  are  needed,  but  in  the  severe  cases  active 
treatment  may  be  essential.  In  general  terms  it  may  be  stated  that  the  treatment 
of  the  patient  suffering  from  dengue  consists  in  absolute  rest  in  bed  from  the  earliest 
stage  of  onset  till  the  conclusion  of  the  second  stage  of  fever.  Indeed,  the  longer 
he  will  consent  to  rest  in  bed  after  the  fever  develops,  the  more  rapidly  will  complete 
convalescence  be  established. 

So  far  as  drugs  are  concerned,  there  are  no  specifics  for  this  disease,  which, 
if  permitted,  will  usually  run  its  own  self-limited  course  to  recovery.  When  the 
pains  are  intolerable  they  may  be  controlled  by  moderate  doses  of  morphine  given 
hypodermically  or  by  the  use  of  acetanilid  or  phenacetin.  A  gentle  antipyretic 
and  sedative  mixture,  containing  5  grains  of  potassium  citrate  and  30  minims  of 
sweet  spirit  of  nitre  in  a  dessertspoonful  of  water,  is  useful  to  keep  the  kidneys 
active.  An  ice-bag  may  be  applied  to  the  head  to  relieve  the  cephalalgia,  and  if  the 
face  is  very  much  flushed,  and  the  head  throbs  a  hot  foot-bath  is  advisable.  Some- 
times a  hot  bath  is  useful  to  develop  the  rash  and  relieve  the  pains  in  the  body 
and  limbs.  In  these  cases  the  salicylates  may  also  be  used  for  the  same  purposes, 
10  grains  of  sodium  or  strontium  salicylate,  or  of  aspirin,  being  given  every  three 
or  four  hours. 

When  the  circulation  is  strong  and  full  McLaughlin  asserts  that  large  doses 
of  tincture  of  gelsemium  serve  to  quiet  the  excited  pulse  and  to  relieve  the  neuro- 


120  DISEA.SES  DUE  TO  A  SPECIFIC  INFECTION 

muscular  pains.  The  dose  he  recommends,  namely,  20  to  30  minims  every  three 
or  four  hours,  seems  to  the  writer  much  too  hirgc  and  capable  of  causing  serious 
depression;  but  as  McLaugliHn  lias  had  large  experience  with  the  disease,  his 
views  demand  respectful  attention.  The  fc\er  is  rarely  sufficiently  liigh  or  pro- 
longed to  require  treatment.  Should  it  require  attention  tejjid  spongings  are 
usually  sufficient  to  control  it  within  safe  limits;  but  should  it  reach  as  high  as 
105°  or  more,  then  it  must  be  reduced  by  cold  spongings,  or  even  by  the  use  of  the 
cold  bath,  with  active  frictions.  Should  nervous  symptoms  be  very  manifest 
and  convulsions  be  threatened,  chloral  should  be  given  in  the  dose  of  5  grains  by 
the  mouth,  or  10  grains  by  the  rectum,  if  the  patient  is  a  child,  and  bromide  of 
sodium  added  to  aid  it  in  its  sedative  action. 

The  patient  should  be  urged  to  drink  water  freely,  if  his  stomach  will  retain 
liquids,  in  order  to  keep  his  kidneys  active  in  eliminating  the  poisons  of  the  di.sease. 
When  the  stomach  is  not  retentive  a  pint  of  cold  water  may  be  gi\'en  by  the  rectum 
every  eight  hours.  Should  diarrhea  be  troublesome  it  can  be  best  controlled  by 
giving  castor  oil  to  cleanse  the  bowels,  following  it  by  opium. 

MENINGOCOCCIC  MENINGITIS. 

Definition. — Meningococcic  meningitis,  cerebrospinal  fever,  sometimes  called 
"cerebrospinal  meningitis,"  "spotted  fever,"  or  "petechial  fever,"  is  an  acute, 
often  malignant,  infectious,  but  rarely  contagious  disease,  due  to  the  diplococcus 
of  Weichselbaum,  which  is  sometimes  called  the  meningococcus  or  the  Dipl<iciicrii.<) 
intracellularis  meningitidis.  It  is  characterized  by  a  rapid  course,  rigidity  of 
the  neck,  retraction  of  the  head  and  the  formation  of  inflammatory  exudates 
under  the  membranes  which  cover  the  brain  and  spinal  cord.  It  is  to  be  clearly 
understood  that  a  number  of  pathogenic  microorganisms  are  capable  of  producing 
inflammation  of  the  pia  arachnoid,  and  consequently  all  the  symptoms  of  true 
epidemic  cerebrospinal  meningitis.  Such  cases  are  not  instances  of  this  disea.se, 
but  rather  are  to  be  considered  as  sporadic  cases  of  meningeal  infection.  Indeed, 
it  is  a  noteworthy  fact  that  the  sporadic  cases  of  cerebrospinal  meningitis  which 
are  due  to  the  pneumococcus,  may  be  more  virulent  than  those  due  to  the  si)ecific 
organism  just  named.  While,  therefore,  the  epidemic  form  has  been  provcil  to  be 
always  due  to  the  Diplococcus  intracellularis  meningitidis,  it  is  not  correct  to  call 
all  cases  of  cerebrospinal  meningitis  instances  of  cerebrospinal  fever. 

History. — No  definite  description  of  this  disease  is  to  be  found  in  medical  literature 
prior  to  the  nineteenth  century.  In  1805  the  first  case  was  described  by  Vieusseux, 
in  Geneva,  Switzerland,  where  several  deaths  took  place  from  the  disease.  In 
America  it  first  appeared  in  Medfield,  Massachusetts,  in  1806.  During  the  next 
ten  years  the  malady  broke  out  in  different  parts  of  Europe  and  America,  but 
disappeared  after  1816  till  1822,  when  it  reappeared  in  France.  In  1828  it  broke 
out  in  Ohio.  It  was  not,  however,  till  1839  that  it  became  sufficiently  prevalent 
in  any  one  place  to  cause  a  very  large  number  of  deaths.  In  that  year,  at  \  ersailles, 
it  ravaged  the  town  and  garrison  and  produced  a  mortality  of  nearly  75  per  cent. 
Scattered  epidemics  have  since  occurred  in  the  United  States  at  intervals  of  every 
few  years,  and  it  is  constantly  present  in  scattered  cases  in  the  central  part  of  the 
State  of  New  York.  (Eisner.)  A  noteworthy  point  in  connection  with  the  disease 
is  the  fact  that  it  suddenly  appears  simultaneously  in  widely  separated  areas,  and 
without  any  dependence  upon  lines  of  travel.  Thus  during  a  recent  period  of 
twelve  months  many  cases  occurred  in  New  York,  but  none  in  Philadelphia,  which 
is  only  ninety  miles  away.  Certain  atmospheric  influences  may  make  this  possible, 
but  the  cause  is  not  definitely  understood. 

Etiology. — There  can  be  no  doubt  that  cerebrospinal  fever  is  due  to  the  diplococcus 
already  named,  but  the  same  anatomical  conditions  and  a  similar  clinical  picture 


MENINGOCOCCIC  MENINGITIS  121 

may  be  produced  by  other  bacteria,  for  example,  the  pneumococcus  and  other 
pyogenic  cocci.  In  cases  of  cerebrospinal  meningitis  which  have  appeared 
sporadically  and  presented  all  the  signs  of  the  epidemic  disease  the  streptococcus, 
the  Staphylococcvs  pyogenes,  the  pneumococcus,  the  gonococcus,  and  even  the 
bacilli  of  influenza  and  typhoid  fever  have  been  found  as  apparently  the  only 
cause  of  the  affection.  Dopter  has  isolated  another  organism  capable  of  causing 
meningitis  resembling  the  specific  disease  under  discussion,  a  parameningococcus. 
A  similar  acute  serofibrinous  meningitis  may  accompany  pyemia  or  septicemia, 
or  may  be  due  to  injury,  with  infection  or  extension  of  infective  processes  from  the 
frontal,  ethmoidal,  sphenoidal,  or  mastoid  sinuses,  middle  or  internal  ear.  Such 
forms  of  meningitis  are  often  called  consecutive,  incidental,  or  secondary,  and  are 
to  be  distinguished  from  the  epidemic  malady. 

Infection  probably  takes  place  through  the  respiratory  passages,  particularly 
in  the  nose,  and  Albrecht  and  Ghon  have  described  epidemics  of  rhinopharyngitis 
due  to  the  meningococcus  when  an  epidemic  of  cerebrospinal  meningitis  has 
been  affecting  other  persons.    Flexner  thinks  the  infection  follows  the  Ijmphatics. 

Many  healthy  persons  act  as  meningitis  carriers  during  epidemics.  Thus 
Bruns  and  Hahn  examined  600  persons  in  health  belonging  to  families  suffering 
from  the  disease  and  found  224  of  them  were  nasal  carriers. 

As  a  rule  the  organism  does  not  persist  in  the  nasal  passages  of  convalescents 
but  it  has  been  found  as  late  as  the  forty-third  day  after  the  onset  of  the  disease. 

Climatic  conditions  undoubtedly  exercise  some  influence,  for  the  disease  confines 
itself  almost  entirely  to  the  colder  parts  of  the  temperate  zone,  but  this  is  not  to 
be  taken  as  indicating  that  it  is  a  disease  of  the  winter  months.  On  the  contrary, 
it  appears  about  equally  frequently  in  winter  and  summer.  While  it  is  true  that 
unhealthy  surroundings  favor  all  diseases,  it  is  also  true  that  they  do  not  seem  to 
greatly  influence  this  malady,  for  it  occurs  on  high  and  on  low  land,  when  it  is 
dry  and  when  it  is  wet,  on  hill  and  in  marsh,  with  equal  frequency.  As  Stille 
says,  "  It  has  passed  by  large  cities  reeking  with  all  the  corruptions  of  a  soil  saturated 
with  ordure  and  populations  begrimed  with  filth,  to  devastate  clean  and  salubrious 
villages  and  the  families  of  substantial  farmers  iidaabiting  isolated  spots." 

The  disease  affects  children  and  young  adults  far  more  frequently  than  persons 
in  advanced  life.  It  is  slightly  contagious,  but  cases  of  undoubted  transference 
from  one  patient  to  another  occur  as  in  one  notable  case  reported  by  me.  The 
specific  germ  if  expelled  in  the  nasal  mucus  by  the  infected  patient  may  find  entrance 
into  the  nasal  spaces  of  the  healthy  in  fine  spray  or  in  the  form  of  dust.  The  occur- 
rence of  the  malady  in  a  number  of  persons  living  in  the  same  district  is  usually 
due  to  the  fact  that  they  have  all  been  exposed  to  the  same  cause. 

Prevention. — ^We  know  of  no  method  of  preventing  epidemic  cerebrospinal 
meningitis,  but  physicians  and  others  who  are  attending  cases,  should  wash  the 
nasal  mucous  membrane  with  normal  salt  solution  to  aid  in  preventing  infection 
and  full  doses  of  hexamethylenamine  should  be  taken  to  exert  an  antiseptic  infiuence 
in  the  nasopharynx.  Iodine  tincture  1  part,  glycerin  2  parts,  and  water  4  parts 
may  be  applied  to  the  pharynx.     All  cases  should  be  isolated. 

Meningococcus  vaccine  containing  from  500,000,000  to  1,000,000,000  cocci  in  each 
cubic  centimeter  has  been  used  for  the  prevention  of  the  spread  of  cerebrospinal 
meningitis,  particularly  on  the  part  of  "carriers,"  in  whose  nasal  pharynx  the 
specific  microorganisms  may  be  found.  Usually  three  injections  are  used  at 
intervals  of  seven  days.  The  first  of  500,000,000  and  the  second  and  third  of 
1,000,000,000. 

Frequency. — From  what  has  already  been  said,  it  is  evident  that  this  disease 
is  met  in  epidemic  form,  but  is  comparatively  rare.  Many  practitioners  never 
meet  with  a  single  or  sporadic  case  in  a  long  career;  whereas,  others  may  be  so 
unfortunate  as  to  meet  several  outbreaks. 


122  DISEASES  DUE  TO  A   SPECIFIC  INFECTION 

Pathology  and  Morbid  Anatomy. — In  fulmiiiatiiig  cases  death  may  occur  before 
the  iiHiiiiitjeal  exudate  torriis;  in  these  the  meninges  may  exliihit  no  exudate, 
showing  only  intense  hy]jeremia  and  edema,  hut  the  memhranes  and  cerebrospinal 
fluid  are  usually  rich  in  the  specific  organism.  Deatli  in  such  cases  seems  to 
depend  on  the  toxic  action  of  the  bacteria-laden  serous  exudate. 

The  characteristic  lesion  of  this  disease  is  an  acute  inflammatory  exudate  of  the 
pia-arachnoid  enveloping  the  brain  and  spinal  cord.  This  membrane  becomes 
infiltrated,  and  the  surface  appears  to  be  covered  by  a  white  or  creamy-white 
exudate,  which  is  most  conspicuous  in  the  sulci.  The  ventricles  may  contain  a 
cloudy,  opaque,  or.  even  distinctly  purulent  fluid.  The  inflammatory  exudate 
is  most  copious  at  the  base  of  the  brain  and  on  the  dorsal  surface  of  the  spinal  cord, 
particularly  in  the  lower  thoracic  and  lumbar  regions.  When  the  disease  aft'ects 
children  the  lateral  ventricles  are  often  found  at  autopsy  to  be  distended  with 
purulent  fluid,  but  in  adults  this  condition  is  rarely  marked.  In  the  early 
stages  of  the  disease  the  diplococcus  is  found  in  large  numbers  in  the  leukocytes 
contained  in  the  exudates,  but  when  death  occurs  late  in  the  course  of  the  malady 
the  germ  may  be  demonstrated  with  difficulty,  if  at  all. 

In  addition  to  the  lesions  in  the  meninges  the  nerves  and  ganglia  exposed  to 
the  toxic  action  of  the  exudate  undergo  inflammatory  and  degenerative  changes. 
The  involvement  of  these  nerves  may  leave  irreparable  damage,  manifested  by 
blindness,  deafness  or  other  phenomena,  dependent  upon  the  structures  involved. 
Secondary  alterations  in  other  parts  of  the  body  may  be  present.  These  are  due 
to  the  toxins  of  the  disease  or  to  the  presence  of  the  microorganisms  in  the  affected 
areas.  Thus,  we  find  petechife  in  the  skin  and  mucous  membranes  and  some- 
what similar  punctate  extravasations  of  blood  in  the  endocardium.  Not  rarely 
multiple  abscesses  are  found  scattered  through  the  body  and  multiple  suppurative 
arthritis  may  be  present.  Hyaline  and  granular  degeneration  of  the  voluntary 
muscles  is  also  demonstrable,  and  the  heart  muscle,  kidneys,  and  li\cr  may  manifest 
necrotic,  degenerative,  or  inflammatory  changes.  Occasionally  there  is  found, 
associated  with  the  meningitis,  croupous  pneumonia,  ulcerative  endocarditis,  and 
otitis  media.  These  pathological  conditions  are  characteristic  of  the  severe  forms 
of  the  disease. 

In  some  cases  the  lesions  are  much  more  moderate,  in  that  hyperemia  or  intense 
congestion  of  the  pia  mater  only  is  seen,  although  the  sulci  between  the  convolutions 
of  the  brain  may  contain  fibrin  or  pus. 

Incubation. — The  period  of  incubation  is  from  one  to  four  days. 

Symptoms. — The  symptoms  of  epidemic  cerebrospinal  meningitis  may  be  grouped 
into  five  classes — viz.,  the  moderate,  the  malignant,  the  intermittent,  the  typhoid, 
and  the  chronic  form. 

In  the  moderate  form,  after  an  unknown  period  of  incubation,  the  patient  suH'crs 
from  a  sudden  chill,  which  may  be  preceded  by  headache  and  dizziness.  The 
headache  rapidly  becomes  very  severe  and  is  accompanied  by  severe  pain  in  the 
back  and  down  the  backs  of  the  thighs,  the  muscles  of  which  are  often  tense  or 
fixed.  The  fever  which  follows  the  chill  is  usually  moderate,  rarely  exceeding 
102°,  and  it  presents  no  characteristic  curves.  On  the  contrary,  it  is  exceedingly 
irregular  and  does  not  show  any  constant  morning  and  evening  variations.  \'ery 
rarely  hyperpyrexia  may  develop. 

As  the  disease  develops  the  tenseness  of  the  muscles  of  the  legs  extends  to  those 
of  the  back,  neck,  and  arms,  and,  finally,  they  may  l)ecomc  almost  rigid,  and 
contracted  to  such  a  degree  that  the  patient  de\elops  opisthotonos.  The  abdomen 
is  rigid  and  scaphoid.  Not  rarely  spasmodic  movements  of  the  muscles  of  the 
face  develop  as  the  result  of  irritation  of  the  roots  of  the  cranial  nerves,  and  by 
reason  of  this  same  cauae  .strahijimus,  ptosis,  nmaiiroxi.'^,  and  iliiilnpid  may  be  ])rescnt. 
The  r()iijini(ti\;e  are  usually  reddened. 


MENINGOCOCCIC  MENINGITIS 


123 


Delirium  is  a  very  frequent  symptom,  and  is  sometimes  so  severe  as  to  he  mani- 
acal.    From  this  state  the  patient  may  pass  into  coma. 

The  2-'Mfoe  and  respiration  are  not  greatly  afl'ected,  except  that  as  the  disease 
progresses  they  may  become  feeble.  Toward  the  end  of  the  attack,  if  it  he  fatal 
in  its  nature,  Cheyne-Stokes  breathing  may  develop  and  the  pulse  become  rapid 
and  small. 

An  eruption  develops  on  the  skin  in  about  one-half  of  the  cases.  When  it  appears 
about  the  mouth  it  is  herpetic,  but  on  other  parts  of  the  body  it  is  usually  petechial, 
although  herpes  of  the  skin  of  the  trunk  and  about  the  genitals  may  appear.  At 
times  a  general  erythema  may  he  present  or  in  its  place  an  urticaria  is  developed. 

The  presence  of  arthritis  has  already  been  referred  to.  It  appears  in  about 
20  per  cent,  of  the  cases,  and,  as  it  is  septic  in  nature,  it  may  cause  serious  changes 
in  the  joints  and  result  in  permanent  deformity  if  the  patient  survives. 

The  Mood  shows  no  marked  changes,  save  that  the  inflammation  of  the  meninges 
results  in  a  leukocytosis  of  the  polymorphonuclear  cells. 

As  an  ahnost  constant  symptom,  mention  should  be  made  of  "Kernig's  sign," 
which  consists  in  the  fact  that  in  inflammatory  processes  in  the  membranes  of  the 
cord  it  is  not  possible  to  extend  the  leg  on  the  thigh  when  the  thigh  is  at  right 
angles  to  the  plane  of  the  body.     Rarely  this  sign  is  unilateral  (Fig.  31). 


Kernig's  sign,  showing  the  strong  contraction  of  the  flexors  on  attempting  to  extend  the  leg. 
(After  Osier's  case.) 

When  the  leg  on  one  side  is  passively  flexed,  the  patient  being  in  the  dorsal 
decubitus,  the  other  leg  is  actively  flexed.  This  is  called  Brudzinski's  contra- 
lateral reflex.  If  the  head  is  lifted  from  the  pillow  the  thighs  are  flexed  on  the 
abdomen  and  the  legs  on  the  thighs. 

In  the  malignant  type  of  the  disease  the  onset  is  remarkably  sudden.  The  patient 
is  seized  by  a  chill,  followed  by  headache,  unconsciousness,  and  death.  Convulsions 
occur  more  commonly  in  children  than  in  adults.  The  fever  may  be  absent,  the 
pulse  slow,  the  breathing  labored,  the  urine  greatly  decreased  in  amount  and  loaded 
with  albumin,  and  the  stupor  profound.  The  patient  in  such  an  instance  is  probably 
overwhelmed  by  toxemia,  so  that  death  may  ensue  in  a  few  hours. 

In  the  intermittent  form,  which  is  probably  due  to  the  Streptococcus  pyogenes, 
or  Staphylococcus  pyogenes  alone,  or  to  association  of  those  organisms  with  the 
specific  coccus  of  Weichselbaum,  the  fever  intermits,  as  in  malarial  fever,  hut 


124  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

the  iiitcrmittcnoe  is  irregular,  as  in  sepsis,  and  is  not  distinctly  perindic,  as  in 
malaria.  The  typhoid  form  is  characterized  by  symptoms  of  apathy,  feebleness, 
and  abdominal  disorders. 

The  chronic  form  consists  in  the  prolongation  of  the  ordinary  type,  with  special 
symptoms,  such  as  headache,  pains  in  the  nerves,  vomiting,  and  progressive  emacia- 
tion, with  secondary  arthritic  clianges  and  increasing  inability  to  move  the  limbs. 
Here,  again,  it  is  probable  that  the  maintenance  of  the  illness  is  due  to  .septic 
organisms  rather  than  to  Weichselbaum's  coccus. 

While  for  the  sake  of  description  these  several  types  of  the  disease  have  been 
named,  it  is,  of  course,  true  that  it  may  manifest  various  degrees  of  severity  in 
the  same  case  at  different  periods.  Some  cases  which  seem  quite  severe  at  the 
onset  gradually  ameliorate  and  pass  into  the  chronic  or  subacute  form.  The 
fact  that  the  malady  presents  widely  different  types  is  well  illustrated  by  the 
seemingly  exaggerated,  but  nevertheless  correct,  statement  of  Hirsch  that  the 
duration  of  epidemic  cerebrospinal  meningitis  may  be  between  several  hours  and 
several  months.  N.  S.  Davis  stated  that  its  duration  in  his  experience  varied 
from  twenty-four  hours  to  twenty-eight  days.  I  have  seen  death  occur  in  eighteen 
hours. 

Complications  and  Sequelae. — The  complications  and  sequelte  of  epidemic  cerebro- 
spinal meningitis  are  very  numerous.  During  the  attack  croupous  pneumonia 
not  only  often  develops  and  aids  materially  in  producing  a  fatal  issue,  but  acute 
pleurisy  also  is  not  uncommon.  So,  too,  inflammation  of  other  serous  membranes, 
such  as  the  pericardium  and  the  endocardium  and  the  synovial  membranes,  is 
often  met  with,  because  the  coccus  has  an  affinity  for  these  membranes  in  all  parts 
of  the  body.  In  the  nervous  system  the  most  common  sequelae  are  blindness  or 
impaired  vision  due  to  optic  nerve  atrophj',  ptosis  due  to  oculomotor  paralysis 
following  neuritis  or  to  changes  arising  from  the  inflammatory  exudate  at  the  point 
where  the  nerves  leave  the  membranes,  and  deafness  arising  from  the  effects  of  the 
acute  inflammation  or  infection  upon  the  auditory  nerves.  Sometimes  the  deafness 
arises  from  an  otitis  media  due  to  the  specific  coccus.  Aside  from  chronic  naso- 
pharyngeal disease  and  scarlet  fever,  this  disease  is  responsible  for  deafness  in  a 
larger  proportion  of  cases  than  any  other  malady. 

Diagnosis. — While  it  is  true  that  in  a  majority  of  cases  the  diagnosis  of  this 
disease  is  readily  made,  it  is  also  a  fact  that  many  other  diseases  may  produce 
symptoms  which  so  nearly  resemble  those  of  epidemic  cerebrospinal  meningitis 
that  it  may  be  absolutely  impossible  to  make  a  symptomatic  differentiation.  In 
the  first  place,  it  must  not  be  forgotten  that  cerebrospinal  meningitis  is,  as  its 
name  implies,  an  inflammation  of  the  cerebrospinal  membranes,  and  this  change 
may  be  produced  by  a  host  of  causes,  none  of  which  have  any  true  relationship 
with  the  true  epidemic  form  of  the  disease.  As  already  pointed  out  in  this  article, 
and  in  that  on  typhoid  fever,  the  liacillus  of  Eberth  may  cause  a  train  of  symptoms 
and  morbid  changes  which  is  identical  with  that  due  to  the  diplococcus  of  Weic'hsel- 
baum,  yet  such  a  case  would  not  be  one  of  epidemic  cerebrospinal  meningitis. 
It  is  evident,  therefore,  that  cases  of  retraction  of  the  head,  rigidity  of  the  limbs, 
and  twitchings  of  the  face  should  not  be  called  true  cerebrospinal  fever  unless 
the  specific  diplococcus  can  be  demonstrated,  or  unless  the  disease  can  be  found 
to  be  present  in  other  patients  in  the  vicinity.  In  the  midst  of  an  epidemic  of 
typhoid  fever  the  development  of  cerebrospinal  symptoms  should  be  credited  to 
this  infection  rather  than  to  the  specific  fever  now  under  discussion.  If  any 
doubt  exists  as  to  the  true  nature  of  the  affection,  it  should  not  be  forgotten  that 
herpes  is  very  rare  in  typhoid  fever  and  in  typhus  fever,  but  is  common  in  true 
cerebrospinal  fever.  Both  these  fevers  run  a  course  which  is  marked  by  a  natural 
limit;  whereas,  epidemic  cerebrospinal  meningitis  does  not  begin  to  decline  after 
the. lapse  of  a  definite  course,  but  is  exceedingly  irregular  in  its  duration. 


MENINGOCOCCIC  MENINGITIS  125 

Croupous  pneumonia  is  the  infection,  above  ail  otiiers,  wliich  is  capaijle  of 
misleading  the  physician  in  his  diagnosis  of  cerebrospinal  fever.  It  has  already 
been  stated  that  pneumococcus  is  often  found  to  be  the  cause  of  inflammation  of 
the  meninges,  and  in  children  in  particular  the  cerebrospinal  symptoms  may  be 
so  well  developed  that  unless  the  physician  examines  the  lungs  very  carefully, 
he  may  diagnosticate  cerebrospinal  meningitis  when  in  reality  the  true  cause  lies 
in  the  lung.  It  would  seem  that  two  types  of  cerebrospinal  symptoms  develop  in 
pneumonia,  namely,  those  due  to  the  secondary  meningeal  infection  with  the 
pneumococcus  and  those  in  which  there  is  no  true  infection,  but  simply  irritation 
produced  by  the  toxemia  of  the  pneumonia. 

Some  cases  of  acute  poliomyelitis,  both  in  adults  and  children,  may  so  closely 
resemble  meningococcic  meningitis  that  a  differentiation  can  be  made  only  by 
the  discovery  of  the  specific  diplococcus.     (See  Acute  Polioencephalitis.) 


A,  space  between  the  third  and  fourth  lumbar  vertebrte  which  can  be  used  for  puncture;  or  B,  the 
space  between  the  foATth  and  fifth  lumbar  vertebrae. 

Tuberculous  meningitis  is  very  rarely  so  sudden  in  onset  as  is  the  true  epidemic 
form,  and  careful  physical  examination  of  the  patient  will  usually  reveal  a  primary 
tuberculous  focus  if  meningeal  tubercles  are  present.  The  von  Pirciuet  or  jNIoro 
tests  may  aid  in  the  diagnosis.  When  the  inflammation  is  tuberculous  the  leukocyte 
count  is  not  materially  increased,  whereas,  in  the  specific  type  it  may  vary  from 
9000  to  26,000. 

When  cerebrospinal  symptoms  develop  in  the  presence  of  an  epidemic  of  influenza, 
the  differentiation  between  true  cerebrospinal  meningitis  and  that  due  to  influenza 
may  be  impossible,  although  the  fact  that  the  case  is  single  points  to  the  influenza 
bacillus  as  the  true  cause  rather  than  that  the  attack  is  a  sporadic  case  of  the 
disease  now  under  discussion.  The  cerebrospinal  symptoms  of  influenza  are 
rarely  so  severe  or  so  persistent  as  those  due  to  epidemic  cerebrospinal  fever. 

The  greatest  aid  that  we  have  in  differential  diagnosis  is  by  means  of  lumbar  punc- 
ture. This  operation  consists  in  inserting  a  large  hollow  needle  between  the  third  and 
fourth  or  fourth  and  fifth  lumbar  vertebrae,  a  little  to  the  side  of  the  median  line 
and  just  below  the  spinous  process.  The  needle  as  it  enters  should  be  directed 
upward  and  inward.  In  children  the  fluid  is  reached  when  the  needle  is  inserted 
about  2  cm.,  and  in  adults  when  it  has  reached  the  depth  of  from  4  to  6  cm.  As 
soon  as  the  membrane  containing  the  fluid  is  punctured  it  flows  from  the  needle 
in  drops,  which  should  be  caught  in  a  sterile  test-tube  in  such  a  way  that  the  fluid 
does  not  run  down  its  side.     If  the  infection  is  due  to  the  specific  organism,  the 


126 


DISEASES  DUE  TO  A  SPECIFIC  INFECTION 


pressure  is  greatly  increased,  so  that  tlic  fluid  may  escape  with  a  spurt.  This 
fluid  is  clear  if  tuberculous  meningitis  is  present,  but  cloudy  if  the  diplococcus  of 
Weichselbaum  is  the  cause  of  the  illness.  If  the  fluid  also  has  a  yellowish  or  greenish 
color  it  is  significant  of  a  virulent  infection.  Under  these  circumstances,  too, 
tile  fiiint  trace  of  albumin  found  in  the  normal  fluid  is  very  distinctly  increase(l 
in  proportion  to  the  severity  of  the  attack,  and  the  absence  of  dextrose  as  shown 
by  the  ordinary  copper  tests  is  pathognomonic  of  meningitis.  The  jxjlynuclear 
cells  are  also  greatly  increased  and  their  excess  is  a  gauge  of  the  severity  of  the 
infection.  The  careful  staining  of  a  single  specimen  or  a  more  exhaustive  bacterio- 
logical examination  may  reveal  the  presence  of  the  diplococci,  most  of  which  are 
intracellular. 


IiitroducUon  of  ueedle  between  the  last  two  lumbar  vertebrae.     The  syringe  is  used  as  a  convenient 
handle  for  the  needle,  and  is  unscrewed  after  the  puncture  is  made. 


Demonstration  of  the  meningococcus  in  the  nasal  mucus  is  an  important  addition 
to  other  signs.  Netter  and  Debre  in  100  tests  in  49  patients  found  it  in  7S.8.3  per 
cent,  in  the  first  week,  in  60  per  cent,  in  the  second  week,  and  in  50  per  cent,  in  the 
third  week.  Even  after  the  fifth  week  it  was  found  in  more  than  15  per  cent.,  but  the 
disease  may  occur  without  the  specific  coccus  being  present  in  the  nose,  and  a  men- 
ingococcus rhinitis  neither  preceded  nor  followed  by  meningitis  is  not  of  excep- 
tional occurrence. 


MENINGOCOCCIC  MENINGITIS  127 

Prognosis. — The  prognosis  of  true  epidemic  cerebrospinal  meningitis  is 
grave,  but  its  rate  of  mortality  varies  in  wide  limits,  namely,  from  20  to  75  per 
cent.  In  children  under  two  it  is  almost  always  fatal,  and  before  puberty  its 
mortality  is  very  high.  The  most  violent  cases  usually  meet  death  by  the  fifth 
day,  but  it  is  not  to  be  forgotten  that  many  others  reach  the  fourteenth  day  before 
death  occurs.  Then,  again,  it  sometimes  happens  that  after  several  days  of 
severe  symptoms  the  general  aspect  of  the  case  impro\-es,  but  the  favorable  signs 
only  persist  for  a  few  hours  and  then  the  sjinptoms  return  with  renewed  \igor. 
Further  than  this,  patients  who  seem  about  to  recover  not  rarely  suffer  from  a 
relapse  which  may  prove  fatal.  Koplik  asserts  that  the  character  of  the  spinal 
fluid  is  of  great  prognostic  value.  If  it  is  thick  and  purulent  the  outlook  is  bad; 
but  if  it  is  of  a  straw  color  and  clear  it  is  better. 

Treatment. — The  treatment  of  true  cerebrospinal  meningitis  whether  it  appear 
in  sporadic  or  in  epidemic  form  consists  in  the  use  of  antimeningococcus  serum 
as  first  prepared  by  Flexner.  It  is  not  an  antitoxic  serum  but  acts  on  the  coccus. 
This  serum  is  that  of  the  horse  which  has  been  inoculated  by  the  Diplococcus 
intracellularis  and  its  products.  It  has  been  proved  that  the  subdural  injection 
of  this  serum,  if  given  early  enough  and  repeated  at  proper  times  and  in  proper 
doses  reduces  the  mortality  from  about  SO  per  cent,  to  about  20  per  cent,  and  also 
shortens  the  duration  of  the  disease.  It  also  prevents  to  a  large  extent  the  patho- 
logical changes  in  the  meninges  and  elsewhere  which  produce  the  secondary  lesions, 
which  so  often  develop  in  those  who  reco\'er*without  the  use  of  the  serum,  such  as 
deafness,  blindness,  and  deformities.  The  subdural  injection  of  the  serum  results 
in  a  remarkable  diminution  in  the  growth  and  number  of  the  specific  coccus  of 
the  disease,  as  they  are  seen  in  the  cerebrospinal  fluid.  Further  than  this  the 
abnormal  turbidity  of  this  fluid  is  overcome  so  that  it  becomes  limpid  and  approxi- 
mately normal  in  appearance. 

The  use  of  the  serum  is  often  followed  by  a  sharp  fall  in  temperature  almost 
like  the  crisis  of  pneumonia.  Consciousness  returns,  the  njind  becomes  clear 
and  headache  and  vomiting  cease  usually  within  twenty-four  hours.  Kernig's 
sign  and  stiffness  of  the  neck,  however,  often  persist  for  a  day  or  two  more. 

Thirty  c.c.  of  sermn  is  injected  into  the  subarachnoid  space  after  30  c.c.  of  cere- 
brospinal fluid  is  withdrawn  by  means  of  lumbar  puncture  and  the  dose  is  repeated 
daily  until  marked  improvement  ensues.  If  a  tendency  to  relapse  occurs  it  is 
again  resorted  to.  In  no  case  should  the  clinical  diagnosis  wait  for  confirmation 
by  the  laboratory  but  the  antiseriun  should  be  given  at  once.  The  earlier  it  is 
used  the  better  it  acts.     Used  late  it  may  do  little  good  save  to  prevent  relapse. 

In  making  the  lumbar  puncture,  for  the  purpose  not  only  of  drawing  off  fluid 
for  diagnostic  purposes  but  with  the  object  of  injecting  the  specific  serum,  it  is  well 
to  use  a  special  apparatus  and  not  to  employ  for  injection  purposes  an  ordinary 
syringe.  This  apparatus  consists  of  a  strong,  hollow  needle  or  cannula  fitted 
with  a  by-pass  which  is  governed  by  a  small  valve  and  which  is  attached  to  one 
side  of  the  cannula  rather  than  at  its  external  orifice,  as  it  may  be  necessary  to 
dislodge  some  obstruction  in  the  cannula  by  inserting  a  trocar.  To  a  piece  of 
tubing  attached  to  the  by-pass  is  attached  a  straight  glass  tube,  which  is  either 
gauged  by  marks  made  upon  it,  or  is  fitted  with  a  gauge  resembling  that  of 
a  thermometer.  By  this  means  an  estimation  of  the  pressure  of  the  cerebrospinal 
fluid  is  obtained.  This  is  important,  because  it  is  un-nise  as  the  fluid  is  with- 
drawn to  permit  the  pressure  to  fall  too  low,  and  when  the  specific  serum  is 
injected  it  is  important  that  the  pressure  should  not  be  too  high.  By  the  use  of 
a  burette  attached  to  the  end  of  the  cannula  and  into  which  the  serum  is  poured, 
the  injection  can  be  given;  the  pressure  of  the  injection  being  modified  by  the 
height  at  which  it  is  held. 

The  treatment  of  true  cerebrospinal  fever,  except  by  antimeningococcic  serum 


128  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

is  not  satisfactory.  We  Icnow  of  no  remedies  which  exercise  any  true  curative 
influence,  and  all  the  physician  can  do  is  to  keep  the  patient  during  the  acute 
stages  in  a  quiet,  darkened  room,  and  to  give  sedatives  in  sufficiently  large  doses  to 
prevent  convulsions  of  sufficient  violence  to  exliaust  the  patient.  Chloral  is  a 
powerful  and  useful  drug  for  this  purpose,  being  given  in  the  do.se  for  an  adult  of 
20  grains  by  the  mouth,  or  60  grains  by  the  rectum,  in  starch-water.  Pain  is  to 
be  relieved,  if  excessive,  by  the  use  of  morphine  in  adecjuate  doses,  as  much  as 
§  a  grain  being  used  if  needed,  particularly  at  night,  to  give  rest  and  sleep. 

Mention  has  already  been  made  of  lumbar  puncture  for  diagnostic  purposes. 
When  headache,  high  temperature,  rigors,  or  stupor  are  marked,  the  relief  of  the 
pressure  upon  the  brain  and  spinal  cord  by  this  means  may  be  temporally  effected, 
but  that  it  aids  the  patient  permanently  is  very  doubtful.  The  amount  of  fluid 
withdrawn  should  equal  40  to  50  c.c. 

Relief  from  the  severe  pains  in  the  limbs  and  back  may  be  obtained  in  some 
cases  by  immersing  the  patient  for  long  periods  of  time  in  a  hot  bath  of  plain  or 
salt  water  at  99°  or  100°. 

The  fever  is  rarely  high  enough  to  need  treatment.  If  it  is  above  105°,  the 
ice-bag  and  the  use  of  cool  spongings  with  frictions  may  be  resorted  to. 

In  all  cases  the  diet  should  be  one  which  is  easily  swallowed  and  easily  digested, 
and  everj'thing  should  be  done  to  support  the  system.  This  is  particularly  neces- 
sary in  the  prolonged  tj'pes,  in  which  marked  emaciation  is  often  present. 

CROUPOUS  PNEUMONIA. 

Definition.— There  is  no  condition  of  the  lungs  which  is  so  apt  to  be  confused 
in  the  mind  of  the  student  as  that  designated  pneumonia.  This  is  because  the 
word  "pneimionia"  is  used  by  some  medical  men  to  designate  a  single  disease 
aft'ecting  the  lung  and  by  others  as  signifying  any  state  in  which,  as  the  result  of 
an  inflammatory  process,  a  part  of  the  lung  becomes  congested  or  consolidated. 
The  latter  is  the  better  use  of  the  word,  and  when  the  physician  desires  to  state 
that  a  definite  lesion  is  present  he  should  specify  the  type  of  pneimionia  by  em- 
ploying an  adjective  to  qualify  the  noun — i.  e.,  he  should  speak  of  the  A'arious  forms 
of  pneumonia  as  croupous  or  lobar  pneumonia,  catarrhal  or  lobular  pneumonia, 
and  of  tuberculous  pneumonia.  The  term  "pneumonia,"  while  commonly  used 
to  signify  croupous  pneumonia,  means  nothing  more  definite  than  consolidation  of 
the  lung. 

Croupous  Pneiunonia  is  sometimes  called  Lobar  Pneiunouia,  Pneumonitis, 
Lung  Fever,  or  Fibrinous  Pneumonia. 

Croupous  pneiunonia  is  an  acute  infectious  systemic  disease  depending  for  its 
existence,  when  in  its  typical  form,  upon  the  activity  in  the  body  of  the  specific 
organism  known  as  the  Micrococcus  lanccohtus,  sometimes  called  the  pneiunococcus 
of  Fraenkel.  As  the  result  of  this  infection,  there  takes  place  in  the  lung  an  acute 
inflammation  accompanied  by  the  exudation  into  the  air  vesicles  of  an  adliesive, 
croupous,  or  fibrinous  exudate,  which  produces  consolidation  of  the  lobe  or  lobes 
aft'ected.  In  addition  to  these  changes  the  patient  suffers  from  a  greater  or  less 
degree  of  toxemia,  due  to  the  poisons  made  by  the  infecting  microorganisms  and 
from  the  changes  produced  in  the  tissues  of  other  organs  than  the  lungs  by  the 
growth  of  the  micrococcus  or  by  its  toxins.  Tliis  disease  is  also  characterized  by 
the  fact  that  it  usually  lasts  about  nine  days  and  ends  by  crisis,  although  this 
crisis  may  occur  as  early  as  the  third  day  or  even  earlier  in  very  rare  instances. 

While  it  is  true,  as  already  stated,  that  croupous  pneumonia  is,  in  its  typical 
form,  due  to  the  Micrococcus  lanceolatus,  it  is  also  a  fact  that  lobar  pneumonia 
or  consolidation  of  the  vesicular  portions  of  a  lobe  or  lobes  may  arise  from  infection 
by  other  microorganisms.     Such  an  occurrence  is,  however,  rare,  the  non-specific 


CROUPOUS  PNEUMONIA  129 

infection  resulting  usually  in  abortive  changes  in  the  pulmonary  parencliyma,  or 
running  a  course  at  variance  with  that  commonly  pursued  by  the  true  infection. 

Etiology. — The  development  of  croupous  pneumonia  is  dependent  upon  many 
causes,  some  of  which  we  do  not  know.  These  causes  are  those  external  to  the  body 
which  produce  conditions  in  the  individual  favorable  to  the  g^o^\'th  of  the  specific 
germ,  and  internal  causes  which  exert  similar  influences.  The  importance  of 
these  conditions  is  shown  by  the  fact  that  the  pneumococci  are  periodically  or 
continuously  present  in  the  oral  secretions  of  a  large  percentage  of  healthy  human 
beings  and  further  they  are  present  in  greater  number  and  greater  virulence  in 
December  and  January,  and  in  less  number  and  virulence  between  April  and  Novem- 
ber. Although  the  organism  is  capable  of  rapidly  increasing  in  virulence,  this 
cannot  be  held  to  account  for  all  cases  of  infection,  as  even  the  most  virulent  strains 
are  sometimes  found  in  normal  persons. 

So  far  as  season  is  concerned,  there  can  be  no  doubt  that  the  summer  and  autumn 
months  are  the  ones  in  which  the  fewest  cases  occur.  Thus,  the  combined  statistics 
of  Seitz,  in  Munich,  and  Jiirgensen  for  sbc  large  German  towns,  and  of  Sturgis 
for  Westminster  Hospital,  London,  show  that  in  winter  the  incidence  is  31.7  per 
cent.;  in  the  spring,  34.6  per  cent.;  in  the  summer,  15.1  per  cent.,  and  in  the  autumn, 
18.5  per  cent.  The  following  chart  is  based  upon  35,828  cases  occurring  in  hospitals 
in  the  United  States,  Germany,  and  Austria,  and  19,000  cases  occurring  in  the 
Confederate  army  during  the  year  1862,  collected  by  Joseph  Jones. 

Exposure  to  cold  was  thought  for  many  years  to  be  a  cause  of  croupous  pneu- 
monia, but  we  know  that  this  acts  only  as  a  predisposing  cause  which  decreases 
the  general  systemic,  or  local,  power  or  resistance  to  infection;  in  other  words, 
it  is  prone  to  affect  all  persons  whose  vital  resistance  is  diminished.  Living  in 
poorly  ventilated  rooms  is  a  predisposing  cause,  as  is  prolonged  physical  or  mental 
strain,  or  any  condition  which  saps  vitality.  A  very  interesting  illustration  of  the 
effect  of  fatigue,  bad  air,  and  exposure  in  the  production  of  croupous  pneumonia 
has  been  recorded  by  Connell,  of  Leadville,  Colorado,  who  reports  the  common 
occurrence  of  the  disease  in  miners  and  others  who  go  on  long  railway  journeys 
for  a  day's  outing  and  live  during  that  time  in  badly  ventilated  railway  cars. 

Croupous  pneumonia  is  also  a  disease  peculiarly  apt  to  attack  those  of  advanced 
years,  and  a  very  large  proportion  of  deaths  among  the  aged  is  due  to  tliis  cause, 
such  patients  seeming  to  possess  little  resistance  to  its  attack.  This  inability  to 
resist  the  infection  depends  upon  at  least  two  causes — viz.,  a  feeble  heart  muscle 
which  cannot  meet  the  circulatory  demands  of  the  disease  nor  resist  the  depressant 
effects  of  its  toxins;  diseased  kidneys,  or  kidneys  impaired  in  function,  whereby 
toxic  materials  cannot  be  speedily  eliminated  and,  as  the  general  result  of  which  the 
vital  resistance  of  all  the  tissues  is  diminished,  so  that  not  only  the  specific  organism 
is  permitted  full  sway,  but  the  patient  is  also  placed  in  a  favorable  condition  for 
the  growth  of  other  infecting  microorganisms  which  aid  in  producing  a  fatal 
issue.  It  is  because  of  these  facts  that  pneumonia  so  frequently  attacks  those 
who  are  already  in  ill  health,  or  who  are  suffering  primarilj^  from  some  other  malady, 
and  it  is  for  these  reasons  that  it  so  often  ends  in  death.  Acute  and  chronic  alcohol- 
ism greatly  predispose  to  croupous  pneumonia,  and  it  is  a  singularly  fatal  disease 
in  persons  addicted  to  alcohol.     In  many  cases  it  is  a  terminal  infection. 

Sometimes  an  injury  to  the  chest  wall  will  be  followed  by  acute  croupous  pneu- 
monia, probably  because  the  trauma  to  the  lung  renders  it  susceptible  to  infection. 
Numerous  experimental  observations  have  confirmed  this  clinical  fact,  which  may 
be  of  great  importance  from  a  medicolegal  stand-point,  as  well  as  from  the  purely 
clinical  aspect.  Without  doubt  local  injury  renders  a  part  peculiarly  susceptible 
to  infection  by  any  pathogenic  microorganisms  which  may  enter  it,  and  as  the 
pneumococcus  is  a  constant  inhabitant  of  the  mouth  in  healthy  persons,  a  source 
of  infection  is  ever  present. 
9 


130 


DISEASES  DUE  TO  .1   SPECIFIC  L\Fl';CTin.\ 


Fio.  34 

i?    =    i?    til    S 


TIkto  can  he  no  (l()ul)t  tluit  tlie  discasL-  is  cai)al)ic  of  \wu\js.  s|)rc:iil  from  oiir  patient 
to  anotlur.  On  several  oecasions  I  have  seen  jjiienmonia  contracted  h.v  the  wife, 
or  (huijjhter,  of  a  j)atient  who  was  engaji;ed  in  nursing  him,  and  re|)eatediy  it  lias 
occurred  that  the  introduction  of  a  case  of  i)nenmonia  into  a  ward  of  a  hospital 
has  resulted  in  the  development  of  the  disease  in  other  patients.  Thus,  out  of 
eleven  women  suii'ering  from  typhoifl  fever  on  admission  to  my  wards  in  the  Jefferson 

Medical  College  Hospital,  no  less  than 
eight  suffered  from  croupous  pneumonia 
after  the  introduction  of  a  single  case  of 
this  disease. 

Unlike  many  of  the  acute  infectious 
diseases,  one  attack  does  not  protect 
against  another,  but  rather  predisposes 
the  patient  to  subsequent  attacks. 

Distribution. — Croupous  pneumonia  is 
met  with  in  all  parts  of  the  world,  but 
it  is  more  common  in  the  temperate 
than  in  the  tropical  zones.  In  the  United 
States  its  greatest  mortality  occurs  in  the 
great  Northwestern  States  east  of  the 
Rocky  Mountains,  in  which  district  it 
causes  120,  or  more,  deaths  per  1000 
deaths  from  known  causes.  Only  a  few 
areas  in  the  States  east  of  this  area  have 
so  heavy  a  mortality,  e^'en  if  large  cities 
like  New  York,  Philadelphia,  and  Chicago 
are  included. 

Frequency.  —  Statistics  as  to  its  fre- 
quency are  to  a  large  extent  \'itiated  by 
the  fact  that  in  many  health  reports  the 
difference  between  the  various  forms  of 
pneumonia  is  not  specified.  There  can  be 
no  doubt,  however,  that  it  is  one  of  the 
most  common  and  most  fatal  of  all  .acute 
infectious  diseases,  and  that  its  frequency 
and  mortality  are  increasing.  The  United 
States  census  shows  the  total  mortality 
per  annum  from  pneumonia  to  be 
105,971,  of  whom  5S,o40  were  males 
and  47,0.31  were  females.  The  propor- 
tion of  deaths  was  106.1  for  each  1000 
deaths  from  all  known  causes.  Its  a\erage  mortality  is  about  1.5  to  2.3  per  1000 
persons  living. 

At  times  croupous  pneumonia  may  occur  in  epidemic  form  and  cause  an  extra- 
ordinary increase  in  the  death  rate  of  a  given  district.  Thus,  the  mortality  from 
this  disease  in  Chicago,  as  shown  by  Reynolds  in  his  official  report  covering  the 
period  from  January  1  to  June  1,  1903,  became  remarkably  high.  There  were 
2891  deaths  from  pneumonia,  as  compared  with  1321  from  consumption  and  1238 
from  all  other  communicable,  contagious  or  infectious  diseases,  including  diphtheria, 
erysipelas,  influenza,  measles,  puerjjcral  fever,  scarlet  fever,  smallpox,  typhoid 
fever,  and  whooi>ing-cough.  This  is  an  excess  of  382  pneumonia  deaths  o\er  the 
deaths  from  all  the  other  preventable  diseases— 1570,  or  118.8  per  cent.,  more  than 
the  deaths  from  consumption,  and  1G53  or  133.5  per  cent.,  more  than  those  from 
the  other  specified  diseases. 


6400 

5200 

,5000 

4800 

4000 

4400 

4200 

I 

; 

4000 

\ 

/ 

asofl 

1 

1 

.SfiOO 

k 

/ 

3400 

\ 

/ 

.<!300 

1 

1 

ROOO 

1 

2,S00 

1 

?00fl 

1  ■ 

2400 

s^on 

?flon 

\ 

ison 

\ 

s 

KiOO 

\ 

1400 

A 

1900 

l\ 

1000 

k 

n/ 

fiOO 

Chart  showing  the  seasonal  incidence  of  croupous 

pneumonia. 


CROUPOUS  PNEUMONIA  131 

Croupous  pneumonia  occurs  with  the  greatest  frequency  between  the  ages  of 
forty  and  fifty  years,  but  it  is  also  very  common  between  fifty  and  sixty.  The 
mortality  is  in  direct  proportion  to  the  age  of  the  patient.  It  afl'ects  males  far 
more  frequently  than  females,  the  proportion  being  as  high  as  88  per  cent,  of  the 
former  to  12  per  cent,  of  the  latter  (Kerr).  This  high  proportion  in  men  is 
probably  too  high  for  the  average,  but  it  serves  to  emphasize  the  fact  staterl,  and 
is  approximately  correct.  The  reason  probably  lies  in  the  greater  e.xposure  of 
men  to  cold  and  wet  and  to  their  abuse  of  alcohol. 

The  relative  frequency  with  which  croupous  pneumonia  affects  the  right  and 
left  lung,  as  based  on  many  thousand  cases  collected  by  Meltzer  in  Russia;  Jiirgen- 
sen,  Moellmann,  and  Brach  in  Germany,  and  West  and  Pye-Smith  in  England, 
is  for  the  right  lung,  51.4  per  cent.;  left,  39.4  per  cent.,  and  for  both  lungs,  9.2 
per  cent. 

In  495  cases  examined  at  autopsy,  and  collected  by  Fowler,  Osier,  Kerr,  and 
Steven  in  this  country  and  England,  the  disease  was  unilateral  in  S3  per  cent.  It 
is  unilobar  in  the  proportion  of  about  50  per  cent.  The  disease  affects  a  lower 
lobe  in  nearly  75  per  cent,  of  the  cases. 

Prevention. — At  the  present  time  we  haA'e  no  means  of  directly  preventing 
de^'elopment  of  this  disease.  It  is  hardly  necessary  to  state  that  the  sputum 
of  the  patient  should  be  received  into  a  spit-cup  containing  some  suitable  disin- 
fectant, or  into  a  cloth  which  should  be  speedily  burned.  A  patient  suffering 
from  croupous  pneumonia  should  not  sleep  in  the  same  bed  with  a  person  who  is 
in  health,  and  should  be  isolated  as  much  as  possible. 

Pathology  and  Morbid  Anatomy. — In  studying  croupous  pneumonia  it  must  not 
be  forgotten  that  the  disease  is,  at  least  in  some  cases,  a  general  infection  with 
the  Micrococcus  kmceolahis,  the  morbid  changes  being  chiefly  manifested  in  the 
lungs,  just  as  in  typhoid  fe^'er  they  are  chiefly  manifested  in  Peyer's  patches.  The 
pneumococcus  is  found  in  the  blood  during  the  progress  of  this  disease  with  great 
freciuency,  now  that  proper  methods  for  its  discovery  are  employed.  Thus, 
Prochaska  has  found  it  in  the  blood  in  38  out  of  40  consecutive  cases,  Rosenow 
has  isolated  it  in  77  out  of  S3  cases,  and  has  discovered  it  in  the  blood  as  early  as 
twelve  hours  after  the  initial  chill.  On  the  other  hand,  the  mere  presence  of  the 
pneumpcoccus  in  the  blood  of  a  patient  does  not  necessarily  mean  that  pneumonia 
is  present,  for  it  has  been  found  in  the  blood  in  cases  of  tonsillitis,  otitis,  arthritis, 
and  in  pulmonary  edema.  Parker  and  many  others  have  even  described  cases 
of  purulent  peritonitis  due  to  this  organism.  Trevisanello  demonstrated  it  in 
pure  culture  in  the  herpes  of  pneumonia  but  in  weakened  virulence.  The  possi- 
bility of  spread  of  the  disease  from  such  lesions  is  obvious. 

Engorgement  Stage. — The  first  change  taking  place  in  the  lung  in  croupous 
pneumonia  is  a  hyperemia  of  the  intervesicular  tissues  of  the  lobe  or  lobes  about 
to  be  consolidated.  This  engorgement  rapidly  becomes  more  marked,  and  is 
accompanied  by  the  exudation  into  the  air  vesicles  and  later  the  smaller  bronchi  of 
white  cells,  red  blood  cells,  and  plasma.  From  the  plasma  fibrin  forms  and  causes  a 
solid  exudate,  so  that  all  that  part  of  the  lung  which  is  affected  may,  in  the  course 
of  a  few  hours,  be  devoid  of  air  and  impervious  to  its  passage,  except  in  those 
bronchial  tubes  which  are  of  some  size. 

Stage  of  Red  Hepatization. — The  lung  is  now  said  to  be  in  the  stage  of  red 
hepatization  (Fig.  35),  since  the  exudate  is  red  from  blood-coloring  matter,  and 
the  consistency  of  the  organ  to  touch  and  on  section  resembles  that  of  fresh  li\'er; 
hence  it  is  said  to  be  hepatized  or  liver-like. 

When  a  cross-section  is  made  of  the  solidified  lung  the  surface  is  seen  to  be  granular 
because  of  the  protrusion  of  the  exudate  from  the  air  spaces.  In  some  instances 
the  cut  surface  is  found  not  to  be  uniformly  solid,  probably  because  the  process  is 
less  marked  in  some  places  than  in  others.     This  appearance  of  the  lung  on  section 


132 


DISEASES  DUE  TO  A  SPECIFIC  INFECTION 


is  also  largely  nioclLfied  in  young  children  and  in  greatly  enfeehied  individuals, 
in  whom  the  degree  of  solidification  may  be  much  less  marked.  If  the  exudate 
is  examined  microscopically,  it  will  he  found  to  contain  not  only  shreds  of  fibrin, 
red  and  white  cells,  and  desciuamated  epithelial  cells  from  the  walls  of  the  vesicles, 
but  large  numbers  of  pneumococci  as  well.  Tiiat  tiie  amount  of  extravasation 
is  in  many  cases  extremely  large  is  shown  by  the  fact  that  a  lung  may  increase  in 
weight  by  six  or  seven  pounds.  The  leukocytes  of  the  exudate  constantly  increase 
in  number  during  this  stage. 

Fig.  35 


Lung;  croupous  pneumonia,  stage  of  red  hepatization.  The  centre  of  the  microscopic  field  is  occupied 
by  an  air  vesicle  containing  a  mass  of  exudate  composed  of  a  nctworlc  of  fibrin,  red  blood  cells,  and  a 
few  leukocytes. 

Stage  of  Gr.\y  Hepatization. — Following  the  stage  of  red  hepatization  there 
ensues  the  stage  of  gray  hepatization.  At  this  time  the  acute  inflammation  in 
the  lung  has  passed  by  and  the  system  is  beginning  the  task  of  clearing  away  the 
results  of  the  disease.  This  is  made  possible  by  liquefaction  (autolysis)  of  the 
fibrin  and  dead  cells,  probably  caused  by  enzymes  from  the  leukocytes  in  addition 
to  fatty  degeneration  of  the  cells.  During  this  stage  of  resolution  the  exudate 
is  gotten  rid  of  by  absorption  and  expectoration.  Finally,  the  air  cells  are  freed 
from  the  exudate  with  which  they  were  filled,  the  epithelial  lining  is  reproduced, 
and  recovery  results. 

Unusual  Changes. — In  rare  instances  the  normal  process  of  resolution  is  not 
followed,  and  in  its  place  organization  of  the  materials  which  have  been  extravasated 
takes  place  to  some  degree,  new  connective  tissue  is  proliferated  into  the  air  vesicles 
from  their  walls,  and  fibrous  bands  containing  bloodvessels  extend  throughout 
the  lungs.  Simultaneously  a  similar  growth  takes  place  in  the  interstitial  tissues, 
and  so  the  lung  gradually  becomes  consolidated  by  overgrowth  of  fibrous  tissue, 
i.  e.,  organizing  lobar  pneumonia. 

Flexner  and  others  have  urged  the  view  that  unresolved  lobar  pneumonia  is 
due  to  the  fact  that,  owing  to  some  disproportion  between  the  leukocytes  and  other 
constituents  of  the  exudate,  or  other  causes  as  yet  undiscovered,  the  normal  process 
of  autolysis  is  not  carried  out,  and  so  the  exudate  undergoes  organization  instead 
of  resolution. 

In  other  instances  which  are  far  more  rare  the  process  of  resolution  is  suj^plantcd 
by  the  development  of  abscess  or  gangrene  of   the  lung,  which  conditions  are 


CROUPOUS  PNEUMONIA 


133 


probably  due  to  secondary  infection  of  the  lung  by  the  streptococcus  pyogenes, 
or  staphylococcus  pyogenes,  or  other  bacteria  capable  of  producing  such  lesions. 
Sometimes  the  process  of  fatty  change  and  death  of  the  extravasated  cells  is  so 
rapid  that  on  section  of  the  lung  the  vesicles  exude  a  purulent  matter  looking  like 
true  pus,  which  indeed  it  may  be,  but  this  in  no  sense  is  an  abscess  of  the  lung. 

Associated  with  the  changes  in  the  lungs  we  find  adjacent  organs  involved 
by  direct  extension  of  the  inflammatory  process  or  by  the  infection  itself.  The 
most  common  of  these  is  inflammation  of  the  bronchi  (bronchitis),  which 
is  practically  always  present.  After  bronchitis  in  frequency  comes  inflammation 
of  the  pleura,  due  to  direct  extension  from  the  underlying  lung  and  to  infec- 
tion of  the  pleura  by  the  specific  organism 

of  the  disease.    Nearly  always  this  is  mani-  ^^°-  ^6 

fested  by  the  formation  of  a  plastic  fibrinous 
exudate  on  the  serosa  and  an  abnormal 
amount  of  fluid  in  some  part  of  the  pleural 
cavity,  which  fluid  is  often  serous  and  not 
infrequently  purulent.     (See  Pleuritis.) 

Sometimes  the  pericardium  is  similarly 
affected,  and  even  the  endocardium  may 
be  infected  by  the  specific  germ.  (See  Peri- 
carditis and  Endocarditis,  under  Complica- 
tions.) 

Reference  is  made  elsewhere  to  the  men- 
ingitis which  sometimes  develops. 

It  is  a  great  mistake  to  view  the  lesions 
just  described  as  representing  all  the  path- 
ology of  croupous  pneumonia.  It  is  true 
that  these  changes  are  the  most  evident, 
but  it  is  not  to  be  forgotten  that  the  toxemia 
of  the  malady  exerts  a  very  great  influence 
in  producing  symptoms  and  lesions  during 
life  which  are  not  so  readily  seen,  but  are 
equally  important  in  their  influence  on  the 
patient.  The  muscular  fibres  of  the  heart 
and  the  epithelial  cells  of  the  kidneys  un- 
dergo albuminous  degeneration,  and  similar 
changes  occur  in  the  liver.  When  the  heart 
is  opened  after  death  we  frequently  find  its 
cavities,  particularly  those  of  the  right  side, 
almost  filled  by  firm  clots,  part  of  which 
may  have  formed  so  long  before  death  as  to 
be  of  the  "chicken-fat"  type.  The  liver  is 
often  found  to  be  greatly  engorged  with  blood, 
because  of  the  impeded  circulation  in  the  vena  cava,  produced  by  the  difficulty 
with  which  the  right  side  of  the  heart  empties  itself.  The  bronchial  lymph  nodes 
also  show  by  the  swelling  of  their  cells  and  by  their  distended  sinuses  that  they 
have  endeavored  to  prevent  the  entrance  of  the  micrococcus  and  its  toxins  into 
the  general  system,  for  in  them  may  be  found  broken-down  cells,  red  cells,  pneu- 
mococci,  and  phagocytes  containing  cells  or  organisms. 

My  colleague,  Coplin,  has  shown  that  definite  changes  take  place  in  the  inter- 
costal muscles  in  the  course  of  pneumonia  and  pleurisy.  1.  Granular  degeneration 
or  cloudy  swelling  of  the  muscle  fibres,  which  is  probably  a  part  of  the  general 
action  of  the  toxic  bodies  circulating  in  the  blood.  2.  The  muscle  fibres  are  dis- 
sociated, edema  is  present,  but  there  is  little  fibrin-containing  substance.    Groups 


f2^ 

'■^^M 

i 

^■HI^I^^^^^V'"'' 

Antemortem  heart-clot  from  a  case  of 
pneumonia,  extending  into  the  vessels. 
(Comrie.) 


134  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

of  imiscle  fi))res  and  biinrlles  sliow  diaiif^es  that  cannot  he  dift'crcntiatcd  from 
the  liyahiie  (h'fieneration  (h'scrilx'd  hy  Zenker  as  oeenrring  in  the  nuiscles  of  the 
ah(h)niinal  wall  in  t\j)hoid  fo\er.  '■'>.  in  addition  to  tlie  changes  already  described, 
lenkoeytes  hecome  ahvnidant,  l)a<t(ri;i  are  often  j)resent,  and,  finally,  if  the  in- 
Haniniatory  process  is  chronic,  tlicrc  is  an  oxiTgrowth  of  fihrons  tissne  and  fatty 
infiltration  of  the  muscle. 

Incubation. — The  incubation  period  of  croupous  pneumonia,  that  is  the  time  at 
which  the  chill  of  onset  occurs  after  exposure  to  another  case,  is  forty-eight 
hours. 

Symptoms. — Before  describing  the  symptoms  met  with  in  cases  of  croupous 
pneumonia,  it  is  essential  to  emphasize  the  fact  that  in  no  other  uifectious  disease 
are  the  manifestations  of  illness  so  variable.  These  variations  depend  not  only 
upon  the  \'irulence  of  the  infecting  germ  and  the  susceptibility  of  the  patient, 
but  upon  his  habits,  age,  and  general  state  of  health.  In  some  cases  the  malady 
develops  as  a  frank,  open  inflammation  of  the  lung.  In  others,  it  is  so  insidious 
as  to  be  overlooked,  except  by  the- most  careful  physician.  In  certain  cases  the 
course  of  the  disease  is  markedly  sthenic,  in  others  profoundly  adynamic.  In 
still  others  the  progress  is  so  mild  that  the  patient  is  never  seriously  ill,  and  in 
some  instances  it  springs  like  a  tiger  upon  a  seemingly  healthy  man  and  destroys 
him. 

The  symptoms  of  croupous  pneumonia  may  be  divided  into  three  stages  for 
readiness  of  description — namely,  those  of  onset,  those  of  the  well-de\eloped 
stage,  and  those  of  convalescence. 

Stage  of  Onset. — The  patient,  usually  an  adult,  is  seized  after,  or  without,  a 
brief  period  of  general  malaise,  with  a  chill,  followed  by  a  well-developed  fe\-er. 
The  chills  may  be  repeated  and  may  vary  from  a  slight  feeling  of  creepiness  to 
a  severe  rigor  of  sufficient  force  to  shake  the  patient  severely,  and  to  last  for  over 
an  hour.  The  pulse  is  cjuickened,  but  not  as  much  so  as  we  would  expect  from 
the  sharpness  of  the  onset,  and  at  first  may  be  small,  but  soon  becomes  full  and 
bounding  if  the  patient  has  been  pre\^iously  in  good  health;  the  rcspiratio^is  are 
also  markedly  increased  in  rate  per  minute.  More  or  less  severe  pain  may  be 
felt  in  the  chest  on  the  affected  side.  The  degree  of  pain,  however,  varies  greatly, 
some  patients  bitterly  complaining  of  it,  while  others  seem  to  have  little  or  no 
sufi'ering,  probably  because  in  the  latter  cases  the  inflammation  of  the  lung  is  so 
deeply  situated  that  it  does  not  extend  to  and  in\-olve  the  visceral  layer  of  the 
pleura.  It  is  important  to  bear  in  mind  the  fact  that  this  pain  not  infrequently 
is  referred  by  the  patient  to  another  part  of  the  body.  I  had  a  case  admitted  not 
•  long  since  to  my  w\ards,  on  the  statement  of  a  well-known  physician  that  she 
had  appendicitis,  when  she  was  really  suffering  from  a  j^leuropnemnonia  of  the 
right  lower  lobe.     Children  are  very  ])rone  to  refer  the  pain  to  the  epigastrium. 

If  the  patient  is  very  feeble  it  sometimes  happens  that  the  onset  of  the  malady 
is  insidious  and  no  pain  felt.  This  is  especially  apt  to  be  true  when  the  disease 
complicates  chronic  alcoholism,  renal  disease,  or  other  grave  malady. 

The  frill pn-dtinr  usually  makes  a  sharp  and  decided  rise,  immediately  after 
or  during  the  chill,  to  fO;i°  or  105°,  and  in  some  cases  even  higher  than  this,  and 
remains  high  throughout  the  disease,  the  variation  in  the  mornuig  and  evening 
temperature  not  f)eing  more  than  a  degree  or  a  fraction  thereof.    (See  Fig.  37.) 

The  fare  is  iisiinlh/  fliishrcL  particularly  over  the  cheek  bones,  and  it  is  a  note- 
worthy fact  that  this  flush  is  usually  most  marked  upon  the  cheek  of  the  same 
side  as  the  lung  involved.  The  expressi(m  of  the  face  is  apt  to  be  somewhat 
anxious,  the  skin  dry  and  hot,  and  a  moderate  degree  of  cyanosis  may  be  seen 
in  the  capillaries  of  the  lijjs  and  finger-tips,  and  about  the  nose. 

Viulciit  liniihiclir  nia\  or  niiiy  not  be  present.  A  more  or  less  active  deliriuin 
may  also  (lc\clnii  at  tliis  time,  and  the  jjatient  may  be  cpiite  restless  mdess  the 


CROUPOUS  PNEUMONIA 


135 


pain  in  the  side  makes  it  more  comfortable  to  lie  quietly  in  bed.    An  incessant 
improdvctive  covgh  is  often  an  early  symptom  of  onset. 

The  physical  signs  of  the  disease  in  the  thorax  in  the  stage  of  onset  are  not, 
as  a  rule,  well  marked.  Inspection  may  reveal  some  impairment  of  expansion 
upon  the  affected  side;  palpation  may  evince  some  increase  in  vocal  fremitus; 
auscultation  will  show  in  many  cases  fine  crepitant  rales,  increased  bronchial 
breathing  or  tubular  sounds,  increased  loudness  of  vesicular  breathing  for  a  few 
hours,  and  often  some  exaggeration  of  the  normal  respiratory  sounds  on  the  sound 
side.  Indeed,  this  increase  in  the  harshness  of  the  breath  sounds  over  the  normal 
side,  due  to  the  increased  activity  on  the  part  of  the  healthy  lung,  to  compen- 
sate for  the  impairment  of  the  diseased  lung,  may  mislead  the  beginner  in  physical 
diagnosis  into  thinking  that  this  is  the  limg  diseased.  Percussion  may  also  reveal 
some  impairment  of  resonance  over  the  affected  area. 


BOWELS    =1                                   >                                                                >                                                      ^             \                  -       \                \             - 

"-  ;                 •                   I                \    \      \\         I 

-i:-3:EEr-±^^±^^EE^± zt ''''W-^^±: 

1- 

-~-o^--H- — '--    '    -■      '■    -*    --'-    -  - -'-    -' i-i--" 1 

■  i  «  '.      .  i        '     .,      ,  ■      ■..■.,'.,               , ,  ■           ^     Y          -•-;-    *  „                1 

"■'  ^s.A;._...  5-    .           - -        . s-S- «~3--S 1 

"■     '         '— '    \                                                  ■ :      ■    .,      1      !-  -+-  ■'  iTi^i-  ?-'-  ---T-  -5'!  s^^n ' ^ 

-.' -1  ..::;..  *^y\  :.',■,.:,:=  ,i      :,    i=  .  j:;.^!  ::ii^ij:s:ji:i.!^       =t:± 

o ^-  ^.    •  A  ■  -  ..  •     ■-■    A'A'/    ^\^A^-\--^2--  ^-^  ^- — ' — ' — ' 

°'             ''     \'^\K\TltT\\     '^"^^'^  ^        " 

0"°                                    V    V  V  -     ^     ■    y      =    V      '                I 

?■      ^.        I  --                         *■                    2            -, 

^ , » = _ ^ 1 _ L_ 

S: 

Vi      1      j           1      j 

i" 

\  -1 

.      S-      S-           S                 ;,i-i!          ;        '.      ■:. -t-S—^           Si       i      1      S,          1          \-    =    =    '           A '  ^   -' 

""^                                                                                                                                                                        1              V.'     '^    *^      \      1- 

^Fi  1                    M                        '    N 1  '  fl 

o!sEA°se       "                                      -^                                              ■=                                               =                       t-                      » 

PULSE    s*$  •?:(.>  f^  -J-"^).  f^  -»\^;  vtjC  s*ic.  -S?-^  «-V  s*j.J  N-O^vS  <g^  s*;i  N*jii  -^^  ^^  -f-^  ^f^^  f-^i  s^jj,'  -.^jj  sJV^  s-^^S  ^*JC 

»Es..  f-4  ti  M  M  fi  H  H  .**■ «« .**  f4  M  H  f-i  U  **  f •*  f-i^  ^*  U  *^'  M  ^^4  ■^i-  ?* 

°"e       s                            §                                  g                           .       s                 S                3 

A  chart  of  croupous  pneumonia  in  a  girl  of  six  years,  showing  the  httle  effect  produced  upon  the 
temperature  by  sponging,  and  the  characteristic  crisis  on  the  sixth  day. 


Developed  Stage. — The  developed  stage  of  the  disease  is  characterized  by 
certain  conditions  and  physical  signs,  some  of  which  are  almost  pathognomonic 
of  the  malady.  The  peculiarity  of  the  jndse  is  that  it  is  quite  slow  as  compared 
to  the  rapidity  of  the  respirations.  Usually  when  high  fe^'er  is  present  the  pulse 
rate  is  as  high  as  110  or  120,  or  even  higher,  while  the  respirations  are  about  24, 
but  in  pneumonia  of  the  croupous  type  the  pulse  rate  is  sometimes  only  90,  while 
the  respirations  are  as  high  as  30  per  minute.  Sometimes,  however,  the  respi- 
ratory rate  mounts  to  as  high  a  point  as  40  or  50  per  minute,  while  the  pulse 
reaches  110  to  120,  the  relative  proportion  being  1  to  3,  while  in  health  it  is  usually 
about  1  to  4.5. 

A  second  peculiarity  of  this  stage  is  the  rusty  or  bloody  spntwm,  which  is  still 
more  characteristic  in  that  it  is  sticky  and  tenacious,  and  therefore  difficult  to 


136  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

expectorate,  and  so  adherent  that  even  when  a  spit-cup  is  filled  witli  it  the  vessel 
can  be  held  nearly  upsidedown  without  losing  its  contents. 

A  third  characteristic  of  croupous  pneumonia  at  this  stage  is  the  develojHnent 
of  single  or  multiple  fever  blisters,  or  spots  of  herpes,  upon  the  lips  or  about  the 
edges  of  the  nostrils. 

Dyspnea  may  or  may  not  be  present.  If  present  it  depends  uj)on  the  fact  that 
so  much  of  the  lung  is  involved  that  respiration  is  difficult,  or  it  is  due  to  feeble- 
ness of  the  heart  from  engorgement  of  its  right  ventricle  by  the  blood  which  can- 
not pass  readily  through  the  diseased  lung;  or,  again,  it  may  ])e  deiJendent  upon 
actual  impairment  of  the  power  of  the  heart  as  a  result  of  the  action  of  the  toxin 
of  the  disease  upon  its  muscular  tissues  and  nerve  centres.  Dyspnea  in  croupous 
pneumonia  may,  therefore,  be  due  to  pulmonary,  cardiac,  or  toxic  causes.  Cyano- 
sis may  be  very  marked,  and  not  uncommonly  the  jugular  and  other  superficial 
veins  can  be  seen  to  be  full  and  distended. 

A  peculiarity  of  the  dyspnea  of  pneumonia  is  the  fact  that  the  patient  does 
not  seem  capable  of  resting  quietly,  but  continually  moves  about  making  exer- 
tions which  seem  scarcely  compatible  with  so  much  shortness  of  breath. 

Delirium  of  an  active  type  is  common  in  this  stage,  and  it  may  be  difficult 
to  keep  the  patient  in  bed,  particularly  if  he  is  an  alcoholic. 

During  the  second  stage  of  croupous  pneumonia  the  imJse  may  become  hob- 
bling or  dicrotic,  the  heart  sounds  tumultuous,  and  the  dyspnea  severe.  In  other 
instances  the  pulse  seems  voluminous,  but  nevertheless  is  very  easily  comjijrcsscd 
to  the  point  of  extinction,  while  the  sounds  of  the  heart  reveal  the  fact  that  that 
viscus  is  laboriously  endeavoring  to  fill  vessels  which,  because  of  their  relaxation, 
fail  to  ofl'er  the  normal  resistance  to  its  action.  In  still  other  instances,  if  the 
heart  is  markedly  affected  by  the  toxemia  of  the  disease,  the  heart  sounds  will 
be  feeble  and  difficult  to  differentiate,  and  the  pulse  be  very  small  and  easily 
extinguished  by  pressure.  In  still  other  cases  auscultation  over  the  area  of  the 
pulmonary  valves  at  the  third  left  interspace  will  reveal  accentuation  of  the  \m\- 
monary  second  sound  or  a  murmur  due  to  incompetency  of  these  valves  under 
pressure,  while  later  on  the  labored  action  of  the  heart  is  shown  not  only  in  the 
signs  named,  but  also  in  the  pulsating  jugular  veins,  which  are  distended  and  full, 
indicating  great  A'enous  engorgement,  as  the  result  of  the  obstruction  of  the  flow 
of  blood  out  of  the  right  ventricle,  or  because  of  incoordination  of  the  auricular 
and  ventricular  contractions,  as  the  result  of  the  formation  of  a  heart  clot  or  from 
toxemia. 

The  physical  sigris  of  croupous  pneumonia  in  the  well-developed  stage  are  ciuite 
characteristic  in  typical  cases.  Inspection  shows  an  even  greater  impairment  of 
expansion  on  inspiration  on  the  affected  side  than  in  the  stage  of  onset,  and  ])al- 
pation  reveals,  when  the  patient  speaks,  a  distinct  increase  in  vocal  frenutus 
over  the  part  of  the  lung  which  is  diseased.  Auscultation  gives  a  harsh  insi)iratory 
sound,  prolongation  of  expiration,  and  a  large  number  of  fine  crackling  or  crep- 
itant rales  in  the  same  area,  so  fine  that  they  may  not  be  heard  by  the  careless 
examiner.  They  sound  very  much  as  does  that  noise  which  is  produced  by  moisten- 
ing the  tip  of  the  forefinger  and  thumb  with  saliva,  pressing  them  together,  and 
separating  them,  or,  again,  as  does  the  sound  made  by  the  hair  which  grows  abo\e 
the  examiner's  ear  when  it  is  rubbed  between  the  finger  and  thumb.  Ordinary 
vesicular  breathing  over  the  area  diseased  is  absent,  and  in  its  place  is  heard 
bronchial  breathing,  which  is  caused  l)y  the  air  in  the  bronchial  tubes,  pro- 
ducing a  sound  which  is  transmitted  through  the  consolidated  lung  unmuflficd 
by  the  vesicular  murmur  usually  present.  Auscultation  while  the  patient  speaks 
will  also  show  a  distinct  increase  in  vocal  resonance.  That  is  to  say,  the  sound 
of  the  voice  will  be  transmitted  through  the  chest-wall  with  a  greater  degree 
of  clearness  than  in  health.    While  auscultation  is  being  performed  in  cases  which 


CROUPOUS  PNEUMONIA  137 

have  a  delicately  developed  chest,  as  in  youths  and  children,  it  is  often  noted  that 
the  movement  of  the  anterior  chest-wall  under  the  ear  is  not  uniform,  but  undu- 
lating, one  part  expanding  at  an  appreciable  interval  before  the  other. 

Percussion,  a  most  valuable  aid  in  the  diagnosis  of  this  disease,  reveals,  if  the 
lesion  in  the  lung  is  near  the  surface,  marked  impairment  of  resonance  amount- 
ing to  dulness,  but  it  is  a  fact  well  worth  remembering  that  if  the  lesion  in  the 
lung  is  deep-seated,  and  not  near  its  surface,  the  percussion  note  over  the  area 
diseased  may  not  be  impaired  or  dull,  but  hyperresonant,  or,  as  Samuel  West  has 
said,  "boxy"  in  character.  Usually  hyperresonance  is  demonstrable  all  over  the 
lung,  except  where  it  is  consolidated,  and  is  also  to  be  found  upon  the  healthy 
side  of  the  chest,  owing  to  the  increased  amount  of  air  which  is  in  these  parts  to 
compensate  for  the  area  of  consolidation;  but  careful  examination  will  reveal  the 
fact  that  the  hyperresonance  over  the  consolidated  area,  or  in  its  immediate  neigh- 
borhood, has  a  different  tone  from  that  in  the  healthy  and  compensating  lung, 
the  "boxy"  note  just  named.  I  have  frequently  been  able  to  determhie  the  pres- 
ence of  deep-seated  pneumonia  by  the  presence  of  this  sign.  By  the  aid  of  care- 
ful auscultation  and  percussion  it  is  usuallj*,  but  not  always,  possible  to  definitely 
determine  the  exact  area  of  the  lung  which  is  in^'olved. 

While  in  the  majority  of  cases  these  positive  signs  of  croupous  pneumonia  may 
be  found  in  a  more  or  less  well-developed  form,  it  is  not  to  be  forgotten  that  nega- 
tive signs  may  be  as  valuable  in  making  a  diagnosis.  That  is  to  say,  there  may 
be  absence  of  any  one  or  all  of  the  signs  just  enumerated,  and  a  total  absence  of 
vesicular  breathing.  In  such  cases,  therefore,  the  physician  must  exercise  care 
lest  the  loud  and  exaggerated  breath  sounds  of  the  healthy  part  of  the  chest  mis- 
lead him  into  thinking  that  that  portion  is  the  one  which  is  diseased. 

In  certain  instances,  in  which  the  action  of  the  heart  is  very  labored,  its  sounds 
distant,  and  the  pulse  is  small  and  insufficient,  careful  examination  may  reveal 
a  pericarditis  with  effusion,  which,  by  its  pressure,  interferes  with  the  movement 
of  the  cardiac  muscle.  This  question  as  to  whether  there  is  pressure  by  peri- 
cardial effusion  is  by  no  means  readily  determined,  because  it  frequently  happens 
that  there  is  a  marked  degree  of  cardiac  dilatation  present  at  this  time,  which 
naturally  increases  the  area  of  cardiac  dulness  downward  and  to  the  right.  Further, 
as  it  is  the  right  ventricle  which  is  most  apt  to  be  engorged,  the  area  of  cardiac 
dulness  may  be  abnormally  great  in  this  direction.  Again,  it  not  infrequently 
occurs  that  the  compensatory  fulness  of  the  healthy  lung,  if  the  disease  is  on  the  - 
left  side,  pushes  the  heart  downward  and  to  the  left,  or,  on  the  other  hand,  if  the 
right  lung  is  diseased,  the  unusual  expansion  of  the  left  lung  causes  an  extension 
of  pulmonary  resonance  to  the  right,  and  so  increased  area  of  cardiac  dulness 
is  very  effectually  masked. 

Patients  suffering  from  croupous  pneumonia  should  always  be  turned  on  the 
side  when  the  back  is  to  be  examined,  as  it  is  dangerous,  because  of  the  state  of 
the  heart,  for  them  to  sit  up  in  bed. 

The  urinary  flow  during  an  attack  of  croupous  pneumonia  is  usually  dimin- 
ished, so  that  the  passage  of  about  twenty  ounces  of  urine  in  twenty-four  hours 
may  be  taken  as  the  average.  This  urine  is  usually  highly  concentrated,  and 
contains,  as  does  the  urine  in  most  febrile  diseases,  an  increased  amount  of  urea 
and  an  excess  of  amorphous  urates  which  are  deposited  on  standing.  It  also  con- 
tains, very  constantly,  a  moderate  amount  of  albumin,  but  the  chief  peculiarity 
is  its  scanty  content  of  chlorides,  which  may  be  entirely  absent.  If  the  albumin 
be  large  in  amount,  or  casts  are  present,  the  probability  is  that  the  kidneys  were 
diseased  before  the  onset  of  the  pneumonia. 

During  the  course  of  croupous  pneumonia  the  function  of  the  alimentary  canal 
is  rarely  seriously  disturbed,  although  loss  of  appetite  because  of  the  fever  may 
be  a  marked  symptom.    The  most  important  change  in  any  part  of  the  digesti\e 


138  DISEASES  DUE  TO  A  SPECIFIC  IXFECTIO.X 

system,  if  it  may  be  so  called,  is  seen  in  the  tongue,  the  state  of  which  is  note- 
worthy, because  it  gives  some  idea  of  the  general  state  of  the  patient.  It  is,  of 
course,  ])rone  to  be  dry  and  somewhat  coated,  caused  by  the  rai)i(]  breathing 
through  the  mouth,  and  because  of  the  fever;  but  if  it  be  exceedingly  (lr\-  and  red, 
narrow  and  pointed  at  the  tip,  it  possesses  a  more  jjositive  significance  as  to  the 
general  state  of  the  patient  than  if  it  be  broad  and  moist. 

Sometimes  when  pneumonia  is  very  severe  and  j)articularly  wheii  toxemia  is 
marked,  an  excessive  degree  of  ti/mpanifes  develops,  which  is  of  evil  significance, 
in  that  it  shows  a  diminution  in  vitality  and  causes  interference  with  the  action 
of  the  lungs  and  heart  by  pressure.  I  have  seen  this  most  commonly  wiien  the 
disease  has  affected  those  addicted  to  the  excessive  use  of  alcohol. 

The  nervovs  symptoms  of  pneumonia  are  quite  various  and  depend  more  uijon 
the  previous  halsits  of  the  patient,  the  location  of  the  lesion,  and  the  degree  of 
toxemia  than  upon  any  other  causes.  Delirium  varies  in  degree  from  mind  wander- 
ing, as  the  patient  is  about  dropping  oft"  to  sleep,  to  active  mania,  during  which 
it  may  be  very  difficult  to  keep  the  patient  in  bed.  The  severity  of  the  delirium 
depends  largely  upon  the  age  of  the  patient  and  his  habits.  Alcoholic  patients 
nearly  always  have  delirium  in  a  well-marked  degree,  and  in  this  class  of  j)atients 
it  is  grave  from  a  prognostic  point  of  view  in  direct  proportion  to  its  constancy 
and  severity. 

The  type  of  the  delirium  also  varies  very  greatly  in  the  strong  and  in  the  weak. 
In  those  who  are  adj'namic  from  some  previous  disease  or  from  bad  habits,  it  is 
often  of  a  low,  muttering  type,  resembling  that  sometimes  seen  in  toxic  cases  of 
typhoid  fever,  while  in  other  instances  it  may  be  violent,  as  already  described. 

It  is  a  noteworthy  fact  that  delirium  is  particularly  prone  to  aft'ect  those  who 
suffer  from  pneumonia  at  the  apex  of  the  lung,  and  I  have  frequently  seen  in 
children,  \\-ho  had  pneumonia  at  the  apex,  a  delirium  in  which  there  seemed  to  be 
a  constant  fear  of  falling,  so  that  the  child  clutched  its  mother  ca  ery  time  it  was 
moved.  Holt's  experience,  on  the  other  hand,  leads  him  to  believe  that  the  por- 
tion of  lung  involved  has  little  influence  upon  the  production  of  nervous  sym])toms, 
and  without  doubt  the  recent  advances  in  the  study  t)f  pneumococcus  infection 
tend  to  show  that  the  toxemia  and  not  the  portion  of  lung  involved  is  resjjonsible 
not  only  for  the  marked  nervous  manifestations,  but  also  for  the  dyspnea  and 
great  acceleration  of  the  respiration.  A  peculiarity  of  the  delirium  in  many  alco- 
holic cases  is  that  they  labor  under  the  delusion  that  they  are  lying  in  a  coffin, 
and  in  their  constant  eft'orts  to  escape  greatly  exhaust  themselves.  This  form  of 
delirium  is  exceedingly  grave  from  a  prognostic  stand-point.  Delirium  is  also  very 
much  more  apt  to  be  marked  in  those  patients  who  suffer  from  toxemia  than  in 
those  in  whom  a  very  considerable  area  of  the  lung  is  involved,  but  who  ha\e, 
nevertheless,  comparatively  slight  signs  of  poisoning  by  the  toxin  of  the  ])Heunio- 

coccus. 
Very  rarely,  in  young  children,  the  onset  of  the  disease  is  characterized  by 

convulsions  instead  of  by  the  ordinary  chill. 

Insomnia  is  a  very  constant  symptom  of  croupous  pneumonia,  and  may  become 

so  persistent  as  to  require  medicinal  measures  for  its  relief,  particularly  if  it  be 

accompanied  by  great  restlessness. 
The  skin  in  an  ordinary  case  of  croupous  pneumonia  is  usually  hot  and  dry, 

but  if  the  toxic  element  in  the  case  is  very  marked,  it  may,  as  death  approaches; 

become  cold  and  clammy  and  even  bedewed  with  sweat.     In  toxic  cases,  too, 

it  is  not  infrequently  somewhat  jaundiced.     If  this  jaundice  is  associated  with 

hemoglobinuria  the  prognosis  is  almost  certainly  fatal.     On  the  other  liand,  in 

some  instances  jaundice  occurs  apparently  as  the  result  of  the  action  of  the  toxin 

upon  the  liver,  and  this  tyjie  is  not  so  grave. 

Profuse  sweating  nearly  always  occurs  at  the  time  of  crisis.     The  frequency 


CROUPOUS  PNEUMONIA  139 

with  which  herpes  appears  about  the  mufoiis  membranes  and  skin  of  the  mouth 
and  nose  has  already  been  mentioned. 

Stage  of  Resolution. — As  the  disease  approaches  tlie  period  of  crisis,  and 
sometimes  not  until  this  event  has  taken  place,  it  will  be  noted  that  the  rapidity 
of  respiration  as  compared  to  the  rapidity  of  the  pulse  more  nearly  approaches 
the  normal  ratio. 

The  first  change  which  can  be  noted  in  the  physical  signs  in  the  chest  is  the 
development  of  fine  moist  rales,  which  indicate  the  early  stages  of  re.solution. 
These  rales,  when  they  are  first  heard,  are  fine  and  crepitant,  and  closely  resemble 
those  heard  in  the  stage  of  onset;   for  this  reason  they  are  called  rales  redux. 

The  rales  in  the  chest  become  more  and  more  coarse  and  moist  in  character 
as  convalescence  is  carried  on,  and  the  speed  with  which  nature  in  an  otherwise 
healthy  individual  clears  away  the  exudate  is  quite  extraordinary,  although  usu- 
ally for  several  weeks  after  a  sharp  attack  of  croupous  pneumonia,  in\oKing  the 
surface  of  the  lung,  impaired  resonance  on  percussion  and  some  prolongation  of 
expiration  with  harsh  inspiration  can  be  demonstrated. 

The  critical  fall  of  temperature  is  often  preceded  by  a  sharp  rise,  but  when  the 
fall  occurs  it  takes  place  with  extraordinary  speed,  the  patient  being  afebrile  or 
with  a  subnormal  temperature  within  a  few  hours,  or  even  within  one  hour  (Fig. 
35).  Sometimes  this  critical  state  is  accompanied  by  a  profuse  sweat,  and  even 
collapse  may  develop,  with  urgent  dyspnea,  due  to  vasomotor  palsy  and  vascular 
relaxation. 

When  the  fall  is  quite  gradual,  extending  over  a  day,  it  is  called  a  frotracted 
crisis;    this  very  commonly  occurs  in  children. 

Often  the  day  after  crisis  the  temperature  returns  to  slightly  above  normal, 
and  sometimes  an  apparent  crisis  fails  to  reach  the  normal  and  the  fever  rises 
again.    Such  a  pseudocrisis  is  rarely  seen  after  the  fifth  day. 

The  critical  fall  of  temperature,  as  has  already  been  stated,  usually  occurs 
on  about  the  eighth  or  ninth  day  of  the  disease,  but  it  may  occur  as  early  as 
the  third  day  (Fig.  38).  In  feeble  persons  and  in  children  the  disease  sometimes 
ends  by  lysis. 

Complications. — The  complications  of  croupous  pneumonia  are  quite  numerous. 
Of  these  the  most  frequent  is  undoubtedly  pleurisy.  Indeed  it  may  be  said  that 
in  almost  every  case  of  croupous  pneumonia  a  certain  amount  of  inflammation  of 
the  pleura  exists.  As  an  illustration  of  this  fact,  the  statistics  of  Kerr  are  of  value. 
Out  of  171  cases  which  came  to  autopsy  from  croupous  pneumonia,  no  less  than 
118  showed  acute  pleuritis.  Of  these,  74  were  acute  fibrinous  pleuritis,  38  sero- 
fibrinous pleuritis,  and  6  acute  empyema.  In  Osier's  103  autopsies  pleuritis  was 
present  in  all  but  2  cases.  The  pleuritis  is  due  to  the  extension  of  the  inflammatory 
process  to  the  visceral  layer  of  the  pleura  and  to  infection  of  the  pleural  mem- 
brane by  the  pneumococcus  or  by  some  other  organism  which  is  associated  with  it. 
(See  Pleurisy.)  The  inflammation  of  the  pleura  manifests  itself  by  an  excess  of 
pain  in  the  area  involved,  by  a  friction  sound  on  auscultation,  and  later,  it  may 
be,  by  the  outpouring  of  a  considerable  amount  of  fluid  which  may  be  serous  or 
purulent.  When  the  fluid  is  serous  it  is  often  absorbed  with  a  rapidity  only  equalled 
by  the  absorption  of  the  croupous  exudate  in  the  lungs.  In  other  instances  it 
persists  and  actually  increases  in  quantity,  relief  only  being  obtained  when  the 
physician  performs  paracentesis.  In  4523  cases  of  croupous  pneumonia,  occurring 
in  twelve  large  hospitals  in  the  United  States  and  England,  pleural  eft'usion  is 
stated  to  have  occurred  in  233  cases,  a  percentage  of  5.15. 

In  still  other  cases  the  effusion  is  purulent  from  the  beginning,  and  in  this  way 
an  empyema  is  formed.  Like  all  collections  of  pus,  recovery  can  only  be  reached 
in  the  majority  of  these  cases  by  giving  vent  to  the  accumulation.  The  presence  of 
the  pus  is  usually  manifested  by  a  return,  or  maintenance,  of  the  febrile  movement 


140 


DISEASES  DUE  TO  A  SPECIFIC  INFECTION 


seen  in  the  early  stages  of  the  disease,  accompanied,  it  may  be,  by  the  ordinary 
manifestations  of  septic  poisoning,  such  as  chills,  sweats,  and  irregular  tempera- 
ture. On  the  other  hand,  all  evidences  of  the 
l)resence  of  pus  may  he  absent,  owing  to  the 
non-absorption  of  toxic  matters  through  the 
pleural  membrane.  In  10,076  cases  of  croujious 
pneumonia  collected  principally  from  the  official 
reports  of  hospitals  in  the  United  States,  Eng- 
land, and  Germany,  empyema  is  stated  to  have 
occurred  in  208  cases,  a  percentage  of  2.0G. 

In  all  cases  in  which  sj^eedy  reco\"ery  from 
croupous  pneumonia  does  not  take  place  and 
where  marked  impairment  of  resonance  persists 
upon  the  diseased  side,  pleural  effusion  or  em- 
pyema should  be  strongly  suspected,  and  the 
tests  for  the  purpose  of  determining  these 
complications  be  instituted.  Sometimes  the 
presence  of  a  pleural  effusion  is  not  suspected 
because  it  produces  no  symptoms  until,  by  the 
increase  in  its  quantity  or  the  taking  of  moderate 
exercise  by  the  patient,  it  produces  dyspnea  by 
interfering  with  respiratory  movements.  (See 
articles  on  Pleural  Effusion  and  Empyema.)  It 
is  a  noteworthy  fact  that  if  the  empyema  be 
due  to  the  pneumococcus,  the  prognosis  is  more 
favorable,  both  as  to  complete  recovery  and  to 
speediness  of  cure,  than  if  it  be  due  to  some 
other  infecting  micro-organism. 

Ilydroimeuviothorax  has  occasionally  been 
recorded  as  a  complication,  but  it  is  very  rare. 
Gangrene  and  abscess  formation  in  the  lungs 
are  two  \-ery  important  and  serious  lesions  wliich, 
fortunately,  are  not  of  common  occurrence  in 
connection  with  cases  of  croupous  pneumonia. 
Eisendrath  has  analyzed  96  recorded  cases  of 
pulmonary  abscess,  gangrene,  and  bronchiectasis 
following  croupous  pneumonia.  When  the  totals 
are  computed  as  to  percentage  of  ^eco^■ery, 
the  result  is  quite  striking,  especially  in  the 
more  acute  cases.  Of  25  cases  of  acute  single 
abscess,  96  per  cent,  recovered  and  4  per  cent, 
improved;  of  28  cases  of  acute  gangrenous  ab- 
scess, 71.4  per  cent,  recovered,  7.2  per  cent, 
improved,  and  21.4  per  cent.  died.  Of  14  cases 
of  chronic  simple  abscess,  42.8  per  cent,  recov- 
ered, 21 .4  per  cent.  im])rovcd,  and  35.8  per  cent, 
died;  while  in  26  cases  of  clironic  putrid  abscess 
with  bronchiectasis  50  per  cent,  recovered,  15.3 
per  cent,  improved,  and  34.7  per  cent.  died. 

Norris  gives  the  incidence  of  pulmonary  abscess 

as  0.5  per  cent,  in  14,214  cases  of  pneumonia. 

Eisendrath  found,  from  his  review  of  the  subject,  that  the  symptoms  usually 

came  on  after  the  crisis  and  consisted  in  a  postcritical  rise  in  temperature,  which 

then  became  remittent  in  type.     The   sputum  becomes  purulent,    and  there  is 


FiG.  38 

til'^ 

-^IlilsifiiiJiiisi 

'''■ 

1 

u 

m 

Sp-- 

^^M 

fl  - 

jPr    ■              -;-j^ 

EEi^p 

-EiBii  ■           '--'i^ 

lUf;   - 

H             '  ^^ 

z 

B 

^, 

■    ^t            ,-=nr 

hHjj 

21^ 

-]  Ih 

-' 

-;       m       ^--■^.-z 

- 

^H-    :                               

!■ 

in'^™ 

«'.< 

^*^H    TXT 

' ^m  ■ 

?-■     - 

^     ■'-^-■:^r-!: 

^M' 

K'T' 

'"  1' 

— ^1 

--          — L-^M 1 

ri::    ^ 

-^3^T:'-^    T|--..|J 

-'' 

'       "      EflpP 

5f    ^i 

2<  "F--i- 

:l:T-.-4.-ti!iS 

Chart  showing  day  of  crisis  in  acute 
croupous  pneumoni.a,  based  on  2100 
casus  in  hospitals  in  the  United  States, 
England,  and  Germany.  Tlie  black 
area  shows  the  proportion  (percentage) 
which  have  their  crisis  on  any  given 
day.  The  percentages  for  third  and 
fourth  days  are  taken  from  Aufrecht's 
statistics  alone,  as  they  could  not  be 
ascertained  in  all  the  other  cases. 


CROUPOUS  PNEUMONIA  141 

a  distressing  cough,  accompanied  by  expectoration  of  pus  in  large  quantities. 
If  the  abscess  cavities  do  not  communicate  with  a  bronchus  there  is  but  little 
expectoration.  There  is  in  all  cases  emaciation,  loss  of  appetite,  and  a  rajjid 
decline  in  strength.  If  the  abscess  becomes  chronic  there  may  be  recurrent  attacks 
of  fever,  with  profuse  expectoration. 

Physical  examination  in  these  cases  is  rather  disappointing.  The  lesions  are 
most  frequently  in  the  lower  lobes,  and  this  is  of  some  aid  in  diagnosis.  There 
are  no  typical  physical  signs,  owing  to  the  fact  that  the  cavities,  be  they  due 
to  abscess,  gangrene,  or  bronchiectasis,  may  be  near  the  surface,  or  cjuite  deeply 
situated,  and  may  or  may  not  communicate  with  a  bronchus.  Dulness,  decreased 
respiratory  murmur,  decreased  vocal  resonance,  and  decreased  fremitus  are  present 
in  the  majority  of  cases,  but  bronchial  breathing  may  be  heard.  The  most  reliable 
sign  is  the  presence  of  large,  moist  rales,  not  infrequently  metallic  in  character. 
Another  striking  feature  is  the  variability  of  the  physical  signs,  so  that  dulness 
and  then  tympany  may  alternate  at  the  same  spot.  Clubbed  fingers  develop  quite 
early,  as  do  also  symptoms  produced  by  pressure  on  the  heart,  liver,  and  spleen. 

Gangrene  must  be  suspected  when  there  occurs  a  rise  of  temperature,  a  few 
days  after  the  crisis,  and  tlie  breath  becomes  fetid.  The  sputum  is  also  fetid  and 
divides  itself  into  three  characteristic  layers.    (See  Gangrene  of  the  Lung.) 

The  frequency  of  hemoptysis  in  cases  of  gangrene  is  due  to  the  fact  that  the 
vessels  are  apt  to  pass  freely  through  the  cavity,  owing  to  the  more  rapid 
destruction  of  tissue. 

In  hroncliiedasis  following  pneumonia  the  sputum  may  be  fetid  at  times,  but 
the  odor  is  not  so  penetrating  as  in  gangrene  and  there  are  no  elastic  fibres.  There 
is  usually  a  history  of  long-continued  expectoration  of  large  quantities  of  pus. 
This,  how-ever,  is  not  characteristic,  for  the  same  history  may  be  true  of  chronic 
simple  abscess. 

Pericarditis  occurs  as  a  complication  of  pneumonia  in  about  1  per  cent,  of  the 
cases.  In  the  majority  of  instances  it  is  of  such  mild  degree  that  it  does  not  jeopar- 
dize the  patient's  life;  but  in  other  instances,  when  the  effusion  which  follows 
it  is  profuse,  it  may,  by  mechanical  pressure,  produce  great  cardiac  disability. 
When  the  accumulation  is  extensive,  a  definite  increase  in  the  area  of  cardiac 
dulness  is  usually  demonstrable.  Not  rarely,  however,  the  presence  of  this  com- 
plication may  be  unsuspected  during  the  patient's  life.  Thus,  Thayer  was  only 
made  acquainted  with  the  presence  of  pericarditis  in  one  of  his  cases  of  croupous 
pneumonia  when  the  autopsy  disclosed  a  thick  layer  of  pyogenic  membrane  over 
the  visceral  pericardium,  with  a  large  quantity  of  pus  in  the  pericardial  cavity. 
Statistics  seem  to  show  that  pericarditis  varies  in  frequency  in  from  5  to 
16  per  cent,  of  all  cases,  but  in  21,383  cases  of  croupous  pneumonia  collected  by 
me,  principally  from  the  official  reports  of  hospitals  in  the  United  States,  England, 
Germany,  and  Austria,  pericarditis  is  stated  to  have  occurred  in  only  266  cases 
of  croupous  pneumonia,  a  percentage  of  1.24.  (See  Pericarditis.)  This  closely 
corresponds  with  Norris'  statistics  of  43,722  cases  with  an  incidence  of  1.1  per 
cent. 

Endocarditis  is  a  rarer  complication  than  pericarditis;  occurring  in  about  0.5 
per  cent,  of  cases.  In  a  considerable  proportion  of  cases  the  pneumococcus  is 
responsible  for  the  lesion.  It  often  affects  the  aortic  valves,  and  it  is  generally 
of  the  ulcerative  type.  In  14,510  cases  of  croupous  pneumonia  collected  from 
several  series  of  cases  reported  by  German,  English,  and  Swedish  physicians, 
and  from  official  reports  of  hospitals  in  the  United  States,  England,  Germany, 
and  Austria,  endocarditis  is  stated  to  have  occurred  in  106  cases,  a  per- 
centage of  0.73.  Norris  in  105  cases  found  it  recorded  five  times,  while 
Sears  and  Larrabee,  in  Boston,  found  it  nine  times  in  940  cases.  Aufrecht, 
in  1500  cases,  met  with  endocarditis  only  once.    Out  of  a  total  of  5738  cases 


142  DISEASES  DUE  TO  A   SI'ECIFJC  ISFEi'TION 

of  cT()iii)<)Us  pneumonia  von  Bracli  found  less  than  0.2  ])er  cent,  coniijlicatcd 
by  endocarditis,  and  less  than  0.5  per  cent,  of  them  complicated  1)\-  ])ericarditis. 
Preble,  from  an  exhaustive  study,  places  the  average  at  1  per  cent,  in  all  cases  and 
5  per  cent,  in  fatal  cases,  and  these  figures  are  probably  correct.  Osier  found 
16  instances  of  endocarditis  in  100  fatal  cases.  Preble  believes  that  while  pneu- 
monia is  more  common  in  males  than  in  females,  endocarditis  due  to  this  infection 
is  more  common  in  females.     (See  Endocarditis.) 

Two  apparently  distinct  types  of  meningitis  are  rarely  found  as  complications 
of  crou])ous  pneumonia;  one  appearing  at  the  onset  of  tjie  disease,  the  other 
diirinf;'  tlie  acti\'e  or  postcritical  stage.  The  former  ^•ariety  is  seen  most  fre- 
quently in  children,  and  is  probably  symptomatic;  it  is  rarely  fatal,  and  tliercfore 
its  patiiology  is  somewhat  uncertain.  On  the  contrary,  meningitis  developing 
during  the  course  of  the  well-developed  infection  is  generally  the  result  of  menin- 
geal infection  and  is  very  frequently  associated  witli  endocarditis.  True  pneu- 
mococcic  meningitis  is,  however,  rarely  met  with.  Roily,  in  Leipzig  found  it  only 
five  times  in  10.50  cases  of  croupous  pneumonia.     (See  Cerebrospinal  Meningitis.) 

Numerous  cases  are  on  record  of  croupous  pneumonia  in  children  which  at 
the  onset  simulated  meningitis,  cerebrospinal  meningitis,  and  even  hemiplegia. 
But  the  subsequent  appearance  of  local  physical  signs,  the  pulse  and  respiration 
ratio,  and  the  crisis,  marked  by  a  sudden  fall  in  temperature  about  the  eighth 
day,  have  confirmed  the  diagnosis  of  croupous  pneumonia.  The  fa\orable  ter- 
mination in  many  of  the  reported  cases  has  not  permitted  an  adequate  pathological 
investigation,  although  meningitis  due  to  the  pneumoeoccus  is  well  recognized. 

Disturbance  of  the  nervous  system  over  and  above  the  signs  of  meningeal  irri- 
tation or  true  meningeal  inflammation  may  occur.  Uemiplecjia  in  croupous  jjneu- 
monia  was  recorded  by  Iluxham;  later  it  was  described  by  Charcot,  Lepine, 
and  Vulpian  as  hcmi'plegie  jmeuiiiouicpie.  It  may  occur  early  in  the  course  of  the 
disease,  or  may  not  develop  until  the  period  of  convalescence.  Such  a  jjaralysis 
has  been  observed  in  cases  as  early  in  life  as  the  eighteenth  month  and  as  late  as 
the  se\'enty-sixth  year. 

Pierre  Boulloche  has  collected  56  cases  of  paralysis  resulting  from  croujious 
pneumonia.  In  this  analysis  the  type  of  paralysis  was  found  to  be  nearly  always 
hemiplegic.  In  advanced  years  death  nearly  always  ensued  upon  this  complication, 
while  in  the  young  the  mortality  was  very  much  lower,  recovery  being  the  rule. 
In  1  case  occurring  at  the  age  of  fifty-eight  years,  hemi])lcgia,  with  aj^hasia, 
developed  during  the  course  of  the  disease,  but  ended  in  reco\er>". 

In  some  instances  the  ixtralysi.'i  i.s  vumopJcqic,  and  this  is  well  illustrated  by  a 
case  descrilied  by  Boulloche  in  a  patient  thirty-two  years  of  age,  who  from  the 
onset  of  the  disease,  was  delirious  and  who  presented  a  typical  right-sided  croup- 
ous pneumonia.  Paralysis  of  the  right  arm  and  right  side  of  the  face  was  dis- 
covered upon  the  sixth  day  of  the  disease.  IMovements  of  the  right  leg  were 
entirely  retained.  There  was  aphasia,  but  no  loss  of  consciousness,  neither  was 
there  any  disturbance  of  sensibility;  twelve  days  later  the  fever  had  subsided, 
the  aphasia  had  diminished  considerably,  and  the  muscles  of  the  face  were  less 
drawn.  Sensation  in  the  pharynx  returned  and  a  day  later  the  aphasia  disapjDeared. 
The  facial  paralysis  passed  ofi';  the  relative  strength  of  the  two  arms  showed  only 
a  decrease  of  10  degrees  in  the  affected  side,  and  at  the  expiration  of  twenty  days 
the  monoplegia  had  entirely  disappeared. 

Tran.iiinrij  aphasia  is  a  comiiliciition  reported  by  Chantemesse.  This  observer 
has  found  that  aphasia  usually  occurs  about  the  second  or  third  day  of  the  disease, 
,  that  it  is  ordinarily  preceded  by  headache  and  giddiness,  e\en  to  the  verge  of  syn- 
cope; in  some  cases  numbness  or  a  sensation  of  pricking  in  the  right  side  of  the 
face  and  right  arm  is  experienced;  in  other  cases  it  may  set  in  abruptly  without  loss 
of  consciousness  or  become  manifest  after  a  typical  apoplectiform  seizure.    The 


CROUPOUS  PNEUMONIA  143 

characteristics  of  the  speech  impairment  do  not  (litter  from  those  (Jepen<lent  ii])oii 
an  organic  lesion  of  the  third  frontal  convolution  upon  the  left  side  of  the  brain. 
The  paralysis  may  involve  the  entire  right  side  of  the  body,  but  usually  only  the 
inferior  portion  of  the  right  side  of  th£  face,  the  right  half  of  the  tongue,  and  the 
right  superior  extremity  are  afi'ected;  as  a  rule,  sensation  and  the  reflexes  are  not 
altered.  In  pronounced  cases  the  paralyzed  parts  may  be  the  seat  of  increased 
redness  and  an  edema,  which  is  more  or  less  circumscribed  and  increased  by  heat. 
The  phenomena  persist  commonly  for  from  a  few  hours  to  a  few  days,  and  seem 
in  no  way  to  influence  the  primary  disease. 

It  is  doubtful  whether  the  clinical  picture  and  pathology  of  these  cases  of  transi- 
tory aphasia  dift'er  in  any  particular  from  many  of  the  cases  already  described  as 
hemiplegic.  They  probably  represent  the  cases  in  which  no  lesion  is  found  post- 
mortem. 

Softening  of  the  brain  has  occurred  in  some  cases.  In  one  case,  reported  by 
Suckling,  it  was  due  to  thrombosis  of  the  basilar  artery,  and  thrombosis  of  the 
circle  of  Willis;  with  plugging  of  the  superficial  arteries  of  the  left  hemisphere. 
While  these  lesions  have  been  found  as  the  causative  agents  in  producing  hemi- 
plegia, there  are  also  cases  on  record  in  which  the  autopsy  has  been  negative. 
In  other  M'ords,  hemiplegia  with  lesions  and  hemiplegia  without  lesions  occurs. 
In  the  former  case  hemiplegia  results  from  either  meningitis  or  softening,  or  is 
due  to  thrombosis  or  embolism.  In  the  second  class  the  paralysis  is  like  that  of 
diphtheria — that  is,  of  the  toxic  type.  It  is  important  to  remember  that  it  is  pos- 
sible for  hemiplegia  to  develop  in  pneumonia  without  there  being  any  relationship 
between  the  two  conditions. 

The  fact  that  these  marked  nervous  manifestations  sometimes  come  on  early 
in  an  attack  of  croupous  pneumonia  emphasizes  the  importance  of  examining  the 
chest  in  all  cases  of  paralysis,  not  only  because  pneumonia  is  competent  to  produce 
hemiplegia  or  other  localized  palsy,  but  also  because  these  conditions  are  quite 
competent  to  produce  secondary  pulmonary  lesions.  In  other  words,  pulmonary 
lesions  may  be  the  cause  of  hemiplegia,  and  hemiplegia  may  be  the  indirect  cause 
of  croupous  pneumonia. 

Neuritis,  occurring  chiefly  as  a  sequel  to  croupous  pneumonia,  has  been  de- 
scribed by  several  observers.  These  cases  resemble  those  described  by  Boulloche 
as  paralysis  with  muscular  atrophy,  coming  on  during  the  period  of  couA'alescence. 

Until  Weichselbaum  isolated  the  pneumococcus  from  the  pus  aspirated  from 
the  synovial  sac  of  joints  involved  during  the  course  of  croupous  pneumonia, 
the  occurrence  of  arthritis  was  considered  a  coincidence,  but  since  1888  arthritis 
and  osteoarthritis  have  been  recognized  as  being  not  rarely  due  to  a  pneumococcus 
infection.  Herrick  has  collected  52  cases  from  the  literature  of  the  subject,  includ- 
ing some  of  his  own,  but  it  is  interesting  to  note  that  in  2292  cases  of  pneumonia 
collected  by  me,  treated  by  various  Swiss  and  German  physicians,  only  2  cases 
of  arthritis  occurred. 

In  regard  to  the  frequency  with  which  different  joints  are  involved  in  this  com- 
plication, the  following  quotation  from  Herrick's  paper  is  of  interest:  "In  2.3 
of  52  cases  the  upper  extremities  alone  were  involved;  in  18  cases  the  joints  of 
the  lower  extremities  alone;  in  11  there  was  involvement  of  joints  of  both  the 
upper  and  lower  extremities.  These  figures  show  a  slight  preponderance  in  favor 
of  limitation  to  the  upper  extremity,  but  so  slight  that  little  or  no  significance 
can  be  attached  to  it.  In  fact,  the  knee  seems  to  be  the  joint  oftenest  affected, 
being  involved  in  22  of  the  52  cases,  in  3  of  which  both  knees  were  affected,  so  that 
out  of  a  total  of  84  joints  the  knee  makes  up  25,  or  about  30  per  cent.  The  involve- 
ment of  other  joints  was  as  follows:  the  sternoclavicular,  eight  times;  the  shoulder, 
twelve  times;  the  elbow,  nine  times;  the  wrist,  eight  times;  the  metacarpo- 
phalangeal, twice;     the  hip,  three  times;   the  knee,  twenty-five  times;   the  ankle, 


144  DISEASES  DUE  TO  A  SPECIFIC  INFKCTIOS 

three  times;  the  mctatarsopJialangeal,  three  times.  The  arthritis  was  monarti- 
cular in  thirty-two  instances,  or  61 .5  per  cent,  of  the  cases.  The  joints  thus  soHtarily 
involved  were:  shoulder,  ten  times;  knee,  nine  times;  wrist,  fi\e  times;  elbow, 
twice;  sternoclavicular,  four  times;  and  the  hip,  ankle,  metacarpophalangeal, 
and  metatarsophalangeal,  each  once.  Of  the  remaining  cases  there  were  involved: 
two  joints,  nine  times;  three  joints,  four  times;  four  joints,  once;  more  than 
four,  three  times."  These  figures  bring  out  the  fact  that  the  larger  joints  are 
more  often  afl'ected  than  the  smaller  ones. 

The  process  in  subacute  cases  is  sometimes  highly  destructive  to  the  joint. 

It  is  a  noteworthy  fact  that  the  prognosis  as  to  life  is  grave,  the  mortality  amomit- 
ing  to  65  per  cent.,  chiefly  because  this  lesion  is  associated,  as  a  rule,  with  affec- 
tions of  the  serous  membranes  elsewhere,  and  particularly  in  the  endocardimn. 

Venous  thrombosis  is  an  exceedingly  rare  complication  of  pneumonia.  Steiner 
could  find  only  38  cases  recorded,  and  reports  3  of  his  own.  In  27  of  these  the 
thrombosis  occurred  during  convalescence.  In  1  case  it  occured  at  the  time  of 
crisis  and  in  4  during  the  course  of  the  disease;  and  in  the  cases  collected  by  him 
the  lower  extremities  were  always  involved.  The  left  lower  extremity  was  involved 
in  IG  cases;  the  right  in  10,  and  both  legs  in  7.  The  more  frequent  invohcment 
of  the  left  extremity  is  attributable  in  this  disease,  as  in  typhoid  fe\"er,  to  the  greater 
length  and  obliquity  of  the  left  common  iliac  vein  and  its  passage  beneath  the  right 
common  iliac  artery.  Adding  Steiner's  3  cases  to  the  38  which  he  found  in  the 
literature,  making  41,  we  find  that  recovery  occurred  in  25,  death  in  9,  and  that 
no  definite  information  is  given  of  7. 

Gangrene  of  a  limb  due  to  arterial  thrombosis  or  embolism  has  been  recorded 
by  Zuppin,  Benedict,  Grimm,  and  Nielsen. 

Parotitis,  while  a  rare  complication  of  croupous  pneumonia,  may  occur,  and 
not  infrequentlj'  goes  on  to  suppuration.  ]\Iost  of  the  cases  so  far  reported  have 
not  been  due  to  the  pneumococcus,  but  to  the  staphylococcus  or  streptococcus. 

Otitis  media  is  quite  a  common  complication  of  croupous  pneumonia  in  children, 
the  infection  taking  place  through  the  Eustachian  tube. 

A  relapse  in  croupous  pneumonia  is  practically  never  met  with,  but  an  extension 
to  adjacent  parts  of  the  lung  and  recurrence  is  very  common. 

Varieties  of  Croupous  Pneumonia. — Croupous  pneumonia  varies  much  in  its  char- 
acter with  the  condition  of  the  patient  that  is  attacked.  I  have  already  men- 
tioned the  type  which  occurs  in  jjersons  who  are  addicted  to  the  excessive  use  of 
alcohol.  In  other  individuals  the  disease  is  accompanied  by  such  marked  symp- 
toms of  adynamia  that  the  patient  seems  to  be  suffering  from  tj'phoid  fever,  so 
far  as  his  general  symptoms  are  concerned.  This  form  is  known  as  typhoid  pneu- 
monia, in  that  it  is  typhoid  in  character;  but  this  term  does  not  necessarily  imply 
that  typhoid  infection  is  associated  with  that  by  the  pneumococcus.  On  the  other 
hand,  it  sometimes  happens  that  patients  suffering  from  typhoid  fc\-er  also  lla^•e 
a  pneumococcic  infection  of  the  lung,  and  this,  of  course,  is  another  form  of  so- 
called  typhoid  pneumonia.  True  croupous  pneumonia  also  occasionally,  although 
rarely,  complicates  malarial  fever,  acute  articular  rheumatism,  and  pulmonary 
tuberculosis.  Sometimes,  too,  it  occurs  as  a  sequel  to  the  administration  of  ether 
as  an  anesthetic.  This  is  probably  due  primarily  to  the  chilling  and  irritation  of 
the  lung  by  the  drug,  and  secondarily  to  the  inhalation  of  pneumococci  from  the 
mouth,  where,  as  already  stated,  they  arc  almost  constantly  present  even  in  healthy 
persons. 

Diagnosis. — Croupous  pneumonia  is  to  be  carefully  differentiated  from  acute 
tuberculous  pulmonary  infection,  from  lobular  or  catarrhal  pneumonia,  from 
infarction  of  the  lung,  accompanied  by  bloody  expectoration,  due  to  cardiac 
di.sease,  from  pleurisy  with  effusion,  and  from  chronic  inflammation  of  the  pleura, 
with  marked  thickening  of  that  serous  membrane.    Finally,  it  is  to  be  separated 


CROUPOUS  PNEUMONIA  145 

from  hypostatic  congestion  due  to  cardiac  feebleness  arising  in  the  course  of  a(  ule 
diseases  or  chronic  ailments. 

The  differentiation  from  acute  pneumonic  phthisis  may  he  quite  impossible 
until  the  development  of  profuse  sweating,  a  feeble  and  rapidl\'  acting  heait, 
and  the  appearance  of  yellow  elastil'  tissue  and  tubercle  bacilli  in  the  s])utum 
takes  place.  From  pulmonary  infarction  it  is  to  be  separated  by  careful  examina- 
tion of  the  heart,  which  may  reveal  valvular  lesions,  and  by  the  fact  that  in  infarc- 
tion the  onset  of  pulmonary  disorder  is  instantaneous  and  the  sputum  contains 
bright  blood.  From  pleural  effusions  it  is  differentiated  by  the  development  of 
the  physical  signs  of  that  condition.  (See  Pleurisy,  with  P^ffusion.)  Hypostatic 
congestion  of  the  lungs  is  discovered  by  the  character  of  the  sputum,  which  may 
be  blood-stained,  although  it  is  usually  serous,  by  the  fact  that  the  lesions  are 
usually  bilateral,  and  also  by  the  fact  that  the  heart  is  primarily  very  weak. 
Catarrhal  or  lobular  pneumonia  is  recognized  by  the  absence  of  the  tyjjical  rusty 
sputum,  by  the  history  of  the  presence  of  some  primary  disease  prior  to  the 
onset  of  the  pneumonic  consolidation,  and  by  the  wide  distribution  of  the  lesions 
and  the  more  diffuse  physical  signs. 

An  important  aid  to  the  diagnosis  of  croupous  pneumonia  is  the  increase  in 
the  number  of  the  polymorphonuclear  white  cells,  the  so-called  leukocytosis  of 
croupous  pneumonia.  In  this  disease,  in  most  instances,  the  increase  in  these 
particular  white  cells  causes  a  leukocytosis  of  from  18,000  to  30,000.  A  count 
below  10,000  may  mean  a  mild  attack  but  more  often  is  found  in  a  case  of  unusual 
severity  in  which  the  patient  is  not  reacting  well  to  the  infection.  In  the  latter 
cases  the  prognosis  is  bad. 

The  blood  serum  of  these  cases  is  capable  of  causing  agglutination  of  the  ijneu- 
mococcus  and  the  degree  of  agglutinative  power  seems  to  be  greatest  about  the 
time  of  crisis,  but  there  are  technical  difficulties  about  the  test  which  render  it  of 
little  value  in  diagnosis. 

It  is  of  the  greatest  importance  that  the  severe  pain  sometimes  described  as 
being  in  the  belly  at  the  onset  of  pneumonia  is  not  mistaken  for  that  due  to  ap- 
pendicitis. Cases  frequently  occur  in  which  pain  due  to  thoracic  disease  is  thought 
to  be  abdominal,  particularly  if  the  base  of  the  lung  is  involved.  The  presence 
of  pain  or  pressure  over  McBurney's  point,  of  some  fixation  of  the  abdominal 
muscles,  and  of  a  high  leukocyte  count  may  be  so  misleading  as  to  lead  the 
physician  to  operate  for  disease  of  the  appendix. 

It  is  characteristic  of  croupous  pneumonia  that  the  chlorides  in  the  urine  are 
greatly  decreased. 

The  physician  should  always  be  on  his  guard  lest  he  overlook  a  "central"  or 
deep-seated  pneumonia,  which  presents  no  marked  physical  signs. 

Prognosis. — The  prognosis  in  croupous  pneumonia  is  always  to  be  governed 
by  the  recollection  of  the  fact  that  its  mortality  in  adults  is  usually  high,  and 
again  by  the  condition  and  habits  of  the  patient.  It  is  to  be  remembered  that 
the  prognosis  in  a  case  of  croupous  pneumonia  is  grave  in  direct  proportion  to 
the  years  of  the  patient.  In  young  children,  unless  it  is  complicated  by  some  grave 
accident,  the  disease  has  a  very  low  mortality.  By  far  the  greater  number  of 
children  recover,  whereas  in  advanced  years  the  disease  is  exceedingly  fatal  (Fig. 
39).  As  an  illustration  of  how  low  the  mortality  may  be  when  young,  healthy 
persons  are  affected  by  the  disease  and  come  under  skilful  treatment  early  in  its 
course,  Osier  states  that  in  40,000  cases  occurring  in  the  German  army  the  mortality 
was  only  3.6  per  cent. 

If  the  mortality  percentage  is  based  upon  the  total  number  of  deaths  from  this 
disease,  it  may  be  stated  to  be  as  high  as  from  25  to  40  per  cent. ;   but  if,  on  the 
other  hand,  those  cases  which  would  naturally  fall  victims  to  its  ravages  are  ex- 
cluded, the  mortality  is  probably  only  about  10  per  cent.,  if  we  accept  the  large_ 
10 


146 


DISEASES  DUE  TO  A  SPECIFIC  INFECTION 


statistics  of  Townsend  and  Coolidge,  who  excluded  patients  over  fifty  years  of 
age  and  those  who  were  delicate  or  suffering  from  some  other  disease  j)rimarily 
present.  In  private  practice  the  mortality  varies  from  6  to  IS  per  cent.  Statistics 
are  of  little  value  because  all  forms  of  pulmonary  consolidation  are  apt  to  be 
reported  as  pneumonia  and  because  they  fail  to  deal  with  the  primary  state  of 


< 

z 

< 

S  o 

z 

Z) 

5  2 

t  i 

1-   < 

Z    o 

5  z 
1-  < 

m  - 

Z    o 

5  i 

1-  < 

Ul    o 

Z    o 

uj  .J- 
to  " 

Z    o 

H 

ul    o 

Z    o 

5  z 

H    < 
Ul    o 

Z    o 

11 

57 
'66 

4-' 

1 

1 

,'' 

5:* 

f 

:i< 

53 

' 

62 

61 

M 

Ml 

1 

iiS 

17 

— 

/ 
/ 

- 

46 

, 

H 

i  1. 

:  1 

1  1  1 

i'S 

1 

ii 

1 

11 

] 

1 

ill 

;is 

T 

1 

1    ' 

3x 

1 

1 



—  - 

30 

3i 

j 

3o 

1 

:12 

1 

30 

1 

1 

2U 
2K 

- 

-      ^ 

-   / 

27 

1 

|l 

aii 

1 

26 
21 

- 

r 

23 
22 

J- 

/A 

21 

,'/ 

y 

•M 

f 

s, 

\i 

- 

-        i 

\ 

-      - 

17 

i 

\ 

lU 

1 

ik 

-r- 

/  1 

s 

13 

/  ■' 

, , 

12 

/ 

1 1 1 

10 

- 

/ 

J 

1 

LLl 

T 

-^-^ 

^Y 

1 

0 
S 

^ 

/ 

/' 

"0 

/ 

/ 

\ 

1 

/ 

--' 

3 

2 

1 

Tr 

-—  -J 

ri-u 

M 

Ti 

'  1  1 

1  1 

f"h;irt  showing  the  morbifhty  and  mortality  of  croupous  pneumonia  at  different  ages,  based  on  868 
eases  in  the  Presbyterian  Hospital,  New  York,  and  Guy's  Hospital,  London.  Solid  line,  morbidity; 
dotted  line,  mortality. 


the  patient.  Thus  in  alcoholic  patients,  diabetic  patients,  or  those  suffering  from 
nephritis  the  proposition  is  far  more  grave  than  in  patients  in  whom  the  disease 
is  primary,  not  secondary. 

Aside  from  advanced  years,  the  other  causes  which  render  the  prognosis  espe- 
cially grave  are  renal  disease,  with  secondary  cardiovascular  lesions,  alcoholism, 
and  diabetes.    Indeed,  these  three  states  contribute  a  very  large  proportion  of 


CROUPOUS  PNEUMONIA  147 

the  number  of  cases  which  suffer  from  this  malady,  and  also  the  largest  proportion 
of  deaths  in  the  statistics. 

It  is  stated  by  some  authors  that  any  history  of  previous  ill  health  distinctly 
increases  the  danger  from  croupous  pneumonia.  While  this  may  be  true  in  certain 
cases  in  which  vitality  is  greatly  depressed,  it  is  also  a  fact  that  nneumonia  in 
chronic  invalids  frequently  runs  a  comparatively  mild  course  unless  the  cause  of 
their  ill  health  be  renal  or  cardiac  disease,  whereas  it  may  speedily  produce  death 
in  robust,  powerful,  muscular  men,  who  frequently  succumb  to  its  ravages  far  more 
rapidly  than  more  lightly  built  and  apparently  delicate  individuals.  Indeed,  the 
physician  of  experience  dreads  the  onset  of  this  disease  in  powerful,  well-developed 
men  much  more  than  when  it  attacks  those  who  are  less  given  to  active  exercise 
and  feats  of  physical  strength.  Stout  persons  also  seem  much  more  susceptible 
to  the  lethal  influences  of  the  disease  than  those  who  are  lean.  This  probably 
depends  upon  two  causes:  first,  the  heart  and  lungs  may  be  overweighted  by  fat, 
and  second,  such  persons  usually  contain  in  their  tissues  a  large  amount  of  serum, 
in  which,  perhaps,  specific  micro-organisms  find  an  opportunity  to  grow  and  to 
prepare  their  toxic  product  in  large  quantity. 

Cases  of  croupous  pneumonia  characterized  by  moderately  high  fever  do  not 
possess  the  unfavorable  outlook  of  other  diseases  which  suffer  from  hj'perpyrexia ; 
that  is,  a  temperature  in  the  neighborhood  of  106°.  On  the  other  hand,  it  not 
infrequently  happens  that  cases  running  a  temperature  course  varying  from  101° 
to  102°  are  more  severe  as  to  toxemia  than  those  which  range  in  the  neighborhood 
of  10.3°  or  104°,  or  even  105°  for  a  short  time.  If,  with  the  drop  in  temperature, 
which  occurs  at  crisis,  the  general  condition  of  the  patient  does  not  markedly 
improve,  the  prognosis  is  bad.  If  in  place  of  the  ordinary  rusty  sputum  it  is  of 
the  color  of  prune-juice,  it  is  usually  considered  that  the  disease  is  malignant. 
On  the  other  hand,  as  stated  by  Sir  William  Jenner,  the  brighter  the  sputum,  the 
less  the  weight,  the  better  the  prognosis. 

An  important  prognostic  point  in  any  given  case  is  the  degree  of  toxemia  which 
is  present.  In  other  words,  the  prognosis  depends  not  so  much  upon  the  area  of 
lung  which  is  involved  as  it  does  upon  the  quantity  of  toxic  material  which  the 
infecting  micro-organisms  seem  to  be  producing.  Again  and  again  death  occurs 
in  apparently  otherwise  healthy  individuals  who  present  a  small  area  of  consolidated 
lung  and  almost  no  typical  signs  of  pneumonia,  but  who  are  apparently  overwhelmed 
by  great  toxemia. 

An  absence  of  leukocytosis  in  a  case  of  croupous  pneumonia  usually  posesses 
an  e\al  import,  since  it  seems  to  indicate  a  degree  of  toxemia  with  which  the  system 
of  the  patient  finds  it  difficult  to  deal. 

A  \'ery  -valuable  prognostic  sign  is  the  ratio  of  blood-pressure  to  pulse  rate. 
If  the  blood-pressure,  in  an  otherwise  healthy  patient,  expressed  in  millimeters 
of  mercury  is  well  above  the  pulse  rate  per  minute  the  patient  is  doing  well. 
If  the  pressure, so  expressed  and  the  pulse  rate  are  identical  numerically  the 
patient  is  in  great  danger.  If  the  pulse  rate  is  greater  than  the  blood-pressure 
expressed  in  millimeters  of  mercury  he  will  almost  certainly  die.  Thus  a  pressure 
of  1.30,  pulse  rate  90,  is  equivalent  to  safety.  Pressure  110  and  pulse  rate  110  is 
equivalent  to  great  danger.  Pressure  100,  pulse  rate  120,  is  usually  followed  by 
death,  if  maintained. 

Treatment. — The  treatment  of  a  case  of  croupous  pneumonia  varies  greatly 
with  the  condition  of  the  patient  who  is  suffering  from  the  disease.  When  it 
attacks  the  stout  and  robust,  the  only  duty  of  the  physician,  in  a  large  number  of 
instances,  is  to  watch  the  patient's  symptoms;  to  insist  upon  rest  in  bed  in  a 
well-ventilated  and  quiet  room,  and  to  administer  a  sufiicient  quantity  of 
Dover's  powder,  or  morphine  to  relieve  pain,  if  that  symptom  is  excessive.  If, 
on  the  other  hand,  the  patient  is  one  who  has  been  addicted  to  the  use  of  alcohol 


148  DISEASES  DUE  TO  A   SPECIFIC  ISFECTIOS 

in  excess,  whiskey  or  brandy  should  be  given  him  in  amounts  varying  with  the 
quantity  which  he  has  been  accustomed  to  ingest  daily.  Not  only  does  his  s\  s- 
tein  require  tlie  eti'ects  produced  l)y  this  drug,  but  its  use  is  also  necessary  to 
prevent  the  rapid  development  of  delirium  tremens,  which  is  a  most  fatal  compli- 
cation in  these  cases.  An  acti\e  stimulation  is  also  usually  required  in  many  cases  of 
croupous  pneumonia  in  which  the  patient  is  just  recovering  from  some  other  severe 
infection,  such  as  typhoid  fever. 

It  is,  however,  a  fatal  mistake  to  think  that  every  ])atient  suftcring  from  this 
disease  .should  be  stimulated.  The  i)hysician  should  always  bear  in  mind  the 
important  rule  not  to  meddle  with  the  course  of  the  disease  unless  sym])toms 
are  so  pressing  as  to  require  interference.  There  can  be  no  d()ul)t  that  one  of  the 
best  stimulants  in  many  cases  of  croupous  pneumonia,  accustomed  to  alcoiiol, 
is  alcohol,  in  some  form  which  will  agree  well  with  the  .stomach.  The  dose  of 
this  drug  in  the  form  of  whiskey  or  brandy  must  depend  upon  tlie  needs  of  the 
individual.  Rarely  will  any  patient  require  more  than  S  to  12  ounces  in  the  twenty- 
four  hours,  and  many  will  do  best  on  much  less  than  tliis.  \'aiuable  adjuvants  to 
alcohol  are  the  aromatic  spirit  of  ammonia,  given  in  the  dose  of  30  minims,  well 
diluted,  every  two  or  three  hours;  and  should  any  sign  of  acute  cardiac  failure 
develop,  HofTmann's  anodyne,  in  the  dose  of  1  or  2  drachms,  in  water,  every  hour 
or  two,  is  an  in\'aluable  remedy. 

For  a  condition  of  acute  cardiac  weakness,  the  value  of  strychnine  should 
also  be  borne  in  mind.  Under  these  circumstances  it  is  often  invaluable,  and  if 
need  be  may  be  given  in  full  dose,  frequently  repeated,  by  a  hypodermic  needle, 
until  the  patient  rallies.  Usually  -^  to  ^V  Rrain,  repeated  once  or  twice,  at  an 
interval  of  two  or  three  hours,  approximates  the  proper  dose.  At  the  present  time 
it  has  become  fashionable  for  physicians  to  administer  strychnine  as  a  cardiac 
stimulant  throughout  the  whole  course  of  pneumonia.  This  is  an  abuse  of  a  good 
remedy.  Strychnine  is  not  a  direct  cardiac  stimulant.  It  increases  the  activity 
of  the  heart  by  rallying  the  nervous  system  and  acting  as  an  indirect  whip  to 
the  circulation.  If  its  use  is  persisted  in  it  soon  loses  its  so-called  stimulant  effects, 
and  is  apt  to  produce  a  condition  of  nervous  irritation,  particularly  in  the  aged, 
which  may  be  quite  distressing.  Its  constant  use  deprives  the  physician  of  a 
valuable  remedy  for  meeting  critical  moments  in  the  course  of  the  di.sease. 

The  value  of  digitalis  for  the  purpose  of  combating  cardiac  failure  in  acute 
croupous  pneumonia  has  been  questioned.  It  is  a  well-known  fact  that  digitalis 
loses  a  large  amount  of  its  power  over  the  heart  in  the  presence  of  high  fever; 
and  fever  is  nearly  always  a  marked  symptom  in  this  disease.  It  is  also  coming 
to  be  a  well-recognized  fact  that  digitalis  is  of  little  value  in  those  cases  in  which 
the  heart  muscle  has  undergone  degenerative  change,  and  the  toxemia  of  pneumonia 
often  produces  such  alterations  in  tjie  muscle  fibres  of  this  viscus.  In  eases  in  which 
there  is  marked  vascular  relaxation  and  cardiac  dilatation,  I  have  known  it  to  do 
good  when  given  in  a  few  large  doses,  particularly  if  strychnine  and  atrojjine  were 
simultaneously  administered.  Although  it  is  a  drug  which  contracts  tlie  blood- 
vessels, the  vasomotor  dilatation  or  relaxation  of  advanced  pneumonia  is  often  so 
marked  that  digitalis  seems  to  be  unable  to  raise  the  arterial  pressure,  and  I  am 
convinced  that  in  many  instances  death  occurs  more  largely  because  of  the  relaxed 
condition  of  the  bloodvessels  than  by  any  direct  effect  of  the  disea.se  upon  the 
heart.  When  I  use  digitalis,  therefore,  I  am  in  the  habit  of  prescribing  5  or  10 
drops  of  a  physiologically  tested  tincture  every  eight  or  six  hours,  and  the  same 
quantity  of  tincture  of  belladomia  every  three  or  four  hours,  in  order  that  the  bella- 
donna ma>-  increase  the  tone  of  the  vessels.  This  treatment,  however,  is  rarely 
instituted  before  the  fifth  or  sixth  day,  or  at  the  ai)i3roach  of  crisis. 

If  cardiac  failure  is  the  result  of  cardiac  dilatation  due  to  the  obstruction  of 
the  flow  of  blood  through  the  lung,  digitalis  may  be  ad^"antageous,  but  when 


CROUPOUS  PNEUMONIA  149 

the  cardiac  weakness  is  due  to  toxemia  it  is  probahly  of  little  value,  and  ii  a  clot 
has  formed  in  a  cardiac  cavity  it  is  manifestly  useless.  Sometimes  when  the  fever 
is  high  and  digitalis  fails  to  act,  it  is  well  to  aid  its  effect  by  c|nieting  the  heart 
through  the  application  of  an  ice-bag  placed  upon  the  precordium.  I  have  also 
known  the  reduction  of  temperature  by  the  local  ajjj)lication  of  the  ice-bag  and  by 
cool  sponging  of  tiie  body,  with  friction,  to  be  followed  b\-  the  manifestation  of 
a  distinct  digitalis  influence.  If  moderate  doses  of  5  to  10  minims  of  a  physiologic- 
ally tested  tincture,  three  or  four  times  a  day,  fail  to  produce  good  effects  under 
these  circumstances,  I  feel  quite  confident  that  larger  ones  will  not  be  of  any  value. 

Should  sudden  collapse  come  on,  a  hypodermic  injection  of  strychnine  and 
atropine  should  be  given,  and  it  may  be  wise  to  introduce  under  the  skin,  by 
hypodermoclysis,  a  pint  of  normal  saline  solution.  The  normal  saline  solution, 
under  these  circumstances,  cannot  do  much  good  directly  because  the  relaxation 
of  the  bloodvessels  is  so  great  that  even  if  it  is  absorbed  its  influence  will  not  be 
felt,  but  it  forms  a  reservoir  from  wdiich  it  will  be  slowly  absorbed  and  so  flush 
the  kidneys. 

The  value  of  saline  infusion  also  depends  upon  the  degree  of  toxemia  which 
is  present  and  upon  the  activity  of  the  kidneys.  If,  in  a  given  case,  the  urinary 
secretion  is  scanty  and  toxic  symptoms  develop,  a  pint  of  normal  salt  solution  may 
be  given  by  hypodermoclysis  every  six  or  eight  hours  for  twenty-four  hours  with 
advantage.  If,  on  the  other  hand,  the  pneumonia  complicates  renal  disease,  and 
there  is  any  tendency  to  edema  of  the  subcutaneous  tissues,  this  method  of  treat- 
ment may  be  disadvantageous,  in  that  it  tends  to  increase  the  dropsy,  and  perhaps 
increase  the  tendency  to  pulmonary  edema.  As  marked  toxemia  is  usually  asso- 
ciated with  renal  inactivity,  this  method  of  treatment  should  be  borne  in  mind. 
Direct  infusion  of  a  saline  solution  into  a  vein  is  probably  not  advisable  in  the 
majority  of  cases,  since  it  is  usually  absorbed  with  sufficient  rapidity  from  the 
subcutaneous  tissues. 

When  the  skin  becomes  relaxed  and  bedewed  with  sweat,  atropine  is  often  a 
life-saving  drug. 

In  cases  in  which  the  heart  is  laboring,  where  there  is  evidence  of  dilatation  of 
its  right  cavity  with  pulsating  jugulars  and  other  evidences  of  venous  stasis,  free 
venesection  may  be  practised  with  advantage,  and  sometimes  gives  wonderful 
relief;  but  in  cardiac  failure  without  these  signs  of  venous  obstruction,  venesection 
is  practically  of  no  value  whatever. 

The  value  of  inhalations  of  oxygen  gas  is  problematical.  I  always  employ  them 
because  they  seem  to  give  comfort  both  to  the  patient  and  his  friends.  The  oxy- 
gen should  not  be  given  through  an  inhaler,  but  be  allowed  to  escape,  through  the 
opening  of  the  rubber  tube  or  glass  nozzle,  about  the  lips  or  nose  of  the  patient, 
for  the  ordinary  individual  who  is  suft'ering  from  dyspnea  in  this  disease  will  not 
permit  one  of  his  nostrils  to  be  blocked  or  his  mouth  closed  by  such  an  inhaler, 
as  his  desire  for  ordinary  air  is  too  great.  If  the  dyspnea  is  due  to  toxemia 
the  oxygen  is  probably  useless.  If  it  is  due  to  a  large  area  of  the  lung  being  inca- 
paciated  by  consolidation,  it  is  conceivable  that  oxygen  can  do  great  good. 

The  treatment  of  the  fever  during  the  course  of  croupous  pneumonia  is  not 
of  as  great  importance  as  it  is  during  the  course  of  a  more  prolonged  malady,  like 
typhoid  fever.  Indeed,  there  is  some  evidence  to  show  that  fever  within  moderate 
bounds  may  be  an  efl:ort  on  the  part  of  the  organism  to  protect  itself  from  the 
infecting  germs.  If  the  temperature  does  not  exceed  102.5°  to  103°,  antipyretic 
measures  need  not  be  instituted,  although  sponging  the  patient  with  tepid  or  cool 
water  three  or  four  times  a  day  will  control  the  temperature  somewhat,  allay 
peripheral  nervous  irritation,  keep  the  skin  clean,  and  often  produce  sleep.  These 
spongings  are,  therefore,  useful  in  the  ordinary  case  of  pneumonia  with  a  tem- 
perature of  103°  or  more,  but  they  are  not  to  be  carried  out  with  the  same  vigor, 


150  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

cither  as  to  the  activity  of  the  rubbing  or  degree  of  cold,  as  is  employed  in  typhoid 
fever,  for  the  temperature,  as  a  rule,  does  not  resist  the  cold,  and  if  it  is  ajjplied  too 
freely  the  patient  may  be  thrown  into  collapse  by  a  sudden  fall  of  fever.  Nearly 
every  case  of  acute  pneumonia  will  be  benefited  if  an  ice-bag  is  kejit  a])plied  to  the 
head,  and  if  the  action  of  the  heart  is  very  rapid  when  the  fever  is  high  an  ice- 
bag  over  the  prccordium,  is  often  advantageous. 

The  administration  of  antipyretic  drugs  to  patients  suffering  from  ])neinnonia 
is  alisi)lutely  inexcusable.  In  the  first  place,  antii^yresis  by  drugs  is  rarely  if  ever 
needed.  In  the  second  place,  there  is  overwhelming  clinical  and  cx]jcrimciital 
evidence  to  show  that  the  use  of  these  drugs  materially  diminishes  the  vital  resist- 
ance of  the  patient,  decreases  the  ability  of  his  blood  to  convey  oxygen  to  his 
tissues,  reduces  its  ability  to  destroy  infecting  micro-organisms,  lowers  vascular 
tone,  depresses  the  heart,  and  is  altogether  evil  in  its  influence,  probably  also 
diminishing  the  elimination  of  toxic  materials  by  the  kidneys,  and  certainly  giv- 
ing these  organs  the  additional  labor  of  eliminating  the  antipyretic  drug,  which, 
])erchance,  may  be  irritating  to  them. 

Quinine  is  employed  by  some  practitioners  with  the  idea  that  it  possesses  specific 
as  well  as  antipyretic  power,  and  there  is  no  objection  to  its  use  in  small  doses; 
large  doses,  which  produce  cinchonism  or  irritation  of  the  stomach,  are  value- 
less, and  may  do  harm  by  irritating  the  stomach,  producing  cerebral  congestion 
and  meningeal  irritation,  or  irritating  the  kidneys. 

When  croupous  pneumonia  is  of  the  typhoid  type  and  asthenia  is  marked, 
valuable  results  can  be  obtained  very  frequently  by  the  hypodermic  injection 
of  1  grain  of  camphor,  dissolved  in  sterilized  olive  oil.  This  injection  may  be 
given  once,  twice,  or  thrice  in  twenty-four  hours  for  one  or  two  daj's,  but  ought 
not  to  be  continued  too  long;  first,  because  it  rapidly  loses  its  effects  if  used  too 
frequently,  and,  second,  because  in  these  doses  there  may  be  some  danger  of 
camphor  poisoning.  Camphor  is  to  be  regarded  as  a  remedy  for  an  emergency, 
and  is  to  be  reserved  for  critical  periods. 

Recently  very  large  doses  of  camphor,  as  much  as  30  grains  a  day,  given  hypo- 
dermically,  have  been  advocated  as  a  specific  treatment  of  croupous  pneumonia. 
I  have  proved  these  doses  not  to  be  poisonous,  but  have  not  used  this  method 
in  a  sufficient  number  of  cases  to  assert  its  usefulness. 

If  great  mental  and  nervous  excitement  is  present  and  persistent,  life  can  often 
be  saved  by  the  administration  hypodermically  of  ^,  ^,  or  \  grain  of  morphine. 
This  will  often  produce  several  hours  of  desired  sleep,  from  which  the  patient 
awakens  much  refreshed  and  perhaps  free  of  the  delirium  which  before  the  admin- 
istration of  the  morphine  was  an  annoying  symptom,  in  that  it  produced  jDliysical 
exliaustion  through  the  constant  activity  of  his  body  and  mind. 

The  employment  of  nitroglycerin  in  the  treatment  of  pneumonia  is  limited 
to  those  cases  which  have  a  very  high  arterial  tension  before  the  acute  illness. 
The  drug,  under  these  circumstances,  is  of  great  value  in  that  it  diminishes  the 
work  of  the  heart  by  removing  the  vis  a  fronte.  If,  on  the  other  hand,  vascular 
spasm  does  not  exist,  the  drug  is  useless,  for  it  is  not,  as  some  have  thought, 
in  any  sense  a  direct  cardiac  stimulant.  A  blood-pressure,  theoretically  high,  is 
often  induced  by  nature  to  aid  in  maintaining  the  circulation  through  fibroid 
vessels,  and  it  is  usually  better  to  leave  it  alone. 

The  question  of  the  employment  of  circulatory  sedatives  in  the  early  stages  of 
acute  croupous  pneumonia  is  one  wliich  has  been  widely  debated,  particularly 
in  this  country.  There  are  many  excellent  practitioners  who  consider  that  full 
doses  of  veratrum  viride  or  aconite  in  the  earlier  stages  of  croupous  pneumonia 
are  advantageous.  Statistics,  or,  to  speak  more  correctly,  wide  personal  expe- 
rience on  the  part  of  many  physicians,  seeius  to  justify  the  use  of  this  drug  in  some 
cases,  namely,  in  those  instances  in  which  the  physician  sees  the  patient  during 


DIPHTHERIA  151 

the  first  hours  of  the  attack,  and  if  the  patient  is  a  strong,  sthenic  individual,  with 
a  full,  bounding  pulse,  and  great  flushing  of  the  face.  Under  these  circumstances 
the  relaxation  of  the  general  vascular  system  produced  by  the  veratnun  viride 
and  the  quieting  of  the  excited  heart  seems  distinctly  advantageous.  Whether 
such  treatment  in  any  way  aborts,  or  jugulates,  or  diminishes  the  violence  of  the 
subsequent  attack  is  difficult  to  determine.  In  a  few  instances  of  acute  croupous 
pneumonia  and  acute  pleurisy,  seen  in  the  very  early  stages,  I  have  noted  good 
results  from  such  treatment.  But  in  the  vast  majority  of  instances  the  physician 
does  not  see  the  patient  for  nearly  twenty-four  hours,  by  this  time  the  disease  is 
well  started  on  its  way,  and  the  symptoms  of  great  circulatory  excitement  have 
usually  passed  by,  so  that  circulatory  sedatives  are  distinctly  contra-indicated. 
The  use  of  chloral  as  a  nervous  sedative  in  the  course  of  croupous  pneumonia  is 
usually  inadvisable. 

The  diet  should  be  liquid  and  consist  of  milk,  with  a  little  pancreatin  and  bicar- 
bonate of  soda,  to  aid  in  digestion,  and  of  animal  broths  and  gruels  made  of  wheaten 
grits,  oatmeal,  rice,  or  barley;  the  digestion  of  these  starchy  foods  being  aided  by 
the  administration  of  taka-diastase  or  pancreatin.  I  am  quite  convinced  that  we 
too  infrequently  resort  to  these  cereal  fluids  in  the  treatment  of  diseases  of  this 
nature,  since  they  possess  much  nutritional  value  and,  if  their  digestion  is  aided, 
agree  with  the  vast  majority  of  patients,  and  enable  us  to  change  the  diet  so  that 
the  patient  does  not  become  tired  of  any  one  particular  kind  of  food,  which  is  a 
great  advantage. 

Care  should  be  taken  in  cases  of  croupous  pneumonia  that  the  patient  receives 
an  adequate  amount  of  water  to  drink,  so  that  the  kidneys  may  be  well  flushed 
with  fluid  in  each  twenty-four  hours;  but  it  is  important  that  only  small  amounts 
of  fluid  be  taken  at  a  time,  as  distention  of  the  stomach  may  cause  fatal  cardiac 
embarrassment.  The  bow^els  should  also  be  moved  each  day  in  the  early  stages  of 
the  attack  by  full  doses  of  calomel,  and  in  the  later  stages  by  salines,  or,  if  the 
patient  is  too  weak  for  the  use  of  these  purgatives,  by  a  rectal  injection  of  water 
or  of  glycerin  and  water. 

The  administration  of  expectorants  in  croupous  pneumonia  is  useless  until 
the  stage  of  resolution  is  reached.  Even  then  they  are  probably  of  little  value  in 
clearing  up  the  exudate  in  the  vesicular  portions  of  the  lung.  But  the  chloride 
of  ammonium,  the  oil  of  sandal-wood,  guaiacol,  and  terpin  hydrate  often  prove 
useful  at  this  time  in  aiding  in  removing  the  symptoms  of  chronic  bronchitis  which 
exist,  a  state  which  results  in  the  formation  of  a  good  deal  of  thick,  tenacious 
bronchial  mucus,  which  the  patient  may  have  difficulty  in  expectorating. 

Excessive  cough  in  all  stages  of  croupous  pneumonia  is  best  controlled  by  the 
administration  of  Dover's  powder,  codeine,  paregoric,  or  the  newer  drug,  heroin. 
In  the  stage  of  resolution  cough  sedatives  should  not  be  administered  unless  the 
physician  is  certain  that  the  cough  is  in  excess  of  the  needs  of  the  patient  in  getting 
rid  of  the  materials  in  his  chest  which  should  be  gotten  rid  of  in  this  way. 

Meningeal  symptoms  are  to  be  treated  by  the  application  of  cold  to  the  head, 
and  sometimes  it  is  wise  to  apply  a  blister  to  the  nape  of  the  neck. 

DIPHTHERIA. 

Defiiutioii. — Diphtheria  is  an  acute  infectious  disease,  which  chiefly  affects 
children  under  puberty.  It  is  due  to  the  Klebs-Loeffler  bacillus,  and  is  char- 
acterized primarily  by  an  acute  local  inflammatory  process  which  affects,  as  a 
rule,  the  pharynx,  larynx,  or  nasal  mucous  membrane,  and  which  is  peculiar  in 
that  it  is  associated  with  the  development  of  a  false  membrane  due  to  a  fibrinous 
exudate.  From  the  spot  upon  which  this  condition  develops  the  general  system 
becomes  affected,  not  by  the  micro-organism  of  the  disease,  but  by  the  poisons  or 


152  DISEASES  DUE  TO  A   SPECIFIC  IXFECTIOX 

toxins  ])ri)(lnc('(I  by  the  specific  organism  ;it  tlic  site  of  iirimary  infcctinii.  Other 
infections  may  occasionally  cause  the  ])n)(lncti()n  ol'  a  false  memhraiic,  Imt  the 
discovery  of  the  presence  of  the  Klehs-Loeffier  l)aei!his  determines  tliat  tiie  affection 
is  diphtheria.  All  cases  in  which  a  false  inemhrane  develops  on  a  \isihle  mucous 
rriembrane  should  he  considered  to  he  cases  of  (ii])htlKTia  and  treateii  as  such  until 
proved  to  he  non-diphtlieritic,  because  in  this  way  the  spread  of  the  disease  is 
prevented  and  the  use  of  the  specific  remedy,  antitoxin,  will  sa\-e  life  if  the  disease 
is  present  and  do  no  harm  if  it  is  not. 

In  the  great  majority  of  ca.ses  the  disease  primarily  afl'ccts  the  pharyngeal 
mucous  membrane,  or  the  mucous  membranes  immediately  adjacent  thereto, 
and  from  this  area  spreads  to  the  nose  or  larynx,  where  the  results  of  its  dcNclop- 
ment  are  very  fatal.  The  sijecific  inflammation  and  false  membrane  may,  ho\ve\er 
develop  on  any  exposed  mucous  membrane,  and  even  upon  the  true  skin  if  the 
epiderm  be  remo\-e<l  intentionally  or  by  accident. 

It  is  possible  for  bacteriologists  to  find  the  Klebs-Loeffler  bacillus  in  cases  of  sore 
throat  in  which  there  is  no  false  membrane  and  no  systemic  symptoms  of  fliph- 
theria,  and  in  some  of  these  instances  even  local  disturbances  may  be  ab.sent 
because  of  the  resistance  offered  to  this  infection  by  some  persons.  These  cases 
are  not  to  be  considered  instances  of  diphtheria,  although  they  are  entirely  capable 
of  conveying  the  disease  to  others  and  hence  are  "carriers." 

On  the  other  hand,  cases  are  not  rarely  seen  in  which  the  physician  finds  a 
shaggy  false  memlirane  on  the  throat  associated  with  signs  of  great  systemic 
toxemia,  and  in  which  the  bacteriologist  fails  to  find  the  specific  micro-organism 
of  diphtheria.  This  condition  is  called  diphtheria  by  the  physician  and  pseudo- 
diphtheria  l)y  the  bacteriologist.  The  streptococcus  is  probably  responsible  for 
cases  of  the  latter  type,  while  in  other  patients  the  pneumococcus  causes  a  similar 
eft'ect.  These  instances  are  met  with  most  commonly  as  complications  of  scarlet 
fever  or  more  rarely  of  measles,  and  also  occur  as  manifestations  of  severe 
tonsillitis  or  angina. 

History. — Diphtheria  has  been  recognized  for  many  centuries  as  a  disease,  but 
it  was  not  until  the  clinical  observations  of  Bretonneau,  of  Tours,  that  its  separate 
identity  was  established  under  the  name  of  "diphtherite."  He  classed  all  cases 
of  "putrid  sore  throat,"  "cyanche  maligne,"  and  "sutt'ocative  angina"  under  this 
one  heading,  and  much  more  recently  those  cases  heretofore  called  "membranous 
croup"  have  also  been  very  properly  put  in  the  class  called  "diphtheritic."  This 
sweeping  classification  is  not  scientificall\'  justifiable,  as  has  just  been  pointed  out, 
but  from  a  clinical  stand-point  it  is  proper  because  in  the  majority  of  instances  the 
false  memlirane  is  due  to  this  cause. 

Distribution. — Diphtheria  is  a  disease  which  occurs  in  nearly  all  parts  of  the 
world,  but  is  much  more  prevalent  in  the  temperate  zones  than  elsewhere.  It 
occurs  in  epidemics  and  in  sporadic  cases,  and  is  endemic  in  nearly  every  large 
city.  While  common  in  cities,  it  is  even  more  common  in  country  districts.  No 
special  influence  upon  its  development  is  known  to  be  exercised  by  bad  drainage, 
although  such  drainage  may,  by  diminishing  \ital  resistance,  very  greatly  increase 
susceptibility  to  the  malady. 

It  is  a  disease  of  the  j^oor  rather  than  of  the  rich,  and  when  it  occurs  in  the  well- 
to-do  it  is  usually  sporadic  and  its  source  can  often  be  traced  to  some  single  expos- 
ure. The  reason  for  this  does  not  lie  so  much  in  greater  susceptibility  of  the  jioor 
as  in  greater  exposure  to  the  infection,  for  when  the  children  of  the  well-to-do  are 
attacked  they  succumb  as  readily  as  their  otherwise  less  fortunate  fellows. 

Diphtheria  occurs  much  more  frequently  between  the  ages  of  two  and  five 
years  than  at  any  other  time  of  life  (Fig.  40). 

Etiology. — Diphtheria  is  due,  as  has  already  been  stated,  to  a  specific  bacillus 
first  described   by   Klebs  in    1SS3,  and   later  isolated   by  Loeffler.     This  micro- 


DU'lITIIIiRIA 


15?. 


organism  is  from  1.5  to  3.5  or  rarely  4.5  micromiilimettTs  in  length,  and  from  0.15 
to  0.8  in  breadth.  It  usually  appears  singly,  in  groups  of  two  or  three,  but  true 
chains  are  said  not  to  occur;  the  organisms  may  lie  side  by  side  or  at  an  angle. 
They  are  slightly  curved  with  straight,  rounded  ends,  sometimes  branched,  and 
commonly  beaded  or  barred.  They  do  not  give  off  spores,  and  flageila  are  absent. 
They  may  contain  highly  refractive  bodies  which  cause  them  to  stain  irregularly. 
The  best  stain  is  that  of  Loeffler,  the  oval  bodies  in  the  organism  staining  more 
highly  than  the  rest  of  the  bacillus.  They  are  grown  best  in  Loeffler's  blood  serum 
but  develop  in  all  the  laboratory  media.  The  organism  is  non-ni<jtile  and  almo.st 
purely  aerobic. 

All  cases  of  diphtheria  are  due  to  the  entrance  into  the  body  of  this  specific 
bacillus  originally  derived  from  some  patient  ill  with  the  disease.  The  transfer 
is  made  in  a  multitude  of  ways.  Sometimes  it  is  by  the  clothing,  by  books,  by  food- 
stuffs, or  drinks,  or  drinking-vessels,  by  pencils,  or  by  the  coughing  of  an  individual, 
who  may  have  the  bacilli  in  the  throat,  in  such  a  way  that  the  infectious  agent  is 
driven  into  the  respiratory  passages  or  mouth  of  the  other  person.  Convalescent 
patients  may  in  this  manner  act  as  disseminators  of  the  disease  long  after  they  are 
apparently  entirely  well,  and  healthy  persons  with  the  bacilli  in  the  mouth  may  also 
carry  the  infection. 


UNDER 
1  YEAR 

1  TO  2 
YEARS 

2  TO  3 
YEARS 

3  TO  4 
YEARS 

4  TO  5 
YEARS 

3  TO  6 
YEARS 

6  TO  7 
YEARS 

7  TO  8 
YEARS 

8  TO  9 
YEARS 

9  TO  10 
YEARS 

1  0  TO  11 
YEARS 

1  1  TO  12 
YEARS 

12  TO  13 
YEARS 

13  TO  14 
YEARS 

12      2$^ qE ^=F 

[\-U-\  1  W^A]       i\  1    1  H  U\--\  hUn-t-     1  M  M 

11    ^:^^'^^,^d^'^EE^:^:E^^^^0^E3^3^^,^^E^^^^^^^ 

10    =  =  =  ===^=i  =  ===:i<;==:=  =  ^===  =  ===  =  =  =  =  =  =  =  =  =  =  =  =  =  = 

1^  H=m+F/q=FT^^^mH4^FT^    q-        M 

U-^hT         H         H^   1  h\M^-^H+                        II 

'  PFMt^l-  '^^THtfrM^ 

« pMiEfepn  __.|i|i^#i4tffl 

'iBMIMMB 

5      ^ V 

M               +^^rrH       M    nd"^^ 

^  H=#H=^^Hq^+m+FF^FH~rrT\     ' 

^  \:pt\r\  MM  MM  1  m-Hm=FR       N  ' 

J          "                                   s 

3    =^EEEEEzEE^EEE±EEEEEEEEEEEEEEeS======== 

2 

Showing  the  age  incidence  of  diphtheria,  based  on  3300  cases  collected  from  various  sources. 


Thus  it  is  entirely  possible  for  a  nurse  who  has  been  in  charge  of  a  case  of  diph- 
theria to  carry  in  the  crypts  of  the  tonsils  the  specific  micro-organism,  to  have 
no  sign  of  the  disease,  and  yet  infect  a  child  or  adult  whom  she  may  care  for  soon 
after  leaving  the  first  case.  It  is  evident,  therefore,  that  while  the  infection  is  not 
carried  by  the  air,  as  in  smallpox,  it  is  very  easy  for  a  patient  who  sneezes  or  coughs 
to  distribute  the  infectious  agent  broadcast  by  its  falling  on  neighboring  sub- 
stances which  act  as  agents  of  conveyance.     These  are  some  of  the  causes  that 


154  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

result  in  the  rapid  spread  of  the  disease  in  tenement  houses,  schools,  and  other 
public  places  where  children  are  congregated. 

As  the  specific  bacillus  possesses  great  vitality,  the  relationship  between  cause 
and  effect  may  not  be  readily  discovered.  Thus,  if  the  bacilli  fall  on  a  garment 
they  have  been  found  to  remain  capable  of  producing  the  disease  six  months 
later,  and  they  have  been  found  in  the  throat  many  months  after  perfect  health 
has  been  established.  So,  too,  the  dust  of  the  room  may  carry  the  infection,  and 
even  the  hair  or  beard  of  the  physician  may  do  likewise,  if  the  patient  expels  any 
secretion  upon  it.  Finally,  as  already  intimated,  milk  may  act  in  this  manner,  and 
cheese  made  from  contaminated  milk  may  even  convey  the  bacillus.  Pet  animals, 
such  as  cats  and  dogs,  also  act  as  distributors,  and  rodents,  such  as  rats  and  mice, 
may  do  likewise. 

While  not  all  the  diseases  of  birds,  cats,  and  calves  characterized  by  the  forma- 
tion of  a  false  membrane  are  communicable  to  man,  the  possibility  of  a  true  diph- 
theritic infection,  in  domestic  animals,  cannot  be  denied. 

There  are  a  number  of  causes  existing  in  the  patient  which  exercise  a  predis- 
posing influence  in  connection  with  this  infection.  Some  of  these  are  at  present 
obscure  and  probably  depend  upon  a  lack  of  antibodies  in  the  blood  and  tissues, 
but  others  are  equally  active,  readily  recognizable  and  in  many  cases  remedialile. 
There  can  be  no  doubt  whatever  that  chronically  enlarged  tonsils,  overgrowth 
of  the  so-called  pharyngeal  tonsil  and  chronic  catarrh  of  the  nasopharynx  very 
materially  increase  the  susceptibility  of  a  child  to  diphtheria.  For  this  reason 
these  conditions  should  not  be  allowed  to  exist  in  otherwise  healthy  children. 
Further  than  this  the  crypts  of  the  tonsils  when  diseased  may  harbor  the  Klebs- 
Loeffler  bacillus,  until  a  time  when  the  system  of  the  patient  is  favorable  for  its 
growth  and  then  develop  rapidly,  or  on  being  expelled  cause  the  malady  in  another 
individual. 

None  of  the  pathogenic  organisms  seems  to  possess  a  greater  degree  of  variance 
in  virulency  than  the  one  under  discussion.  In  some  instances  it  fails  to  exert 
any  malign  effect  beyond  a  local  influence,  and  even  this  may  amount  to  nothing 
more  than  a  sore  throat.  In  other  cases  it  attacks  the  patient  with  a  virulence 
which  is  perfectly  terrifying. 

It  is  not  probable  that  sex  has  any  influence  as  a  predisposing  cause.  Statis- 
tics vary,  however,  some  showing  that  a  greater  number  of  cases  occur  among 
boys  than  among  girls.  That  these  differences  are  merely  fortuitous  is  exemplified 
by  the  fact  that  of  22,005  cases  collected  by  me  from  various  sources  11,006  oc- 
curred among  boys  and  10,099  among  girls,  a  difference  of  only  seven  cases. 

Pathology  and  Morbid  Anatomy. — In  studying  the  pathology  and  morbid  anatomy 
of  diphtheria  it  is  essential  to  remember  that  the  disease  is  primarily  local  and 
secondarily  systemic;  that  the  local  area  of  infection  is  the  site  at  which  the 
specific  organism  multiples  and  produces  local  changes  by  its  growth,  and  at  the 
same  time  elaborates  a  toxin  which,  being  absorbed,  acts  on  distant  parts  and  so 
endangers  life.  The  bacillus  enters  the  blood  stream  in  a  relatively  constant 
percentage  of  cases. 

Local  Lesions. — The  local  change  produced  by  the  growth  of  the  bacillus 
is  now  well  understood,  for  a  large  number  of  researches  in  Europe  and  America 
have  given  us  clear  conceptions  of  it.  Of  these  researches  by  far  the  most  note- 
worthy is  that  carried  out  by  Councilman,  Mallory,  and  Pearce  in  Boston. 

The  poison  produced  by  the  specific  bacillus  in  the  mucous  membrane  of  the 
throat  results  in  the  death  of  the  tissues  and  in  this  necrotic  mass  the  bacilli  then 
very  rapidly  develop.  The  epithelium  in  many  cases  manifests  more  or  less  pro- 
liferation, becomes  hyaline  and  necrotic,  eventually  fragmenting  and  disintegrat- 
ing. The  inflammatory  exudate  which  jjcrmeates  the  mucosa  and  even  the  sub- 
mucous stratum  is  very  rich  in  fibrin  elements,  and  when  brought  in  contact 


DIPHTHERIA  155 

with  the  necrosing  structures  forms  a  fibrinous  reticulum  entangling  within  its 
meshes  the  cells  and  bacteria.  The  membrane  formed  by  the  coagulation  necrosis 
and  hyaline  degeneration  of  the  cells  may  be  so  transparent  as  almost  to  escape 
detection  during  life  (hyaline  type),  or  it  may  be  granular  or  fibrillar.  The  necro- 
sis may  extend  into  the  superficial  epithelium  only  or  penetrate  the  submucosa 
and  cause  ulceration,  in  some  instances  involving  the  parenchyma  of  the  tonsil 
or  even  the  submucous  muscular  structures.  This  necrotic  membrane  is  subject 
to  a  number  of  important  changes.  It  may  disintegrate  and  form  a  mass  of  shreddy 
detritus  on  the  surface  or  it  may  be  thrown  off  by  being  elevated  by  the  exudate 
which  forms  beneath  it.  In  the  latter  process  a  very  thick,  false  membrane  formed 
of  consecutive  layers  may  be  produced.  The  membrane  always  develops  on  a 
necrotic  surface,  but  it  may  extend  a  short  distance  over  the  surrounding  mucous 
membrane. 

The  depth  of  the  destructive  process  is  not  very  great  in  the  majority  of  cases, 
but  in  rare  instances  it  has  become  deep  enough  to  erode  the  carotid  artery.  In 
many,  if  not  all,  such  instances  other  organisms  play  an  important  part  in  the 
spread  of  the  necrosis  and  add  to  the  intoxication  their  own  poisonous  products. 
It  is  important  to  bear  in  mind  in  diphtheria  that  the  infection  is  "mixed"  in  the 
vast  majority  of  cases;  that  is,  the  false  membrane  not  only  holds  in  its  meshes  a 
multitude  of  the  specific  bacilli  but  many  other  micro-organisms  as  well,  many 
of  which  possess  a  power  for  evil,  as,  for  example,  the  streptococcus. 

The  membrane  is  closely  attached  to  the  tissues  beneath  and  is  stripped  off 
with  great  difficulty  except  when  it  develops  in  the  larynx  and  bronchi,  where 
it  is  dislodged  quite  readily. 

The  false  membrane  may  develop  on  any  mucous  membrane  or  upon  any  wound 
or  abrasion,  but  it  most  frequently  appears  on  the  tonsils.  According  to  Lennox 
Browne,  of  London,  the  relative  frequency  of  its  appearance  is  as  follows: 

Above  the  larynx,  84.1  per  cent.:  841  cases. 

Fauces  (including  tonsils)  alone 672  cases. 

Nose  alone 2  cases. 

Fauces  and  nose 165  cases. 

Mouth  or  lips  alone 1  case. 

Hard  palate  alone 1  case- 
Involving  larjnQx,  15.9  per  cent. :  150  cases. 

Larynx  alone 4  cases. 

Larynx  and  fauces 100  cases. 

Larynx,  fauces,  and  nose 46  cases. 

Cornwell  in  600  cases  in  Philadelphia  found  the  tonsils  involved  in  460  instances. 

The  growth  of  the  membrane,  whatever  its  site,  varies  greatly  in  rapidity,  in 
the  area  covered,  and  also  in  its  thickness,  but  the  virulence  of  the  systemic  in- 
fection is  not  always  in  direct  ratio  to  the  size  of  the  diphtheritic  patch.  On  the 
other  hand,  the  degree  of  secondary  infection  depends  largely  upon  the  particular 
surface  involved,  and  if  it  develops  in  the  nasopharynx  the  toxemia  is  apt  to  be 
profound.  In  many  severe  cases  the  accessory  nasal  cavities  are  infected,  particu- 
larly the  antrum  of  Highmore. 

Visceral  and  Systemic  Lesions. — The  action  of  the  toxin  of  diphtheria  is 
chiefly  expended  upon  the  heart,  the  nervous  system,  and  the  kidneys.  The 
heart  suffers  from  an  acute  myositis  or  inflammation  of  its  interstitial  and  muscular 
tissues,  and  this  may  be  followed  by  conversion  of  the  muscle  fibres  into  hyaline 
masses.  In  a  large  proportion  of  the  cases  in  which  sudden  death  from  heart- 
failure  occurs  the  cause  lies  in  the  effect  of  the  poison  upon  the  nervous  mechanism 
of  the  heart,  possibly  to  a  greater  degree  than  its  effect  upon  the  myocardium. 
In  some  of  these  cases,  however,  death  is  due  to  thrombi  in  the  heart  cavities  (see 
Sequelae),  or,  again,  portions  of  these  thrombi  are  swept  out  of  the  heart  and  produce 
embolism  in  the  coronary  arteries,  in  the  pulmonary  vessels  or  in  the  general 


156  DISEASES  Dl'E  TO  A  SPECIFIC  IXFECTIOX 

arterial  system.  As  would  he  expected  from  tlio  effects  U])()n  tlie  heart,  just  de- 
scrihed,  the  l)l()odvessels  are  also  affected.  .\ii  acute  arteritis  often  occurs  and 
affects  particularly  the  intinia. 

The  Jicrvuiis  .sysfeni  is  inNoKcd  cliii'Hy  in  its  |)cri|)licral  |i(irti(ins.  'i'lic  ner\e 
trunks  suffer  from  acute  to.xic  neuritis  and  less  commonly  autojj.sy  re\eals  hemor- 
rhage into  the  spinal  cord  and  its  membranes  as  a  result  of  the  vascular  action  of 
the  poison.  A  much  more  common  spinal  lesion  is,  however,  an  acute  anterior 
poliomyelitis,  that  is,  involvement  of  the  cells  in  the  anterior  horns  of  the  gray 
matter.  Sometimes  the  posterior  nerve  roots  in  the  cord  may  he  also  affected. 
The  special  crania!  nerves  are  also  involved  in  many  instances  and  loss  of  function 
in  the  oculomotor,  vagus,  hypoglossal  and  spinal  accessory  fibres  takes  place.  It 
is,  however,  interesting  to  note  that  while  paralysis,  due  to  ])eripherai  diphtheritic 
neuritis,  may  be  absolute  and  widespread,  it  usually  gets  well  unless  the  function 
of  some  vital  part  is  so  interfered  with  that  death  speedily  ensues.  Tlie  brain  is 
very  rarely  affected. 

The  kidneys  are  more  or  less  affected  in  all  cases  of  diphtheria.  In  some  there 
is  only  a  mild  albuminuria  produced  by  the  irritative  effect  of  the  toxin  upon  the 
renal  epithelium.  In  more  severe  cases  an  acute  toxic  nephritis  develops.  This 
nephritis  primarily  is  parenchymatous,  involving  the  Malpighian  tufts  and  the 
tubules,  but  it  speedily  becomes  diffuse.  Hyaline  degeneration  also  takes  place 
in  the  renal  vessels,  as  elsewhere  in  the  body. 

The  spleen  is  enlarged,  markedly  congested,  and  minute  hemorrhages  are  to 
be  seen  beneath  its  capsule.  The  liver  may  be  found,  on  cross-section  to  be  dotted 
with  small  areas  of  coagulation  necrosis. 

x\s  the  infection  is  most  marked  in  the  throat  the  cervical  li/niph  glands  are 
usually  infiltrated  and  the  poison  may  also  cause  enlargement  of  the  lymphaiics 
in  the  mediastinum  and  in  the  retroperitoneum.  The  inflammation  of  the  lynii)h 
nodes,  however,  rarely  ends  in  suppuration  or  extensive  necrosis. 

The  lungs  are  often  the  site  of  bronchopneumonia  resulting  from  a  complicat- 
ing pneumococcus  infection,  but  true  croupous  pneumonia  is  a  rare  complication. 
When  great  dyspnea  is  present  because  of  laryngeal  stenosis  compensatory  emphy- 
sema may  develop.  In  the  laryngeal  form  the  membrane  may  extend  to  the 
smaller  bronchi. 

The  blood  is  affected  very  deleteriously  by  the  poison  of  di])litheria,  so  that 
a  great  diminution  in  the  number  of  the  red  cells  takes  place  with  a  corresjioniling 
fall  in  hemoglobin.  A  leukocytosis  occurs  except  in  the  very  malignant  forms 
of  the  disease.    Myelocytes  are  said  to  be  present  in  severe  cases. 

Symptoms. — After  a  period  of  incubation  ^•arying  from  two  to  seven  days  the 
disease  has  its  onset  in  the  form  assumed  by  most  acute  infections,  namely,  with 
general  malaise,  chilliness,  nnd  fever,  the  temperature  often  reaching  102°  or  even 
103°  in  the  first  twenty-four  hours.  The  severity  of  these  symptoms  varies  greatly. 
In  some  cases  they  are  so  mild  that  the  child  is  scarcely  thought  to  be  ailing,  and 
the  physician  at  his  second  visit  is  shocked  on  examining  the  throat  to  find  distinct 
local  lesions.  In  other  cases  the  disease  is  fulminating  in  its  onset.  1  have  seen  a 
small  patch  of  membrane  on  a  tonsil  within  twelve  hours  involve  the  larynx  and 
necessitate  tracheotomy,  the  membrane  involving  the  external  edges  of  the  wound 
in  less  than  twehe  hours  more.  In  nearly  every  case  there  is  some  com])laint 
of  sore  iliroal.  or  of  difficulty  in  swallowing  arising  from  this  cause.  The  pharyngeal 
mucous  membrane  is  reddened  and  u])on  the  tonsil  or  tonsils  is  seen  a  liny  patch, 
which  is  the  l)eginning  of  the  memhrane,  ])ut  which  may  be  due  to  the  exudate 
thrown  out  by  a  follicular  tonsillitis.  This  membrane  rapidly  spreads  and  may 
extend  to  the  pillars  of  the  fauces,  the  pharynx,  nasopharynx,  and  the  uvula.  It 
is  grayish  or  light  mouse  color  in  hue,  and  in  many  cases  speedil\'  becomes  shaggy 
and  dirty  looking.    If  the  physician  attempts  to  remove  it  it,  is  found  to  adhere 


Dll'IITIlERlA  157 

to  the  nuicoiis  membrane,  and  it  can  be  taken  off  l)y  only  tearing  it  loose,  so  that 
a  raw,  bleeding  surface  is  exposed  over  which  a  false  membrane  speedily  reforms, 
for  reasons  given  when  discussing  the  pathology  and  morbid  anatomy  of  the  disease. 
There  is  nearly  always  some  enlargement  of  the  glamh  at  the  angle  of  the  jaw. 
The  degree  of  systemic  disturbance  depends  in  every  case  upon  the  virulence 
of  the  infecting  bacillus  and  the  rapidity  with  which  the  toxin  is  absorbed. 

Some  patients  who  present  on  examination  a  large  area  of  membrane  suffer 
slightly  in  a  comparative  sense.  The  fever  does  not  rise  above  102°  or  llj:5°,  the 
pulse  does  not  go  above  100  to  110,  and  the  general  state  of  the  i)atient  is  favor- 
able. In  other  instances  from  the  ver.y  onset  the  general  systemic  state  is  bad, 
even  when  the  local  changes  may  seemingly  be  slight.  Even  in  severe  cases,  how- 
ever, the  fever  is  not  prone  to  be  high,  and  often  it  never  rises  above  101°. 

The  nervous  symptoms  consist  in  restlessness,  sometimes  in  delirium,  and  rarely 
convulsions  come  on.  As  the  disease  approaches  a  fatal  issue,  the  child  becomes 
apathetic  and  it  may  be  difficult  to  rouse  it. 

The  circulation  is  feeble  and  irregularity  of  the  pulse  is  a  very  frequent  symptom. 
In  White's  exhaustive  study  of  946  cases  this  irregularity  was  present  in  (30  per 
cent.  The  younger  the  patient  the  greater  the  frequency  of  irregularity  of 
pulse.    Endocardial  murmurs,  systolic  in  point  of  time,  occurred  in  94  per  cent. 

Albumi7iuria  is  a  very  constant  symptom  in  these  cases,  appearing  as  early  as 
the  third  day.  The  albumin  may  appear  in  considerable  quantities,  but  the  urin- 
ary flow  is  in  many  cases  not  greatly  increased,  although  the  presence  of  granular 
and  hyaline  casts  shows  that  a  true  nephritis  is  present.    Dropsy  is  uncommon. 

In  cases  which  are  not  complicated  or  are  treated  by  antitoxin,  the  membrane 
ceases  to  grow  by  the  fifth  or  sixth  day,  and  gradually  separates  at  about  the 
seventh  or  tenth  day,  leaving  at  its  former  site  a  bright  red  surface  which  bleeds 
easily.  The  nasal  false  membrane  persists  longer  than  this  in  the  pharynx, 
and  often  comes  away  in  one  mass. 

After  this  period  convalescence  gradually  goes  on,  the  patient  being  profoundly 
weak  and  anemic  and  in  great  danger  of  sudden  death  from  heart-failure  if  any 
sudden  change  in  posture  is  made.  A  great  many  cases  thought  to  be  on  the  high 
road  to  recovery  meet  an  unexpected  fatal  ending  at  this  time. 

Special  Forms. — There  still  remain  to  be  described  the  special  symptoms  con- 
nected with  those  cases  of  diphtheria  in  which  particular  portions  of  the  respiratory 
mucous  membrane  are  involved,  or  in  which  the  disease  presents  conditions  which 
may  be  considered  aberrant.  In  nasal  dipMhria  the  false  membrane  may  be  so 
hidden  by  the  swollen  turbinated  bodies  that  it  is  overlooked  until  it  extends  well 
forward  into  the  nostril,  when  it  may  completely  occlude  the  nares.  Only  a  careful 
rhinoscopic  examination  will  reveal  this  form  in  its  early  stages.  Because  of  the 
importance  of  instituting  treatment  in  all  cases  of  this  disease  at  the  earliest  pos- 
sible moment  the  nasal  cavities  should  always  be  examined  at  the  same  time  the 
throat  is  in^'estigated,  and  any  signs  of  nasal  obstruction  taken  as  of  importance. 
A  valuable  sign  of  nasal  diphtheria,  but  one  which  unfortunately  does  not 
manifest  itself  until  the  disease  is  well  advanced,  is  a  nasal  discharge  which  may 
excoriate  the  upper  lip. 

It  is  never  to  be  forgotten  that  nasal  diphtheria  is  a  very  malignant  type  of 
the  disease  in  nearly  every  instance  in  which  it  occurs,  and  it  is  particularly  prone 
to  aft'ect  infants  or  very  young  children. 

Some  practitioners  confuse  a  condition  of  membranous  rhinitis  with  this  state 
and  do  not  appreciate  the  gravity  of  nasal  diphtheria  although  it  is  a  state  very 
prone  to  be  characterized  by  profound  toxemia. 

Laryngeal  diphtheria  manifests  itself  chiefly  by  the  marked  respiratory  obstruc- 
tion which  it  produces  very  shortly  after  the  pathological  process  begins  in  the 
mucous  membrane  of  the  larynx.    Hoarseness  on  speaking,  or  crying,  and  a  harsh 


158  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

cough  of  a  metallic  sound,  sometimes  called  "brassy,"  develop.  Following  these 
symptoms  it  is  noted  that  there  is  slight  inspiratory  stridor  which  is  accentuated 
at  intervals  by  what  seems  to  be  associated  laryngeal  spasm.  This  is  followed  by 
persistent  stridor,  harsh  breathing,  and  manifest  unrest  and  respiratory  anxiety. 
The  child  may  grasp  its  throat  with  its  hands  as  if  endeavoring  to  remove  the 
obstruction,  and  as  it  becomes  livid,  partly  from  mechanical  failure  of  respiration . 
and  partly  from  toxemia,  it  often  grinds  its  teeth  and  looks  from  side  to  side  for 
relief,  presenting  at  the  same  time  signs  of  profound  toxemia.  Its  pallid  skin 
may  be  bedewed  with  sweat.  As  the  disease  advances  the  child  becomes  more 
and  more  limp,  and  struggles  less  and  less  for  its  breath.  In  children  old  enough 
and  strong  enough  to  cough  violently  in  an  effort  to  dislodge  the  membrane  it 
often  happens  that  they  expel  pieces  of  false  membrane,  and  in  some  instances 
they  may  expel  complete  casts  of  the  larynx.  The  fever  in  this  type  of  diphtheria 
may  not  be  at  all  high  after  the  larynx  has  become  infected,  but,  as  would  be 
expected,  the  pulse  is  usually  exceedingly  rapid  and  small. 

Laryngeal  diphtheria  rarel.y  occurs  without  extension  to  the  pharynx,  so  that 
at  the  time  of  death  the  membrane  usually  covers  a  wide  area.  When  the  pharyn- 
geal symptoms  are  very  marked  there  is  usually  great  enlargement  of  the  cervical 
glands. 

Bronchopneumonia,  due  to  the  inspiration  of  septic  material,  is  a  frequent  com- 
plication of  this  type.  Like  nasal  diphtheria,  laryngeal  diphtheria  has  a  very 
high  mortality,  partly  because  it  causes  suffocation  and  partly  because  it  is 
associated  with  toxemia  of  a  grave  type. 

Diphtheria  of  the  conjimctiva  may  occur  as  a  complication  or  as  a  primary  lesion. 

Complications  and  Sequelae. — The  complications,  involving  the  cervical  glands, 
the  lungs,  heart,  kidney,  and  nervous  system,  have  already  been  mentioned. 
Nevertheless  it  is  proper  to  say  something  more  concerning  them. 

Sudden  heart-failure  toward  the  close  of  the  attack,  or  after  convalescence  is 
established,  sometimes  occurs  on  the  slightest  exertion.  The  child  sits  up  to  take 
a  drink,  or  to  grasp  a  toy,  or  becomes  angry,  and  drops  over  dead. 

In  other  instances,  instead  of  almost  instantaneous  cardiac  failure  with  sudden 
death,  a  more  gradual  manifestation  of  grave  heart  disease  is  developed.  A  patient 
apparently  on  the  high  road  to  con\'alescence,  except  for  the  reddened  throat  and 
profound  anemia,  is  found  to  have  developed  a  weak  pulse,  which  flags,  and  he 
presents  unduly  feeble  heart  sounds.  Endocardial  murmurs  may  be  present. 
Sometimes  the  pulse  is  abnormally  slow.  In  other  cases  it  is  too  fast,  and,  with 
these  circulatory  symptoms,  some  epigastric  distress  or  even  vomiting  occurs. 
The  pulse  becomes  weaker  and  weaker  and  arrhythmia  increases,  the  face  is  more 
and  more  pallid,  and  cardiac  dyspnea  with  lividity  comes  on.  Auscultation  reveals 
fetal  heart  sounds  or  there  may  be  a  "delirium  cordis."  Death  finally  closes  the 
scene  at  the  end  of  twenty-four  or  forty-eight  hours,  in  the  presence  of  gradually 
deepening  asthenia  and  a  mind  which  is  clear  almost  to  the  very  last.  Acute 
cardiac  dilatation  may  occur. 

There  are  three  causes  for  the  types  of  heart-failure  which  arise  as  a  result  of 
diphtheria.  When  the  heart  fails  in  the  course  of  an  attack  it  is  usually  the  result 
of  cardiac  tlirombosis.  When  it  occurs  after  an  attack  it  is  due  usually  to  a  toxic 
myocarditis  or  to  the  failure  of  the  nervous  supply  of  the  heart  through  bulbar 
paralysis  or  paralysis  of  nerve  fibres.  Some  statistics  indicate  that  thrombosis 
is  the  most  common  cause  of  death  after  disappearance  of  the  membrane.  Of  course 
all  three  of  these  factors  may  be  present  simultaneously.  It  is  probable,  however, 
that  thrombosis  is  more  frequently  the  cause  of  sudden  death  than  is  generally 
thought.  Barbier  in  71  autopsies  on  cases  of  sudden  death  in  diphtheria  found  an 
antemortem  cardiac  thrombus  in  no  less  than  52  per  cent.  These  thrombi  were 
commonly  found  on  the  right  side  of  the  heart,  usually  in  the  right  auricle. 


DIPHTHERIA  159 

Sometimes  death  is  clue  to  paralysis  of  the  -phrenic  nerves,  so  that  diapliragmatic 
paralysis  ensues. 

The  septic  condition  of  the  throat,  the  labored  respiration,  the  decreased  vital 
resistance  of  the  patient,  and  the  feebleness  of  the  pulmonarj'  circulation  in  severe 
cases  very  greatly  predispose  the  patient  to  hroncho-pneumonia,  and  this  complica- 
tion or  sequel  of  diphtheria  is  the  cause  of  death  in  a  very  large  number  of  young 
children. 

Local  or  widespread  paralysis  often  follows  an  attack  of  diphtheria,  and  if  it 
involves  vital  nerves  causes  death.  On  the  other  hand,  these  palsies  are  note- 
worthy because  of  the  fact  that  they  usually  recover.  It  is  by  no  means  uncom- 
mon to  see  a  child  so  paralyzed  that  it  can  neither  move  hand  nor  foot  or  e\en  move 
its  head,  that  lies  perfectly  limp  in  its  mother's  arms,  entirely  recover  muscular 
power.  These  palsies  are  not  usually  immediate  sequences  of  an  attack  of  diph- 
theria, but  are  all  the  more  alarming  because  thej'  may  manifest  themselves  from 
one  to  three  weeks  after  an  attack.  Again,  it  often  happens  that  a  very  mild 
attack  of  the  disease  is  followed  by  this  distressing  sequence,  although  as  a  rule 
severe  cases  usually  have  this  result.  The  palate  is  the  part  most  commonly 
paralyzed,  and  this  results  in  difficulty  in  swallowing,  regurgitation  of  liquids 
through  the  nose,  and  in  a  peculiar  tone  to  the  voice.  When  the  throat  is  exam- 
ined the  palate  is  seen  to  hang  relaxed  and  motionless  when  the  patient  attempts 
to  phonate,  and  it  is  also  somewhat  anesthetic,  so  that  the  contact  of  food  is  not 
well  recognized. 

The  time  of  onset  of  the  paralysis  varies  somewhat  with  the  parts  invoh"ed. 
The  form  that  occurs  most  frequently  and  which  affects  the  muscles  of  the  pharynx 
and  ej^es  and  extremities,  or  even  that  of  the  heart  or  the  muscles  of  respiration, 
is  a  late  palsy  of  the  seventh  to  the  twentj'-first  day  of  convalescence,  whereas 
that  form  which  affects  the  palate  is  more  frequently  met  with  at  the  end  of  the 
first  week. 

True  facial  paralysis  very  rarely  occurs  except  as  a  result  of  otitis  media  arising 
secondarily  from  the  diseased  state  of  the  pharynx. 

Statistics  as  to  the  frequency  with  which  paralysis  accompanies  or  follows 
diphtheria  vary.  Hoppe-Seyler  states  it  to  be  27  per  cent.  Johannessen,  for  all 
Norway,  12.5  per  cent.;  the  report  of  the  Metropolitan  Asylums  Board  of  London, 
18.5  per  cent. 

The  collective  investigation  of  the  American  Pediatric  Society  based  on  3384 
non-hospital  cases  treated  with  antitoxin  showed  that  328  cases  of  paralysis  oc- 
curred, which  gives  a  percentage  of  9.6. 

Hemorrhage  from  the  ulcerative  process  in  the  nose  may  be  sufficiently  free  to 
seriously  exhaust  the  patient.  When  subcutaneous  hemorrhages  appear  they  are 
always  a  sign  of  very  profound  toxemia. 

When  that  practically  constant  sequel  of  diphtheria,  profound  anemia,  remains 
persistently  present  and  is  but  little  improved  under  treatment,  the  possibility 
of  renal  disease  being  a  serious  sequel  is  to  be  recalled. 

Diagnosis. — There  is  no  disease  in  which  it  is  more  important  for  the  physician 
to  make  a  correct  diagnosis  promptly  than  diphtheria,  because  if  it  be  recognized 
in  its  earliest  stage  it  can  be  cured  by  antitoxin  in  the  majority  of  instances.  On 
the  other  hand,  there  is  no  disease  which  is  more  difficult  to  prompt  diagnosis  in 
some  cases.  As  diphtherial  infection  may  be  present  without  marked  formation  of 
membrane,  all  cases  which  manifest  sore  throat  during  an  epidemic  or,  after  expo- 
sure, should  receive  antitoxin  as  a  preventive,  and  the  throat  should  be  swabbed 
and  the  secretion  obtained  examined  bacteriologically  for  the  bacillus. 

In  every  large  city  at  the  present  time  the  health  authorities  provide  tubes 
and  swabs  for  the  transmission  of  cultures  from  the  patient  to  a  laboratory.  Usu- 
ally the  swab  is  delivered  in  a  sterile  tube  and  the  culture  medium  is  placed  in  a 


160  DISEASES  DUE  TO  A   SI'ECJFIC  ISFECTinx 

second  sterile  tul)e.  The  directions  issued  by  the  New  Yoriv  Board  of  IIc;dtii  are 
as  follows:  "The  patient  should  be  placed  in  good  light,  and,  if  a  child,  ])r()i)erly 
held.  In  cases  where  it  is  possible  to  get  a  good  view  of  the  throat,  de]>ress  the 
tongue  and  rub  the  cotton  swab  gently  but  freely  against  any  visible  exudate. 
In  other  cases,  including  those  in  which  the  exudate  is  confined  to  tlie  larynx, 
avoiding  the  tongue,  pass  the  swab  far  l)ack  and  rub  it  freely  against  the  mucous 
nieml)rane  of  the  pharynx  and  tonsils.  Without  laying  the  swab  down,  withdraw 
the  cotton  plug  from  the  culture-tube,  insert  the  swab,  and  rub  that  portion  of  it 
which  has  touched  the  exudate  gently  but  thoroughly  all  o\cr  the  surface  of  the 
blood  serum.  Do  not  push  the  swab  into  the  blood  serum  nor  break  the  surface 
in  any  way.  Then  replace  the  swab  in  its  own  tube,  plug  both  tubes,  i)ut  them  in 
the  box,  and  return  the  culture  outfit  at  once  to  the  station  from  which  it  was 
obtained." 

It  is  worthy  of  note  that  in  some  instances  cultures  made  from  the  tliroat  of 
suspected  diphtheria  carriers  are  negative,  although  nasal  cultures  are  jjositive. 

A  loss  of  valuable  time  is  prevented  during  the  bacteriological  test  by  using 
antitoxin,  but  many  hours  need  not  be  lost  if  the  bacteriologist  is  skilful.  Dr. 
Park,  of  New  York,  who  has  done  such  excellent  work  along  these  lines,  has  this 
to  say  in  regard  to  this  matter:  "The  examination  by  a  competent  bacteriologist 
of  the  bacterial  growth  in  a  blood-serum  tube  which  has  been  projierly  inoculated 
and  kept  for  fourteen  hours  at  the  body  temperature,  can  be  thoroughly  relied  upon 
in  cases  where  there  is  visible  membrane  in  the  throat,  if  the  culture  is  made  during 
the  period  in  which  the  meml)rane  is  forming,  and  no  antiseptic,  especially  no 
mercurial  solution,  has  lately  been  applied.  In  cases  in  which  the  disease  is  con- 
fined to  the  larynx  or  bronchi,  surprisingly  accurate  results  can  be  obtained  from 
cultures,  but  in  a  certain  proportion  of  cases  no  diphtheria  bacilli  will  be  found 
in  the  first  culture,  and  yet  will  be  abundantly  present  in  later  cultures.  We 
believe,  therefore,  that  absolute  reliance  for  a  diagnosis  cannot  be  placed  upon  a 
single  culture  from  the  pharynx  in  purely  laryngeal  cases." 

Diphtheria  is  to  be  separated  from  tonsillitis  with  exudation  from  the  follicles 
of  the  tonsils  and  from  the  diphtheroid  false  membrane  produced  by  the  strepto- 
coccus and  by  an  organism  closely  allied  but  not  identical  with  the  Klebs-Loeffler 
organism,  which  is  found  in  scarlet  fever,  typhoid  fever,  and  measles.  Sometimes 
this  can  be  done  only  by  the  bacteriological  test. 

In  follicular  tonsillitis  the  exudate  may  be  scattererl  o^•c^  the  openings  of  se\eral 
follicles,  it  is  rarely  as  dark  in  hue  as  the  true  membrane,  it  can  be  wiped  oft'  with 
an  applicator  more  readily  than  the  membrane  of  diphtheria,  and  the  tonsillar 
swelling  is  marked.  The  systemic  symptoms  are,  however,  of  little  value  in  dift'er- 
entiation,  because  tonsillitis  is  a  disease  characterized  by  very  severe  symptoms 
as  compared  to  its  gravity,  for  aching  in  the  back  and  limbs,  high  fe\er,  and  great 
evidence  of  systemic  depression  are  frequently  seen  during  its  course.  Holt  has 
pointed  out  the  fact  that  the  surfaces  of  the  wound  left  after  tonsillotom\'  may  for 
a  few  davs  closely  resemble  tonsillar  diphtheria,  and  I  have  seen  the  free  applica- 
tion of  a  strong  solution  of  silver  nitrate  to  the  jjliarynx  jiroducc  an  a])i)earance 
which  might  readily  be  mistaken,  if  examined  in  a  ])()or  light,  for  diphtheria. 

Reference  has  been  made  to  di]ihtheroid  conditions  of  the  throat.  These 
states  are  probably  in  a  large  numlier  of  instances  due  to  the  streptococcus 
pyogenes.  The  false  membrane,  if  none  of  the  true  bacilli  of  Klebs  and 
LoefHer  are  ])resent,  is  usually  more  soft  and  creamy  in  its  consistency,  it  is  not 
so  tightly  adherent  to  the  underlying  mucous  membrane,  and  is  often  very  foul. 
Occurring  as  a  complication  of  grave  infectious  diseases  such  as  scarlet  fever  and 
typhoid  fever,  it  is  dangerous,  but  otherwise  the  mortality  is  not  high,  being  about 
2.5  per  cent.,  if  we  can  take  the  New  York  ('it>-  statistics  as  representative  of  all 
cases. 


DII'IITIIKUIA  101 

Prognosis. — At  the  present  time  it  may  he  said  that  the  prognosis  of  diplitheriu 
depends  entirely  upon  the  promptness  with  which  antitoxin  is  used.  Witiiout  anti- 
toxin the  death  rate  varies  greatly  in  difl'erent  epidemics.  In  some  it  reaches  the 
appalling  rate  of  50  per  cent.,  while  in  others  it  is  not  more  than  30  per  cent.  It 
is  very  much  more  fatal  in  babies  than  in  older  children.  Symptoms  of  evil  prog- 
nostic import  are  grinding  of  the  teeth,  gallop  rhythm  of  the  heart  sounds,  epigastric 
pain,  and  vomiting. 

The  cases  manifesting  laryngeal  and  nasal  in^•olvement  are  always  grave  as  to 
prognosis.  The  physician  should  also  be  most  guarded  as  to  his  prognosis  as  the 
disease  passes  its  most  active  period,  because  everyone  of  experience  knows  that 
an  attack  of  sudden  heart-failure  often  occurs  as  the  child,  once  more  feeling 
strong,  attempts  to  sit  up.  A  rapid  or  gradual  heart-failure  may  come  on  during 
convalescence.     (See  Sequelse.) 

The  presence  of  much  membrane  and  an  afebrile  temperature  is  evil  in  import. 
Marked  pallor,  or  yellowish  pallor,  with  duskiness  of  the  lips  not  due  to  respiratory 
obstruction ;  not  due  to  membrane,  but  to  toxemia,  bodes  death.  Paralysis  is  usually 
not  of  serious  import  unless  the  respiratory  or  cardiac  innervation  is  attacked. 

Prophylaxis. — As  the  intimate  association  of  a  person,  or  garments,  bearing 
the  specific  bacillus  with  another  individual  who  is  susceptible  to  the  disease  is 
essential  for  its  spread,  it  is  evident  that  by  proper  quarantine  and  isolation  per- 
fect prophylaxis  is  possible.  All  patients  who  have  diphtheria  should  be  isolated 
at  once,  and  the  attendant  who  nurses  the  child  or  adult  who  is  affected  should 
not  associate  with  other  persons  until  after  a  bath  has  been  taken,  the  face  and 
head  well  shampooed  and  the  pharynx  and  nasal  cavities  well  douched.  Cultures 
from  the  throat  of  the  nurse  should  be  made  before  she  proceeds  to  another  case 
which  is  not  diphtheritic.  After  the  patient  is  convalscent,  it  is  to  be  recalled  that 
the  specific  bacillus  may  remain  in  the  nasopharyngeal  mucus  for  a  long  period 
and  so  isolation  is  still  essential.  The  child  should  not  play  with  other  children 
for  at  least  two  weeks,  and  during  this  period  should  have  its  nasopharynx  sprayed 
daily  with  some  bland  antiseptic  wash  such  as  Dobell's  solution,  alkathymol,  or 
normal  saline  solution.  Particularly  in  public  institutions,  the  nasopharyngeal 
secretion  should  be  examined  bacteriologically  during  convalescence  to  prove  the 
presence  or  absence  of  the  specific  infecting  germ  before  the  child  is  discharged. 
As  illustrative  of  this  fact  the  results  of  the  New  York  Board  of  Health  investi- 
gation are  of  interest.  Out  of  605  cases  examined  it  was  found  that  the  bacilli 
were  not  present  in  304  on  the  third  day  after  the  membrane  disappeared,  in  176 
they  were  present  for  seven  days,  in  64  for  twelve  days,  and  in  36  cases  for  fifteen 
days.  Twenty-one  days  after  the  membrane  was  gone  12  showed  bacilli,  and  4 
cases  showed  them  for  twenty-eight  days.  Another  set  yielded  4  cases  of  bacilli 
for  thirty-five  days,  and  2  for  sixty-three  days. 

It  seems  hardly  necessary  to  add  that  the  garments,  bedding,  and  toys  of  all 
diphtheritic  patients  should  be  destroyed  or  thoroughly  disinfected  by  steam  or 
formaldehyde.  The  floors  and  walls  of  the  room  and  the  furniture  should  also 
be  treated  with  formaldehyde,  and  it  should  be  done  as  thoroughly  as  if  the  case 
had  been  one  of  smallpox.  All  discharges  from  the  patient  should  be  received 
in  a  vessel  containing  bichloride  solution,  or,  if  cloths  are  used,  these  should  be 
burned. 

A  very  important  measure  in  all  cases  in  which  the  disease  arises  in  a  family  of 
children  is  the  use  of  immunizing  doses  of  antitoxic  serum  for  the  protection  of 
the  well  from  the  diseased.  There  is  no  doubt  whatever  that  this  is  a  most  efficient, 
never-to-be-neglected  measure.  The  dose  is  not  less  than  500  to  1000  units  and 
the  protection  lasts  about  three  or  four  weeks.  Nurses  as  well  as  children  should 
be  protected  by  its  use. 

The  Schick  test  is  a  test  used  to  determine  the  natural  immunity  of  an  individual 
11 


162 


DISEASES  DUE  TO  A  SPECIFIC  INFECTION 


to  diphtheria  infection.  Its  field  of  usefulness  is  during  an  epidemic  in  an  institu- 
tion or  family  where  there  are  a  considerable  number  of  persons  exposed.  It  con- 
sists in  injecting  y^  part  of  a  dose  of  diphtheria  toxin  that  would  be  lethal  to  a  guinea- 
pig,  into  the  superficial  layers  of  the  skin.  If  the  patient  is  susceptible  to  diph- 
theria a  red  spot  develops  at  the  side  of  the  injection  in  about  forty-eight  hours, 
whereas,  if  it  does  not  appear,  it  may  be  considered  that  the  individual  is  relatively 
immune    and    less    in    need    of    antitoxin. 

When  treating  or  examining  the  throat  the  physician  and  nurse  may  protect 
themselves  from  the  discharges  by  looking  through  a  pane  of  glass  held  before  the 
face  of  the  patient. 

Treament. — ^The  treatment  of  diphtheria  at  the  present  time  is  more  scientifically 
accurate  in  its  basis  and  in  its  results  than  that  of  any  other  malady  save  malarial 
fever,  in  which  we  know  not  only  the  cause  but  the  remedy  for  its  removal.  The 
keystone  of  the  treatment  is  the  liberal  use  of  antidiphtheritic  serum. 

It  is  not  necessary  in  a  work  of  this  character  to  give  massive  accumulations  of 
statistics  to  prove  that  this  plan  is  based  not  only  on  scientific  laboratory  investi- 
gations, but  upon  bedside  experience  as  well. 

The  following  figures,  which  are  Baginsky's,  show  the  decrease  in  mortality  ac- 
cording to  age: 

Before  the  introduction  of  antitoxin  the  mortality  of  diphtheria  according  to 
age  was — 


0  to  2  years  ....  60.2 
2  to  4  years  .  .  .  .  .51.2 
4  to  6  years  ....     38.0 


6  to  8  years  . 
8  to  10  years  . 
12  to  14  years  . 


Since  the  introduction  of  antitoxin  the  death  rate  is- 


0  to  2  years  ....  2.5. 88 

2  to  4  years  .      .      .      .  17.12 

4  to  6  years  .      .      .      .  17 . 24 

6  to  8  years  ....  11.39 


8  to  10  years 
10  to  12  years 
12  to  14  years 


22.9 
28.8 
18.5 


5.17 
10.0 
13.3 


The  following  chart  of  Park  and  Bolduan  is  another  illustration  of  the  life- 
saving  effects  of  antitoxin. 

Fig.  41 


'73  '79 

'30]'31 

'i: 

safsifSoi'sG 

77 

'88 

'sa 

'sOi'ai 

'92!'03j'91 

'J.5 

'i)6 

'07'98j'il!) 

00 

0l,'03'03,'0l 

'0.5 

1 

/ 

^ 

/ 

V 

^ 

s/ 

-V 

V 

■y 

/ 

^ 

\ 

V 

\ 

vj 

N 

^ 

-~ 

V, 

■v 

^ 

Chart  showing  thr 


iibinod  curve  of  mortality  of  diphtheria  in  19  ritita  in  .\mtrica  and  Europe. 
The  use  of  antitoxin  began  in  1894. 


The  physician  who  fails  to  use  antitoxin,  when  it  is  to  be  had,  is  guilty  of  a  gross 
lack  of  professional  knowledge  or  is  atrociously  careless  of  his  patient's  welfare. 


DIPHTHERIA  1G3 

There  are  several  points  to  be  borne  in  mind  in  regard  to  the  use  of  antitoxin, 
namely  (1)  it  must  be  employed  early  in  the  attack  to  get  the  best  results,  for  it 
is  manifest  that  after  the  disease  has  existed  long  enough  to  do  permanent  damage 
to  the  tissues  no  antidote  can  be  satisfactory.  No  one  would  expect  to  give  the 
antidote  for  arsenic  two  days  after  the  poison  was  taken  and  expect  good  results. 
Nevertheless,  when  antitoxin  has  not  been  used  early  it  must  be  given  freely  in  the 
hope  of  its  aiding  the  patient  sufficiently  to  help  him  withstand  the  infection. 
(2)  The  antitoxin  should  be  given  liberally.  A  few  large  doses  in  the  onset  of  the 
attack  not  only  are  of  great  value,  but  are  really  economical  so  far  as  cost  is  con- 
cerned. (3)  It  must  be  given  in  particularly  large  doses  in  cases  of  nasal  and 
laryngeal  diphtheria,  because  these  are  forms  in  which  rapid  absorption  of  the 
toxin  of  the  disease  and  respiratory  obstruction  takes  place  and  the  malady  must 
be  most  actively  opposed.    In  these  cases  it  may  be  useful  to  give  it  intravenously. 

(4)  Whenever  a  person  is  exposed  to  diphtheria  he  should  receive  a  moderate  dose 
of  antitoxin  to  protect  him  from  infection.    The  dose  should  be  about  1000  units. 

(5)  When  diphtheria  is  suspected  to  be  present  it  is  well  to  give  antitoxin  at  once 
rather  than  run  the  risk  of  waiting  for  a  sure  diagnosis.  In  administering  anti- 
toxin the  following  rules  should  be  followed: 

1.  The  skin  over  the  outer  surface  of  the  thigh  or  over  the  flank  or  lateral  abdom- 
inal wall  should  be  cleansed  with  soap  and  water  and  alcohol. 

2.  The  serum  should  be  injected  by  means  of  a  syringe  or  bulb,  tlirough  a  large 
hypodermic  needle  which  is  inserted  through  the  skin  where  it  has  been  cleansed. 
If  the  injection  is  made  on  the  outer  side  of  the  thigh  it  is  best  given  directly  into 
the  belly  of  the  vastus  externus  muscle. 

3.  The  injection  should  be  made  slowly  and  quietly  and  the  swelling  which 
results  should  not  be  rubbed. 

4.  At  least  4000  to  5000  units  of  antitoxic  serum  should  be  gi\-en  at  the  first 
dose  and  repeated  in  four  to  eight  hours,  according  to  the  severity  of  the  case. 

If  the  patient  is  seen  as  late  as  the  second  day  the  dose  should  be  6000  units, 
and  if  seen  on  the  third  day,  from  9500  to  20,000  units  if  the  membrane  is  large 
or  the  other  signs  severe. 

5.  In  nasal  and  laryngeal  cases  6000  or  more  units  for  the  first  dose  are  usually 
necessary. 

The  result  of  this  plan  of  treatment  is  often  magical.  The  symptoms  of  general 
systemic  disturbance,  such  as  a  rapid  pulse  and  fever,  become  modified,  the  mem- 
brane ceases  to  grow  and  loses  its  tenacious  hold  of  the  subjacent  tissues,  becoming 
not  only  loose  but  softened,  and  speedily  disappears. 

The  only  disagreeable  effects  of  using  antitoxin  in  large  doses  are  the  subsequent 
development  of  some  pain  or  soreness  in  the  joints  or  the  appearance  of  an  urticarial 
rash;  but  even  if  these  symptoms  appear  thej^  are  not  serious  and  need  give  no 
alarm.  "These  symptoms  of  so-called  serum  sickness"  are  largely  avoided  by 
the  use  of  antitoxin  in  the  form  of  globulins,  as  it  has  been  found  that  they  depend 
upon  a  certain  substance  or  substances  in  the  serum,  which  are  present  in  compar- 
atively small  amounts  in  the  globulins,  which,  in  turn,  contain  most,  if  not  all,  of 
the  antitoxic  power.  Besredka  also  claims  that  if  a  few  drops  of  antitoxin  or 
globulin  solution  are  first  injected,  this  small  dose  if  repeated  two  or  three  times  at 
half-minute  intervals,  desensitizes  the  patient  so  that  the  large  dose  may  be  injected 
with  much  less  danger  of  serum  sickness  or  anaphylaxis. 

It  is  impossible  to  determine  beforehand  what  cases  will,  because  of  idiosyncrasy, 
suffer  from  anaphylaxis,  save  that  asthmatics  and  patients  of  a  marked  lymphatic 
type  seem  more  prone  to  it  than  others.  Notwithstanding  the  startling 
effects  in  these  cases  it  is  to  be  distinctly  understood  and  sharply  emphasized 
that  thejnumber  of  these  accidents  has  been  so  infinitesimal  as  compared  to  the 
hundreds  of  thousands  of  injections  given  during  the  last  ten  years  that  no  hesita- 


104  i)/si':.\si':s  due  to  a  specific  ixfection 

tion  should  he  allowed  in  the  use  of  antitoxin  in  (hphtheria  except  in  the  class  of 
cases  already  referred  to  and  under  the  conditions  ahout  to  be  named,  for  the 
danger  of  the  disease  is  great  and  that  of  the  injection  is  a  negligible  quantity. 
An  important  fact  to  be  borne  in  mind  is  that  the  injection  of  antitoxin  for  the 
purpose  of  immunizing  an  individual  who  has  l)een  exposed  to  the  disease  or  for  the 
purpose  of  combating  an  attack  of  diphtheria  already  present  produces  after  the 
lapse  of  several  days  a  condition  whereby  the  j)atient  develops  an  increased 
susceptibility  to  the  serum  or,  in  other  words,  becomes  sensitized  to  its  effects, 
thereby  producing  a  state  in  which,  the  severe  symptoms  already  sjjoken  of  may 
ensue  when  a  subsequent  dose  is  given.  This  condition,  called  anaphylaxis,  does 
not  take  place  if  the  doses  of  serum  are  given  every  few  hours  or  even  every  day 
for  an  indefinite  period  of  time.  It  is  only  when  an  interval  elapses  between 
doses  amounting  to  several  days  or  more  that  the  patient  is  in  danger  of  anaphylaxis 
when  an  injection  is  given.  In  other  words,  a  patient  who  has  received  an  immu- 
nizing dose  of  antitoxin  or  a  curative  dose  on  one  occasion  is  far  more  likely  to 
develop  evil  symptoms  after  a  dose  given  some  time  later  than  a  patient  who 
receives  the  antitoxin  for  the  first  time.  The  lesson  to  be  learned  from  this  in 
practical  medicine  is  that  when  a  patient  gives  a  history  that  antitoxin  has  been 
comparatively  recently  used,  the  physician-should  be  cautious  in  the  administration 
of  the  remedj-  or  prophylactic.  When  a  second  attack  of  diphtheria  is  actually 
present  the  danger  to  life  is  probably  far  greater  from  the  disease  than  from  the 
possible  development  of  anaphylaxis,  but  the  fact  that  hypersensitiveness  to  anti- 
toxic serum  may  have  been  developed  by  a  previous  injection  must  be  carefully 
considered  when  the  question  of  giving  a  dose  for  immunization  arises.  The 
rule  would  seem  to  be  that  where  a  child  is  thoroughly  exposed  to  infection,  an 
immunizing  dose  had  better  be  given,  but  where  the  exposure  is  not  so  great  as 
to  lead  the  physician  to  the  belief  that  infection  is  almost  certain  to  occur,  it  may 
be  well  to  avoid  the  use  of  an  immunizing  dose  for  the  reasons  given.  The  physician 
is  placed  in  the  difficult  position  of  determining  whether  there  is  greater  danger 
to  the  child  of  an  attack  of  diphtheria  or  of  the  development  of  the  symptoms  of 
anaphylaxis,  and  each  case  must  be  decided  upon  its  merits.  In  orjihanages  and 
ho.spitals  a  large  number  of  children  are  gathered  together,  the  certain  mortality 
of  an  outbreak  justifies  the  universal  use  of  immunizing  doses,  since  the  flanger 
of  the  disease  is  infinitely  greater  than  the  danger  of  anaphylaxis.  In  private 
practice,  however,  the  question  is  quite  different  and  must  be  decided  in  each 
instance  on  its  own  merits. 

So  far  no  method  has  been  devised  by  which  these  desperate  symptoms  of  anaphy- 
laxis can  be  combated.  Adrenalin  has  been  used  without  any  very  good  grounds 
for  its  employment,  and  without  very  much  success.  The  drug  which  would 
seem  to  promise  the  most  relief,  so  far  as  the  pulmonary  edema  is  concerned,  is 
atropine  in  full  doses. 

The  local  treatment  of  diphtheria  consists  in  the  application  to  the  false  membrane 
of  peroxide  of  hydrogen  by  means  of  a  spray  or  swab.  This  active  disinfectant 
disintegrates  the  exudate  and  aids  in  its  removal.  The  other  local  applications 
which  have  been  used  in  the  past  are  painful,  injurious,  or  ineffective  as  compared 
to  this  agent. 

The  systemic  treatment,  aside  from  the  use  of  antitoxin,  consists  in  the  employ- 
ment of  foods  which  are  easily  swallowed  and  which  will  maintain  the  vitality 
of  the  patient  to  the  highest  degree,  such  as  gruels  made  of  barley  or  rice,  which  are 
digested  in  great  degree  by  the  administration  of  2  to  4  grains  of  taka-diastase. 

When  the  pulse  fiags,  .small  doses  of  aromatic  spirit  of  ammonia  or  Hoffmann's 
anodyne  (10  to  30  drops  in  water  may  be  used)  or  brandy  which  is  old  enough  to 
have  a  "bouquet"  may  be  given.  Full  doses  of  strychnine  should  also  be  used  for 
the  same  purpose.     Perfect  rest  of  mind  and  body  should  be  obtained  if  possible 


GONORRHEAL  INFECTION  165 

and  great  care  taken  during  the  illness  and  during  convalescence  tliat  no  sudden 
exertion,  which  may  cause  cardiac  failure,  is  permitted. 

When  obstruction  of  the  larynx  takes  place  the  patient's  life  may  often  he  saved 
by  intubation  or  tracheotomy.  In  these  cases  tiic  patient  should  be  kept  in  a 
room  the  air  of  which  is  moistened  by  steam. 

The  complications  and  sequelae  are  treated  in  the  following  manner:  The  anemia 
is  to  be  controlled  by  the  use  of  moderate  doses  of  reduced  iron.  Large  doses  are 
unnecessary  and  tend  to  cause  constipation  and  disordered  digestion.  A  quarter 
grain  three  times  a  day  is  quite  sufficient,  given  in  a  small  chocolate-coated  tablet 
or  placed  in  a  gum-drop.  In  some  instances  3  to  5  minims  of  tincture  of  the  chloride 
of  iron  is  equally  good;  y^^^  grain  of  arsenous  acid  in  a  sugar-coated  granule  may 
be  given  simultaneously  or  in  alternate  weeks.  This  treatment  is  also  advisable 
for  the  relief  of  the  local  or  general  paralysis,  which  is  usually  associated  with 
marked  anemia.  In  other  instances  the  syrup  of  the  hypophosphites  may  be 
used,  and  phosphorus  is  often  of  value  in  the  dose  of  y,yiy  grain  three  times  a  day. 
Another  remedy  of  great  value  as  a  roborant  is  cod-liver  oil. 

In  regard  to  the  use  of  strychnine,  which  is  so  largely  used  as  a  circulatory  and 
nervous  stimulant  in  all  conditions  of  depression,  it  should  be  remembered  that 
it  is  never  a  stimulant  which  in  any  way  increases  the  nutrition  of  the  part  in\-ol\-ed. 
It  simply  acts  as  an  irritant  stimulant.  If  there  is  reason  to  believe  that  a  "whip" 
is  needed  to  spur  atonic  nerves  to  greater  effort,  it  may  be  used,  but  if  there  is  an>- 
evidence  of  nervous  irritation  it  is  better  not  to  employ  it.  Aside  from  the  treat- 
ment already  named  there  is  little  which  can  be  done  to  benefit  the  paralysis. 

GONORRHEAL  INFECTION. 

There  are  still  some  roues,  and  ignorant  persons,  who  lie  under  the  delusion, 
at  one  time  prevalent,  that  an  attack  of  gonorrhea  is  of  little  more  gravity  "  than 
a  bad  cold."  A  considerable  number  of  both  classes  learn  by  experience  sooner 
or  later  that  this  is  a  most  mistaken  conception  of  the  disease.  It  must  not  be 
forgotten  that  within  the  last  few  years  it  has  been  proved  again  and  again  that 
the  gonococcus  may  find  entrance  into  the  general  system  from  the  urethra  and 
there  cause  the  most  disastrous  consequences.  Further  than  this,  while  systemic 
dissemination  of  the  gonococcus  usually  is  secondary  to  venereal  infection,  it  is 
to  be  remembered  that  gonococcal  inflammation  of  any  susceptible  mucosa,  as 
the  conjunctiva,  may  afford  a  point  of  entrance.  Heimann  has  reported  a  case 
of  gonococcemia  in  which  he  thinks  infection  occurred  through  a  wound,  and 
Kimball  believes  the  mouth  or  upper  air-passages  may  constitute  portals  of  entry. 
He  has  also  reported  a  series  of  cases  of  gonorrheal  pyemia  due  to  volvovaginitis 
in  children,  some  cases  being  only  three  months  old.  If  it  gains  access  to  the  joints, 
it  may  not  only  produce  a  temporary  gonorrheal  arthritis,  but  it  may  also  cause  a 
chronic  arthritis  which  is  usually  multiple,  and  sometimes  is  so  widespread  that  the 
patient  is  crippled  hand  and  foot,  finger  and  toe,  for  the  balance  of  his  life,  the 
incapacity  of  the  patient  being  even  greater  and  more  rapid  in  its  onset  than  if 
he  were  suffering  from  rheumatoid  arthritis. 

Symptoms. — The  appearance  of  a  joint  suffering  from  gonorrheal  inflammation 
does  not  difi'er  materially  from  that  of  acute  rheumatic  fever.  It  is  swollen  and 
exquisitely  temler.  The  skin  about  the  joint  is  hot,  but  often  it  is  not  much  reddened ; 
on  the  contrary,  in  some  cases  it  presents  a  peculiar  leaden  hue.  The  temperature 
of  the  body  in  general  is  usually  normal,  but  there  is  often,  at  the  time  of  onset, 
some  fever.     In  some  cases  there  is  a  notable  serous  peri-arthritis. 

Gonorrheal  arthritis,  as  a  rule,  attacks  the  large  joints.  It  is  most  commonly 
multiple,  but  it  may  be  single.  I  have  seen  not  only  all  the  large,  but  the  small 
joints  infected  simultaneously.    Even  the  sacro-iliac,  maxillary,  and  sternoclavicular 


166  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

joints  may  be  involved.  This  is  a  noteworthy  point  when  we  remember  that  infec- 
tion of  the  maxiihiry  joint  almost  never  occurs  in  ordinary  rheumatism. 

According  to  French  statistics  the  knees  are  attacked  more  freciuently  tlian  any 
other  joint  in  the  body — 83  times  out  of  119  cases;  the  ankle  32  times,  fingers  and 
toes  23  times,  the  hips  16  times,  the  WTist  14,  the  shoulder  12,  and  the  elbow  11. 

It  must  be  distinctly  understood  that  gonorrheal  arthritis  has  no  relation  whatever 
to  acute  articular  rheumatism.  The  tendency  on  the  part  of  many  physicians  to 
call  all  swellings  of  joints  rheumatism  is  to  be  deplored.  The  mere  presence  of 
heat,  swelling,  and  pain  in  a  joint,  with  or  without  fever,  does  not  necessarily 
indicate  that  rheumatism  is  the  cause. 

Suppuration  of  a  joint  as  a  result  of  gonorrheal  infection  very  rarely  occurs,  but 
ankylosis,  due  to  thickening  of  the  synovial  membranes,  ligaments,  and  periarticular 
tissues,  and  atrophic  changes  in  the  cartilages  and  in  the  ends  of  the  bone  are  met 
with.  In  other  words,  gonorrheal  infection  of  a  joint  may  result  in  fibrous  ankylo- 
sis, or  in  atrophy,  or  in  overgrowth  of  bony  tissue,  as  in  rheumatoid  arthritis. 

The /a*cia  in  different  portions  of  the  body  may  also  be  infected.  This  is  particu- 
larly- apt  to  occur  in  the  plantar  region  and  not  infrequently  stiffening  and  inflamma- 
tion of  the  tendo  Achillis  is  met  with. 

A  second  serious  consequence  of  gonorrheal  infection  is  the  development  of  a 
gonorrheal  endocarditis.  As  long  ago  as  1854  Brandes  recorded  two  cases  of  gonor- 
rhea with  arthritis  and  endocarditis,  and  in  1862  Traube  reported  another  of 
gonorrheal  endocarditis  without  joint  infection.  None  of  these  cases  were  proved 
to  be  due  to  the  gonococcus  because  this  organism  was  not  known  at  that  time, 
but  in  1893  Leyden  proved  the  presence  of  the  gonococcus  in  the  heart.  Since 
then  many  more  cases  have  been  reported  in  which  the  gonococcus  has  been  isolated 
from  the  endocardium  or  the  circulating  blood.  Perhaps  the  most  noteworthy 
report  was  that  of  Thayer  and  Lazear  in  1899. 

There  is  no  special  time  in  the  course  of  the  attack  of  gonorrhea  at  which  the 
endocardial  involvement  takes  place.  Occasionally  it  has  come  in  the  stage  of 
onset,  but  in  most  cases  it  occurs  at  about  the  fifth  week.  In  others  it  is  postponed 
for  weeks,  or  even  for  months.  In  a  case  reported  by  Finley  and  ^NlcCrae  a  fatal 
endocarditis  developed  nine  months  after  the  onset  of  the  uretliral  discharge, 
and  when  that  discharge  was  no  longer  present,  although  a  microscopic  examination 
of  the  urethral  mucosa  revealed  gonococci. 

While  it  is  true  that  these  cases  are  comparatively  rare  when  we  consider  the 
frequency  of  gonorrhea,  it  is  probable  that  they  occur  with  more  frequency  than 
has  been  generally  thought,  and  it  is  a  noteworthy  fact  that  in  those  cases  in  wliich 
the  physician  is  skilful  enough  to  examine  the  blood,  or  the  endocardium,  for  the 
gonococcus,  that  it  is  found  as  a  pathogenic  micro-organism  much  more  frequently 
than  in  those  cases  in  which  the  physician  does  not  possess  such  pathological 
training.  With  improvements  in  technique,  general  gonorrheal  infection  will 
probably  be  recognized  as  being  by  no  means  as  infrequent  as  it  has  been  thought 
in  the  past. 

Males  are  very  much  more  frequently  affected  by  systemic  infection  of  this 
character  than  are  females. 

Systemic  gonorrheal  infection  follows  not  only  the  primary  disease  in  the  urethra 
or  vagina,  but  has  been  met  with  in  infants  suffering  from  ophthalmia  neonatorum 
due  to  the  gonococcus.     In  some  cases  the  infection  is  pure;  in  others  it  is  mixed. 

Diagnosis. — The  statement  of  a  patient  suffering  from  an  acute  arthritis,  acute 
ophthalmia,  or,  indeed,  an  acute  endocarditis,  that  he,  or  she,  is  also  suffering 
from  gonorrhea  will  do  much  toward  making  the  diagnosis  of  the  condition  clear. 
But  in  the  majority  of  instances  the  patient  neglects  to  give  this  important  informa- 
tion, and  in  a  considerable  number  of  cases  denies  gonorrheal  infection  of  the 
genitalia,  thinking  that  it  can  have  no  bearing  upon  the  inflammation  elsewhere, 


GONORRHEAL  INFECTION  107 

and  that  therefore  it  is  unnecessary  to  mention  the  fact  that  such  a  local  infection 
exists.  Not  rarely  patients  will  deny  the  existence  of  a  local  genital  lesion,  and 
it  can  only  be  discovered  upon  careful  examination.  It  may  be  necessary  in  some 
cases  to  examine  the  secretions  of  the  urethra  or  the  vagina  hy  staining  and  by 
the  microscope. 

It  may  be  said  that  in  every  male  suffering  from  acute  arthritis  between  the 
ages  of  fifteen  and  sixty  the  possibility  of  gonorrheal  infection  should  be  considered 
as  having  almost  equal  rank  with  the  possibility  of  acute  articular  rheumatism, 
and  the  development  of  endocarditis  should  not  be  considered  as  indicative  of  one 
condition  more  than  the  other,  although  as  a  matter  of  fact  endocarditis  is,  of 
course,  infinitely  more  common  in  true  articular  rheumatism  than  it  is  in  gonorrheal 
infection.  On  the  other  hand  the  mere  discovery  by  the  physician  of  a  presence 
of  a  purulent  discharge  from  the  urethra  does  not  by  any  means  prove  that  the 
patient  has  gonorrheal  arthritis.  It  is  entirely  possible  for  him  to  have  acute 
articular  rheumatism  and  gonorrhea,  and  again,  it  sometimes  happens  that  gouty 
persons  have  a  purulent  discharge  from  the  urethra  which  does  not  depend  upon 
the  gonococcus.  Rarely,  too,  a  purulent  urethral  discharge  is  found,  in  persons 
who  are  not  gouty,  which  does  not  depend  upon  the  gonococcus,  but  is  due  to 
another  form  of  infection. 

A  therapeutic  test  of  some  value  lies  in  the  fact  that  full  doses  of  the  salicylates 
usually  cause  remarkable  improvement  in  the  arthritis  of  rheumatism,  and  affect 
in  no  way  whatever  the  arthritis  of  gonorrhea.  Again,  it  is  characteristic  of  true 
rheumatism  to  leave  one  joint  as  it  affects  another;  whereas,  in  gonorrheal  rheuma- 
tism it  is  rare  for  the  inflammation  to  diminish  in  the  joint  primarily  affected  when 
other  joints  become  involved. 

Prognosis. — The  prognosis  in  gonorrheal  rheumatism  is  favorable  in  the  majority 
of  instances,  provided  the  infection  is  not  very  severe,  and  is  not  persistent.  The 
physician,  however,  must  be  most  guarded  in  expressing  an  opinion  as  to  ultimate 
complete  recovery,  for,  as  already  stated,  some  of  the  severest  cases  of  clironic 
multiple  arthritis  are  met  with  as  the  result  of  this  infection  of  the  joints.  The 
prognosis  is  also  influenced  to  some  extent  by  the  history  of  the  patient.  If  he 
has  already  suffered  from  previous  attacks  of  gonorrheal  arthritis,  the  probability 
of  complete  recovery  is  not  as  good  as  in  primary  attacks. 

Endocarditis  due  to  gonorrheal  rheumatism  is  a  very  serious  condition  and 
often  results  in  death. 

Treatment. — The  treatment  of  gonorrheal  arthritis  consists,  first,  in  the  cure  of 
the  local  area  of  primary  infection  as  rapidly  as  possible.  For  this  purpose  the 
ordinary  forms  of  treatment  for  gonorrhea  are  to  be  followed.  The  arthritis  is 
to  be  relieved  by  the  use  of  a  splint  and  by  the  application  of  a  50  per  cent,  ichthyol 
ointment  to  the  joint.  If  the  inflammation  is  exceedingly  acute  an  ice-bag  may 
be  employed,  and  if  the  effusion  is  considerable  aspiration  may  be  needed  to  relieve 
pressure.  In  some  instances  the  best  results  are  obtained  by  opening  the  joint 
and  permitting  free  drainage.  Should  the  physician  place  the  limb  of  the  patient 
suffering  from  gonorrheal  arthritis  upon  a  splint,  it  should  not  remain  so  fixed 
for  any  length  of  time,  as  ankylosis  is  particularly  prone  to  ensue.  The  splint  is 
used  only  for  the  relief  of  pain  in  the  acute  inflammatory  stages. 

As  already  stated,  the  salicylates  are  useless  in  gonorrheal  arthritis.  Indeed, 
they  are  worse  than  useless  in  that  they  in  no  way  influence  the  infection  and  they 
are  apt  to  disorder  the  stomach.  Rest  in  the  acute  stages  and  the  treatment  of 
the  local  infection  is  the  most  that  can  be  done  for  the  patient  aside  from  local 
applications.  Later,  passive  movements  of  the  joints  and  the  use  of  the  iodides 
or  of  the  syrup  of  the  iodide  of  iron,  if  anemia  is  also  present,  must  be  resorted  to. 
Endocarditis  is  to  be  treated  as  is  ordinary  ulcerative  endocarditis. 

The  use  of  antigonococcic  serum,  derived  from  the  blood  of  sheep,  has  proved 


168  DISEASES  DUE  TO  A   SI'ECIF/f  IXFECTIOX 

of  very  great  valiR-  in  the  trcatiiiciit  (if  j^oiiorrheal  arthritis,  l)iit  useless  in  ureliilis, 
epididymitis  and  iiretliritis  due  to  tiie  same  organism.  Tiiis  serum  eauses  a  distinct 
general  and  local  reaction.  The  dose  is  2  e.e.  given  every  second  or  third  day. 
Given  at  long  intervals  it  may  eau.se  anaphylaxis.  So,  too,  gonorrhea  phylacogen 
may  be  used,  beginning  with  2  c.c.  at  a  dose  and  increasing  the  dose  every  second 
day. 

ERYSIPELAS. 

Defimtion. — Erysipelas  is  an  acute  infectious  disease  due  to  the  entrance  into 
the  sicin  in  its  deeper  layers  of  the  Streptococcus  pyogenes,  sometimes  called  the 
Streptococcus  erysipelatis.  The  skin  of  the  part  affected  becomes  dusky  red,  and 
swollen.  A  peculiarity  of  the  area  of  redness  is  that  it  has  a  sharp  line  of  demarca- 
tion separating  it  from  the  surrounding  healthy  tissue,  which  is  usually  of  its 
natural  color  and  appearance.  The  line  of  demarcation  can  be  not  only  seen  but 
can  be  felt  by  the  finger-tip,  and  if  the  affected  area  be  punctured  and  the  serum 
which  then  exudes  stained  with  methylene  blue  the  chains  of  streptococci  can  readily 
be  found  under  the  microscope.  p]r\sipelas  is  sometimes  called  "St.  Anthonv's 
Fire." 

Frequency. — Erysipelas  is  found  in  nearly  all  parts  of  the  world  and  is  not  infre- 
quently present  in  epidemic  form  in  hospitals  and  other  institutions  in  which  large 
numbers  of  persons,  with  impaired  health,  are  together  in  wards  and  dormitories. 
Under  these  conditions  it  spreads  rapidly  from  patient  to  patient,  particularly 
if  wounds  afford  an  entrance  into  the  body.  For  this  reason  the  outbreak  of  the 
disease  in  an  institution  should  be  followed  by  the  immediate  isolation  of  the 
patient  and  a  thorough  disinfection  of  the  entire  ward  in  which  he  has  l)een  lying. 
The  disease  occurs  most  frequently  in  the  spring  months,  particularly  in  April, 
but  is  met  with  at  all  seasons  of  the  year. 

Etiology. — As  already  stated  the  cause  of  erysipelas  is  the  entrance  into  the 
deeper  layers  of  the  skin  of  the  streptococcus  in  a  form  which  cannot  be  separated 
from  that  which  sometimes  produces  purulent  infection  in  other  parts  of  the  body. 
The  anatomical  and  many  of  the  clinical  features  of  this  disease  may  be  produced 
by  several  closely  allied  bacteria,  but  the  clinical  manifestations  of  erysipelas  are  so 
constantly  associated  with  the  Streptococcus  erysipelatis  that  the  different  infections 
may  be  ignored  or  grouped  with  this  one.  Two  additional  factors  are  nearly 
always  active  in  the  production  of  the  disease,  namely,  a  break  in  the  skin  or  in  a 
neighboring  mucous  membrane,  so  that  the  streptococcus  gains  access  to  the  tissues, 
and,  secondly,  some  cause,  local  or  general,  which  diminishes  vital  resistance  to 
such  a  degree  that  the  tissues  afford  a  favorable  site  for  the  growth  of  the  micro- 
organism. Thus  erysipelas  may  be  due  to  the  infection  of  a  small  pim])le,  by 
scratching  it  with  the  finger-nail,  and  it  is  not  uncommonly  met  with  in  those  who 
are  suffering  from  renal  disease,  from  diabetes,  from  alcoholism,  or  from  some 
condition  which  distinctly  decreases  the  ability  of  the  body  to  protect  itself  from 
infection. 

Sometimes  the  resisting  power  is  decreased  by  local  causes,  as  by  exposure  to 
great  cold,  but  it  is  very  doubtful  if  this  cause  alone,  with  the  presence  of  the  strepto- 
coccus, is  capable  of  causing  the  disease  unless  the  general  systemic  vital  resistance 
is  impaired. 

The  course  tt)  be  followed  in  cases  of  early  erysipelas  is  to  examine  into  the  state 
of  the  urine  at  once,  and,  even  if  this  be  found  normal,  to  examine  it  re])eatedly 
for  evidences  of  renal  disease  or  diabetes,  since  such  causes  render  the  patient  \ery 
susceptible.  Search  for  other  causes  of  im[)aired  health  should  also  be  made, 
because  erysipelas  is  a  malady  which  is  particularly  prone  to  attack  those  who 
are  already  ill,  even  if  the  primary  illness  is  not  apparent.  Occasionally  the  physi- 
cian meets  with  a  case  in  which  there  is  no  underlying  dyscra.sia  which  predisposes 


ERYSIPELAS  109 

to  the  disease.  In  these  instances  the  patient  may  have  repeated  attacks,  due 
apparently  to  general  susceptibility  to  this  infection,  the  streptococci  remaining 
inactive  in  the  tissues  in  certain  cases  for  weeks  at  a  time.  Women  during  the 
puerperal  period  are  especially  susceptible  to  the  infection. 

Pathology  and  Morbid  Anatomy. — Primarily  the  lesion  of  erysipelas  consists  of  a 
hyperemia;  later,  an  exudate  composed  of  cells  and  fluid  appears  in  the  layers  of 
true  skin,  associated  with  a  rapid  growth  of  the  streptococcus  in  the  lymph  spaces 
in  the  margin  of  and  often  beyond  the  inflammatory  zone.  In  severe  cases  the 
lesion  spreads  with  great  rapidity  and  may  affect  not  only  the  deeper  layers  of 
the  skin,  but  the  underlying  connective  tissue  as  well.  The  destructive  action  of  the 
bacterial  toxin  may  lead  to  the  formation  of  sloughs,  gangrenous  erysipelas,  or  the 
polymorphonuclear  leukocytes  may  accumulate  in  such  numbers  as  to  constitute 
pus,  forming  the  so-called  phlegmonous  erysipelas.  In  rare  instances  the  strepto- 
coccus, after  entering  the  body  through  some  dissolution  of  continuity  in  the  skin 
or  mucous  membrane,  is  carried  by  the  blood  or  lymphatic  system  to  distant  parts, 
causing  a  development  of  the  disease  far  from  the  site  of  the  primary  lesion. 

The  accompanying  visceral  lesion  may  be  due  to  the  absorbed  toxin  or  to  strepto- 
coccemia.  The  former  may  cause  degenerative  changes,  such  as  focal,  or  even 
diffuse,  necrosis  in  the  liver,  spleen,  kidneys,  or  myocardium.  The  entrance  of 
the  streptococcus  into  the  blood  may  be  manifested  in  an  endocarditis,  pericarditis, 
nephritis,  pleuritis,  meningitis,  arthritis,  osseous  or  pulmonary  infections,  or  other 
evidences  of  colonization  of  the  germ  in  the  various  organs  or  tissues. 

The  onset  of  erysipelas  is  associated  with  a  leukocytosis  of  polymorphonuclear 
cells,  except  in  malignant  cases  in  devitalized  persons. 

Incubation. — The  period  between  the  introduction  of  the  streptococcus  and  the 
development  of  the  disease  varies  greatly  in  different  cases.  Usually  the  period 
of  incubation  lasts  from  three  to  seven  days. 

Symptoms. — In  the  great  majority  of  cases  erysipelas  affects  the  skin  of  the  face 
about  the  corners  of  the  nose  or  near  the  ear.  A  tingling  of  the  skin  is  felt  which 
speedily  becomes  an  intense  burning,  and  is  increased  bj'  rubbing  or  scratching 
the  part.  This  reddened  area  spreads  rapidly  and  is  characterized  at  the  end  of 
twenty-four  hours,  or  before,  by  the  presence  of  a  sharp  line  of  demarcation,  which 
marks  the  advancing  line  of  inflammation,  a  margin  which  can  often  be  felt  as  a 
slightly  indurated  and  raised  edge.  Sometimes  the  inflammatorj^  process  projects 
well-defined  areas  of  extension  into  the  healthy  skin.  Palpation  of  the  diseased 
skin  also  reveals  the  fact  that  it  is  hot  and  somewhat  brawny  and.  tender.  The 
color  of  the  part  is  not  a  bright  red,  but  is  dusky  in  hue.  The  swelling  of  the  face 
when  well  developed  is  sufficient  to  render  the  patient  unrecognizable,  and  the 
eye,  or  eyes,  may  be  completely  closed  by  the  infiltration  of  the  eye-lids.  The  ears 
when  involved  become  swollen  to  an  extraordinary  degree  and  the  skin  seems 
very  tense  and  indurated.  Not  infrequently  blebs  or  blisters  form  over  the  inflamed 
area. 

After  the  early  stage  of  onset  it  has  been  my  experience  that  patients  rarely 
complain  very  greatly  of  pain  and  burning. 

The  amount  of  systemic  disttirbance  varies  very  much  in  different  cases.  In 
those  who  have  previously  been  in  moderate  health  the  local  lesion  and  the  degree 
of  systemic  disturbance  may  be  so  slight  as  to  be  scarcely  noticeable.  The  patient 
may  complain  of  a  slight  chilliness,  the  pulse  may  be  slightly  accelerated,  and  the 
temperature  raised  one  or  two  degrees.  In  other  cases  in  which  vital  resistance 
is  poor  and  the  infecting  germ  virulent  in  form,  the  symptoms  just  described  are 
very  severe  in  degree,  so  that  rigors,  high  fever,  a  rapid  pulse,  delirium,  and  great 
prostration  may  be  present.  In  still  other  cases,  not  so  common,  when  by  reason 
of  great  diminution  of  vital  powers  the  general  health  has  been  greatly  undermined, 
as  in  advanced  diabetes  or  I3right's  disease,  the  disease  attacks  the  patient  so 


170  DISEASES  DUE  TO  A  SPECIFIC  INFECTIOX 

vigorously  that  he  sinks  beneath  its  onset  without  having  enough  stamina  to  resist 
the  infection,  and  may  pass  into  semi-coma  or  e\'en  convulsion.^  followed  by  colla'pse 
due  to  the  apparent  exacerbation  of  the  underlying  malady  by  the  secondary 
infection.  In  rare  instances  the  part  involved  may  become  [langrenoiis  and  death 
may  follow  from  sepsis  and  exhaustion. 

In  cases  of  ordinary  severity  the  fever  lasts  about  five  days  and  ends  by  crisis. 

One  attack  of  erysipelas  does  not  protect  but  rather  predisposes  the  patient 
to  another. 

Under  the  name  erysipelas  migrans  a  form  of  the  disease  is  met  with  in  which 
the  disease  spreads  from  part  to  part  and,  in  the  course  of  its  wandering,  may 
affect  successively  almost  the  entire  surface  of  the  body. 

Complications  and  Sequelae. — When  erysipelas  attacks  individuals  who  are  greatly 
impaired  in  health  the  results  are  often  grave,  not  only  because  the  onset  of  erysip- 
elas is  dangerous  in  itself,  but  because  it  is  an  indication  in  many  cases  of  a  grave 
disease,  hitherto  unrecognized,  which  may  speedily  cause  the  death  of  the  patient 
by  an  exacerbation.  Thus  the  development  of  erysipelas  in  cases  of  chronic 
Bright's  disease  not  only  means  that  the  renal  lesion  has  resulted  in  poor  resistance, 
but  in  addition  the  task  of  eliminating  the  toxins  of  the  new  malady  may  so  over- 
whelm the  kidneys  that  they  may  cease  to  perform  their  function. 

Again  in  cases  of  greatly  impaired  health  the  inflammatory  process  goes  on  to 
suppuration  and  the  deeper  tissues  become  filled  with  pus,  forming  the  phlegmonous 
form  of  the  disease.  In  other  instances  septic  embolism  occurs  in  the  lungs,  brain, 
kidneys,  liver,  and  spleen. 

A  focus  of  erysipelatous  inflammation  also  results  sometimes  in  the  production 
of  ulcerative  endocarditis  or  even  imrulent  pleuritis  or  pericarditi.s,  but  these  complica- 
tions probably  are  of  less  common  occurrence  than  has  been  thought.  In  1674 
cases  of  erysipelas  collected  by  Anders  from  the  records  of  five  large  hospitals 
and  from  private  practice,  endocarditis  occurred  only  once,  and  pericarditis  not 
at  all.  Pleurisy  was  present  in  7  cases.  Roger,  of  Paris,  did  not  have  a  single  case 
either  of  endocarditis  or  pericarditis  in  957  cases,  and  only  1  case  of  pleurisy. 

In  2631  cases  of  erysipelas  croupous  pneumonia  is  said  to  have  occurred  in  17 
cases,  and  the  catarrhal  form  in  2.  Of  these  cases  957  occurred  in  the  practice 
of  Roger,  of  Paris,  and  the  remaining  1674  were  collected  by  Anders,  and  represent 
chiefly  the  statistics  of  five  large  American  hospitals. 

Prognosis. — The  prognosis  in  a  case  of  erysipelas  depends  largely  upon  the  general 
state  of  the  patient.  As  already  stated  the  presence  of  grave  \-isceral  disease,  as 
of  the  liver  or  kidneys,  renders  it  very  dangerous,  but  in  the  great  majority  of 
cases,  when  it  occiu-s  in  otherwise  healthy  persons,  the  outlook  is  \"ery  fa\-orable. 
Anders'  statistics  give  the  mortality  at  7  per  cent,  for  hospitals  and  4  per  cent,  for 
private  practice.  When  it  occurs  frequently  or  develops  in  diti'erent  parts  of  the 
body  consecutively,  it  may  cause  death  by  exliaustion,  but  in  nearly  all  these  cases 
there  is  a  chronic  malady  as  a  predisposing  cause. 

Treatment. — The  treatment  of  erysipelas  is  local  and  systemic.  If  the  l)o\vels  arc 
not  active  they  should  be  freely  moved  by  a  dose  of  2  grains  of  calomel  followed 
in  twelve  hours  by  a  saline  purge  such  as  a  Seidlitz  powder  or  a  half-ounce  of  Rochelle 
salts.  As  soon  as  the  bowels  have  been  evacuated  thoroughly  the  patient  should 
receive  10  minims  of  the  tincture  of  the  chloride  of  iron,  well  diluted  with  pure 
water,  every  three  or  four  hours,  or  30  minims  four  times  a  day.  The  excess  of 
water  protects  the  stomach  from  being  disordered  by  the  drug  and  also  aids  in 
flushing  the  kidneys,  the  activity  of  wliich  prevents  tiie  accumulation  of  toxic 
material  in  the  body.  The  diet  should  be  as  easily  digested  and  as  nutritious  as 
possible,  in  order  that  the  vital  resistance  of  the  patient  may  be  maintained,  and 
such  foods  as  eggs,  rare  meats,  broths,  and  milk  should  be  freely  given  if  the  diges- 
tion of  the  patient  is  capable  of  dealing  with  them.     If  it  is  not,  the  food  should  be 


SEPTICEMIA  AND  PYEMIA  171 

given  in  small  quantities  every  two  or  three  hours,  and  if  necessary  it  should  be 
predigested  by  a  peptonizing  tablet  or  powder. 

The  local  treatment  is  a  very  important  factor  in  these  cases.  For  many  years 
I  have  used  with  excellent  results  an  ointment  of  equal  parts  of  ichthyol  and  lanolin, 
or  lard,  smeared  over  the  inflamed  area  and  the  adjacent  skin,  and  kept  in  contact 
with  the  skin  by  also  smearing  this  salve  on  a  mask  of  gauze  or  lint  which  is  applied 
to  the  part  so  that  the  medicinal  efi'ect  is  continuous.  By  this  means  the  pain  and 
burning  is  almost  entirely  relieved  and  a  very  definite  and  distinct  influence  for 
good  is  exercised  both  in  curing  the  inflammation  and  preventing  its  spread. 

In  cases  in  which  the  general  systemic  state  is  very  much  impoverished  and  the 
vitality  of  the  patient  is  impaired,  sufficient  quantities  of  a  good  whiskey  or  brandy 
should  be  given  to  sustain  the  flagging  powers.  Moderate  doses  of  quinine  (about 
3  grains  t.  i.  d.)  may  also  be  useful  at  this  time  to  support  the  system,  but  large 
doses  are  useless  and  produce  headache  and  a  disordered  digestion  without  causing 
any  benefit.  If  the  fever  is  excessive  it  may  be  controlled  by  the  use  of  an  ice-cap 
and  cold  sponging  with  friction.  The  coal-tar  antipyretics  should  never  be  used, 
as  they  decrease  vital  resistance. 

Antistreptococcic  serum  is  sometimes  useful  but  vaccine  is  useless  unless  it  be 
autogenous. 

SEPTICEMIA  AND  PYEMIA. 

Definition  and  Etiology. — Septicemia  and  pyemia  are  terms  which  are  dependent 
upon  antiquated  ideas  of  septic  processes,  and  do  not  strictly  represent  the  states 
they  are  now  used  to  describe.  Septicemia  originally  meant  that  putrid  material 
was  in  the  blood,  and  pyemia,  that  the  blood  contained  pus.  We  now  know  that 
blood  infection  is  due  to  the  presence  in  it  of  bacteria  (bacteriemia)  or  to  the  entrance 
into  this  fluid  of  poisons  made  by  microorganisms  not  in  the  circulation  (toxemia). 
The  older  terms  are  placed  at  the  head  of  this  article  because  they  are  still  commonly 
applied. 

Pyemia,  as  it  is  understood  today,  is  that  state  in  which  bacteriemia  is  present 
with  associated  septic  foci,  or,  in  other  words,  metastatic  abscesses.  As  a  rule 
these  abscesses  appear  chiefly  in  the  tissues  which  are  not  far  removed  from  the 
seat  of  primary  infection.  But  this  is  by  no  means  always  true,  for  a  septic  process 
in  the  foot  may  cause  metastatic  abscesses  in  the  lungs,  kidneys,  or  liver. 

Cases  are  not  rarely  seen  in  which  the  patient  is  unable  to  give  any  history  of 
even  a  small  abscess  or  minute  break  in  the  skin  through  which  germs  may  enter 
the  circulation,  and  yet  a  diagnosis  of  septicemia  or  pyemia  may  be  made  even  when 
no  point  of  entry  can  be  found 

The  obscurity  of  most  of  these  cases  depends  upon  our  inability  to  find  the  portal 
of  entry,  which  may  be  the  genito-urinary  organs,  the  cranial  sinuses,  the 
middle  ear  or  mastoid,  the  mouth  or  pharynx,  possibly  the  alimentary  canal, 
the  biliary  passages  or  gallbladder,  an  unrecognized  appendicitis  or  other  point 
of  slumbering  infection  which  may  or  may  not  be  recognized  during  life  or  deter- 
mined with  certainty  even  at  a  postmortem  examination. 

Pathology  and  Morbid  Anatomy. — The  results  of  septicemia  are  not  seen  in  equal 
degree  in  all  cases.  In  some  they  may  be  so  slight  as  not  to  be  readily  recognized, 
except  by  careful  bacteriological  or  microscopic  examination.  In  other  instances 
the  secondary  results  are  so  patent  that  the  most  careless  observer  cannot  fail  to 
be  impressed  by  their  character.  Thus  it  not  infrequently  is  found  that  septic  infec- 
tion is  the  cause  of  a  severe  inflammatory  process  in  any  one  of  the  serous  mem- 
branes, so  that  pericarditis,  peritonitis,  meningitis,  or  pleuritis  may  occur.  Septic 
inflammation  of  these  parts  results  either  in  a  distinctly  fibrinous  or  sero-fibrinous 
exudate  or  in  one  which  is  purulent.  The  synovial  membranes  and  other  con- 
nective tissues  of  the  joints  are  frequently  infected,  so  that  septic  arthritis  develops. 


172  DISEASES  DUE  TO  A  SPECIFIC  IXFECTIOX 

Examination  of  the  veins  may  reyeal  thrombi  near  or  reinotc  from  tlic  i)riinary 
seat  of  infection,  and  these  thrombi  may  be  soft  and  even  ])uruleMt.  It  is  important 
tliat  a  clear  distinction  be  made  between  sim])ie  or  liiand  tliroinbi  and  septic 
thrombi.  Emboli  of  the  former  tyi)e  canse  infarction  when  they  ])lni;  terminal  vessels 
and  mechanically  disturb  the  circulation,  whereas  septic  emboli  not  only  plug  the 
vessel  and  so  disturb  bloofl  supj^ly,  but  as  they  contain  bacteri;i  they  constitute 
new  foci  of  infection. 

Very  intimately  associated  with  the  sul)jcct  of  septicemia  and  ])yemia,  so  called, 
are  the  subjects  of  vital  resistance  and  terminal  infection.  By  vital  resistance 
is  meant  that  power,  or  property,  possessed  by  the  li\-ing  body  of  protecting  itself 
from  the  various  micro-organisms  which  are  continually  gaining  access  to  the  sys- 
tem. This  power  lies  largely  in  the  ability  of  the  blood  to  exercise  its  so-called 
bacteriolytic,  or  bacteria-destroying,  power,  and  to  the  ability  of  the  cells  of  the 
body  to  destroy  invading  micro-organisms  by  phagocytosis,  and  to  manufacture 
certain  other  antibodies  by  the  action  of  which  bacterial  toxins  may  be  antagonized, 
neutralized,  or  rendered  inert.  A  numlier  of  valuable  papers  on  the  presence  of 
bacteria  in  the  blood  have  been  jjublished  within  recent  years  (see  Rosenberger 
in  the  American  Jourmd  of  the  Medical  Sciences,  August,  1903,  for  early  facts  and 
references).  AVhen,  because  of  diminution  of  vital  resistance  the  invading  pathogenic 
micro-organisms  obtain  a  foothold  and  multiply,  we  have  developed  an  infection. 
When  a  patient  suffers  from  some  malady  which  saps  his  vitality  and  so  causes 
the  approach  of  death,  even  in  a  remote  degree,  these  micro-organisms  at  once 
attack  his  debilitated  body,  and  the  patient  now  suffers  from  what  is  called  a 
"terminal  infection."  Very  commonly  this  terminal  infection  is  the  actual  cause 
of  death,  so  that  it  has  been  well  said  that  death  is  "rarely  due  to  the  primary  cause 
of  the  illness." 

Sjrtnptoms. — The  symptoms  of  septic  infection  vary  greatly  with  the  particular 
organs  which  may  be  the  seat  of  the  primary  or  secondary  lesions.  The  manner  of 
their  onset  varies  likewise.  In  some  instances  the  earliest  manifestations  consist  in  a 
rigor  or  chill,  more  or  less  severe,  followed  by  fever  which  varies  in  its  degree  with 
the  severity  of  the  infection  and  the  vitality  of  the  patient.  The  chill  and  fever 
are  followed  usually  by  a  period  of  normal,  or  nearly  normal,  temperature,  and  this 
is  ffgain  followed  by  chill  and  fever.  In  this  way  the  dominant  symptoms  of  the 
case  may  closely  resemble  the  cpiotidian  malarial  infection,  a  resemblance  which  is 
still  further  emphasized  by  the  frequent  occurrence  of  a  distinct  sweat  as  the  fever 
falls.     These  sweats  may  be  very  profuse. 

Not  rarely  the  pus  in  the  primary  focus  of  infection  changes  its  character,  and 
becomes  less  healthy  looking.  It  is  thinner  and  more  ichorous,  that  is,  to  use  a 
word  now  rarely  heard,  it  is  no  longer  "laudable  pus."  The  infection  causes 
general  malaise,  rapid  loss  of  weight,  and  loss  of  appetite  with  gastric  distress  and 
perhaps  vomiting,  .inemia  is  rapidly  developed,  the  skin  of  the  hands  and  face 
becomes  not  only  pallid  but  develops  a  peculiar  cadaveric  hue,  an  appearance 
difficult  to  describe,  but  alluded  to  by  those  of  experience  as  the  "septic  facies." 
Sometimes  the  skin  may  be  slightly  jaundiced. 

If  the  .septic  process  develops  secondarily  in  any  special  organ,  localized  symp- 
toms may  at  once  appear,  but  it  is  noteworthy  that  they  do  not  always  ensue. 
Severe  pain  in  the  chest  may  betoken  the  presence  of  a  septic  j)lcurisij  or  pneumonia, 
or  if  the  pain  develops  in  the  left  side  it  is  often  due  to  septic  infarction  of  the  spleen. 
A  ])hysical  examination  of  these  organs  may  reveal  the  typical  signs  of  these 
afl'ections. 

As  the  case  progresses  pulmonary  abscess,  empyema,  or  suppuration  of  the  kidney 
follows  as  the  result  of  emboli  in  these  organs.  The  2>iil-se  becomes  more  and  more 
rapid,  the  general  state  more  and  more  feeble,  and  the  patient  dies  from  general 
a.stlienia  or  fnmi  one  of  the  acute  complications  just  named. 


SEPTICEMIA   AND  PYEMIA  173 

There  are  other  cases  in  which  the  onset  of  the  systemic  infection  is  not  so  pro- 
nounced, the  chili,  fever,  and  sweat  being  absent,  but  in  their  place  a  rapid  extension 
of  the  local  inflammatory  process  with  the  absorption  into  the  general  system  of 
the  poisonous  products  of  the  germ  growth  as  well  as  the  organisms  themselves. 
In  such  cases  the  patient  may  speedily  become  not  only  feeble,  but  suft'er  from 
stupor  and  finally  die  vnconscious  within  a  few  days  of  the  beginning  of  the  illness. 
These  cases  are  usually  those  which,  suffering  from  nephritis  or  diabetes,  offer  no 
vital  resistance  to  infection,  and  die  not  only  from  this  cause  but  by  reason  of 
rapidly  increasing  evidences  of  the  primary  disease  as  well. 

Still  a  third  class  of  cases  may  be  called  subacute  or  chronic,  and  last  for  weeks. 
Not  rarely  these  cases  tax  the  diagnostic  acumen  of  the  physician  to  the  utmost. 
A  child  was  brought  to  me  in  July  with  the  statement  that  in  the  pre\'ious  ]\Iarch 
she  had  acute  articular  rheumatism,  but  no  cardiac  complications.  The  fever 
of  the  disease  in  onset  had  lasted  but  a  short  time,  and  in  its  place  only  a  slight 
evening  rise  of  temperature  took  place.  The  acute  swelling  of  the  joints  disap- 
peared, but  they  remained  tender,  and  the  child  was  unable  to  walk.  There  was 
marked  pallor,  a  septic  hue  of  the  skin,  and  a  large  boil  on  the  buttock  with  smaller 
ones  on  other  parts  of  the  body.  Occasional  attacks  of  vomiting  occurred.  A 
diagnosis  of  chronic  septic  infection  was  made,  and  on  the  child's  death,  six  weeks 
after,  evidences  of  the  correctness  of  this  view  were  found  in  nearly  every  organ  of 
the  body,  although  in  none  of  them  were  distinct  purulent  foci  discovered.  Circum- 
stances prevented  bacteriological  examination  of  the  blood  either  before  or  after 
death. 

Diagnosis. — The  presence  of  chill,  fever,  and  sweat  in  any  case  should  recall 
the  fact  that  these  symptoms  may  be  due  to  sepsis  as  well  as  to  other  forms  of 
infection.  It  must  be  recalled  that  a  history  of  an  infected  wound  is  not  needful 
to  reach  the  conclusion  that  infection  has  occurred,  for  it  may  take  place  by  a 
needle-prick,  or  through  a  small  blister  due  to  a  badly  fitting  shoe,  or  through  a 
break  in  the  mucous  membrane  of  the  alimentary,  respiratory,  or  genito-urinary 
tract.  Typhoid  fever  often  fails  to  cause  death  of  itself,  but  a  terminal  septic 
infection  following  it  may  cause  death.  In  other  cases  a  fatal  general  infection 
follows  gonorrhea,  and  in  tuberculosis  of  the  lungs  the  septic  symptoms  are  due 
to  the  pyogenic  organisms  which  are  associated  with  the  tubercle  bacillus,  rather 
than  to  that  organism  itself.  So,  too,  gallstones  with  septic  infection  of  the  gall- 
bladder may  afford  the  opening  for  infection.  Finally,  whenever  a  patient  presents 
acute  arthritis  the  physician  should  think  first  of  sepsis  rather  than  rheumatism, 
and  when  he  has  a  chill,  fever,  and  sweat  which  does  not  promptly  yield  to  quinine, 
he  should  also  think  of  sepsis  or  tuberculosis. 

Treatment. — The  treatment  of  these  states  consists  first  in  seeking  and  remo^'ing 
the  cause  and  in  the  support  of  the  vitality  of  the  patient  by  every  possible  means, 
such  as  fresh  air  and  sunshine,  and  good  food  which  is  easily  digested  and  absorbed. 
Second,  many  cases  are  vmdoubtedly  aided  in  combating  infection  by  the  use  of 
tonic  doses  (5  grains  t.  i.  d.)  of  quinine,  with  or  without  whiskey.  In  some  instances 
well-diluted  whiskey  certainly  seems  to  benefit  the  patient,  and  it  is  surprising  how 
much  can  be  taken  without  producing  any  signs  of  intoxication.  Great  care  must  be 
taken  that  doses  large  enough  to  be  toxic  are  not  given,  for  if  they  are,  the  toxemia 
of  alcohol  aids  the  toxemia  of  the  infection.  Full  doses  of  tincture  of  the  chloride 
of  iron  are  valuable.  The  coal-tar  products  are  never  to  be  used,  as  they  decrease 
vital  resistance,  increase  sweating,  and  do  not  give  any  comfort  or -relief. 

If  abscesses  form  they  should  be  opened  and  drained  as  early  as  possible. 

When  bacteriological  tests  reveal  the  presence  of  streptococci  as  the  cause  of 
the  trouble,  antistreptococcus  serum  should  be  used.  Usually  the  patient  is  too 
ill  to  admit  of  the  use  of  vaccines.  If  a  specific  germ  is  isolated,  and  the  patient 
is  not  too  ill  to  react,  an  autogenous  vaccine  should  be  employed. 


174 


DISEASES  DUE  TO  A  SPECIFIC  INFECTIOS' 


ACUTE  RHEUMATIC  FEVER. 

Definition. — This  disease,  also  known  under  the  name  of  acute  arliciilitr  rhniiim- 
tmn,  or  acute  injlainmatory  rhewnatisvi,  is  an  acute,  infectious,  non-contagious, 
febrile  malady  characterized  chiefly  by  acute  inflammation  of  the  synovial  mem- 
branes and  adjacent  tissues  about  the  joints  of  the  extremities  and  by  involvemertt 
of  the  heart  valves,  heart  muscle  and  its  surrounding  serous  membranes.  It  is  to 
be  distinctly  separated  from  the  various  forms  of  septic  arthritis.  In  other  words 
it  is  a  general  infection  with  especially  severe  lesions  in  tlie  parts  named. 


PERCENTAGE 

UNDER 
10  YEARS 
OF  AGE 

BETWEEN 
10  AND  20 

BETWEEN 
20  AND  30 

30  AND  40 

BETWEEN 
40  AND  50 

BETWEEN 
60  AND  60 

OVER  60 

39 

:«                           T» 

1 

87 r 

30                               T    ._. 

35                             / 

M        / 

:33                     /            r 

32— t"     ' 

31 

30 

29 

^        j"::::::|: 

21i                   f 

25                    1 

24                    / 

S3 1                         t 

21        1           ll 

2U       1        f       T-               J 

19--"  r 



18             1 

IT           7 



1«             7 

15              f 

14 

i T 

13 

12 

"*\ 

"           \ 

5         

lo'iii:::::::::::: 

9 

\ 

s 

"""i:^::::::::::::: 

7 

_   _     A    

6 

% T 

5 

_   .     .^ 1 

4--I- 

V,                T 

3 

:::d::_l  \"::_L  • 

2 

1          !      I>^ 

I 

.__llll  i'iLj:!^^...^ 

Chart  showing  age  incidence  of  acute  articular  rheumatism,  based  on  432S  cases. 


Distribution. — Acute  articular  rheumatism  is  a  disease  which  is  fotuid  chiefly 
in  the  temperate  zone  and  rarely  occurs  in  the  tropics  or  in  the  far  North.  At 
present  we  lack  reliable  statistics  concerning  its  frequency  because  in  many  countries 
its  occurrence  is  not  reported,  and  in  those  in  which  records  of  the  frequency  of 
rheumatism  are  preserved,  so  many  cases  are  reported  which  are  not  true  acute 
articular  rheumatism  that  the  statistics  are  valueless.  Osier  states^that  he^saw 
more  eases  in  Montreal  than  in  Philadelphia  and  Baltimore  while  connected  with 


ACUTE  RHEUMATIC  FEVER  175 

hospitals  in  those  cities.  I  was  firmly  convinced  from  my  experience  in  English 
hospitals  that  the  disease  was  more  prevalent  in  England  than  in  the  United  States, 
but  when  I  came  to  the  study  of  the  statistics  of  the  relative  frequency  of  acute 
rheumatism  in  these  two  countries,  I  found  that  out  of  74,808  medical  cases  in 
hospitals  in  London,  there  were  3822  cases  of  acute  rheumatism,  a  percentage  of 
5.1,  and  out  of  73,839  medical  cases  in  hospitals  in  different  cities  in  the  United 
States,  there  were  4153  cases  of  acute  rheumatism,  a  percentage  of  5.6.  It  would 
seem,  therefore,  that  no  marked  difference  in  frequency  exists  in  these  parts  of 
the  world. 

Etiology. — The  influence  of  season  upon  the  occurrence  of  the  disease  is  marked. 
It  is  more  common  in  the  cool,  damp  months  of  the  year  than  at  other  times.  In 
London  its  greatest  prevalence  is  in  September  and  October,  whereas  in  Montreal 
it  is  most  frequent  in  March  and  April. 

The  influence  of  age  upon  the  frequency  of  the  disease  is  notable.  It  is  met 
with  in  a  very  large  proportion-  of  the  cases  between  twenty  and  thirty-five  years 
of  age  and  is  very  rare  in  children  below  five  years.  Between  the  ages  of  sLx  and 
twelve  years,  however,  it  is  not  only  common  but  has  its  greatest  direct  mortality. 
Thus  in  250  cases  under  twelve  years  recorded  by  Poynton,  Agassiz  and  Taylor 
there  were  59  deaths.  Whereas  in  99  cases  over  twelve  years  there  were  only  2 
deaths.  After  forty-five  years  it  is  also  rarely  met  with,  comparatively  speaking 
(Fig.  42.)  It  must  be  remembered,  however,  that  infection  with  the  specific  organ- 
ism of  this  disease  is  more  frequent  in  adolescents  than  is  commonly  supposed, 
and  it  often  causes  very  mild  arthritic  symptoms  and  yet  makes  a  serious  attack 
upon  the  heart. 

Males  are  more  frequently  affected  than  females,  but  this  proportion  is  reversed 
when  the  patient  is  under  twenty  years  of  age,  at  which  time  females  suffer  more 
frequently. 

The  question  of  the  influence  of  heredity  is  still  undecided.  It  is  probable  that 
it  plays  a  very  unimportant  part  in  the  causation  of  the  malady. 

Of  the  immediate  etiological  factors  we  must  include  exposure  to  dampness 
and  cold.  These  influences  are  not  provocative  of  the  disease  unless  the  specific 
micro-organism  is  present,  nor  unless  the  exposure  reduces  the  vital  resistance  of 
the  joints  so  that  the  specific  organism  is  enabled  to  multiply  and  induce  its  patho- 
logical effects. 

Acute  rheumatic  fever  is  a  disease  which  is  endemic,  but  it  has  periods  in  which 
it  is  distinctly  epidemic.  In  other  words,  it  is  much  more  frequent  in  some  years 
than  in  others. 

There  can  be  no  doubt  that  the  infection  usually  gains  access  to  the  general 
system  through  the  tonsils. 

The  old  theory  of  acute  rheumatism  being  due  to  uric  acid  is  now  exploded.  The 
excess  of  uric  acid  present  in  the  urine  in  this  disease  is  the  result,  not  the  cause, 
of  the  affection. 

B.\CTERiOLOGT. — A  very  large  number  of  investigators  have  endeavored  to 
isolate  the  specific  micro-organism  of  this  disease,  but  until  recently  no  satisfactory 
proof  that  this  had  been  accomplished  was  forthcoming.  About  twenty  years  ago 
Achalme  asserted  that  he  had  done  this,  and  later  Triboulet  and  Wassermann 
made  similar  claims.  Up  to  the  present  time  it  would  appear  that  Poynton  and 
Paine  have  come  nearer  to  success  in  this  line  of  research  than  any  of  their  predeces- 
sors, and  Meyer  has  also  carried  out  studies  which  seem  to  prove  the  correctness 
of  their  conclusions.  Still  more  recently  Walker  and  Beaton  have  further  confirmed 
the  correctness  of  the  views  of  Poynton  and  Paine.  These  last  investigators  believe 
it  is  impossible  to  separate  this  special  organism,  for  which  they  advise  the  name 
Micrococcus  rhemnaticus,  from  the  ordinary  streptococcus.  Meyer  succeeded 
in  obtaining  it  in  a  form  which  produced  all  the  lesions  found  in  the  course  of  the 


176  DfSKASI'JS  DUE  TO  A  SPECIFIC  IXFECTIOX 

disease,  and  found  the  same  organism  in  the  sore  throat,  in  the  iiiHamed  endocar- 
dium, in  the  pleura,  and  in  tlie  inflamed  joints  of  ])ersons  attacked  hy  this  malady. 
[More  recently  still  Poynton  has  further  endorsed  his  views. 

Beattie  of  J']dinhurp;h  also  feels  confident  that  the  M'nrornrot.s  rhi-iinudlcins  has 
a  close  relationship  to  the  strei)tococcus  and  is  a  specific  orf,'anism. 

Rosenow  (191.'J)  by  means  of  graded  oxygen  pressure  isolated  organisms  from 
the  joint  exudate  of  14  of  16  cases  of  articular  riieumatism,  the  2  negative  cases 
being  convalescent.  He  also  found  organisms  in  tlie  blood  in  4  of  7  cases.  Three 
types  of  organisms  were  found  in  the  series.  One  producing  long  chains  and  another 
resembling  a  micrococcus,  when  injected  into  animals,  produce  arthritis,  endocardi- 
tis, and  pericarditis  but  never  a  myositis.  The  third,  a  diplococcus  from  a  case 
with  muscular  involvement,  produces  these  three  lesions  but  especially  myocarditis 
and  myositis.  Each  of  the  three,  by  cultural  methods,  can  be  converted  into 
the  other  types.  These  findings  indicate  that  acute  articular  rheumatism  is  due 
to  streptococci  having  peculiar  properties  and  that  muscular  rheumatism  is  due 
to  closely  related  streptococci.  For  these  Rosenow  says  the  name  Strcittocomis 
rhcumaticus  may  be  retained  to  call  attention  to  the  lesions  iiuluccd.  but  not  with 
the  idea  that  the  organisms  so  called  always  produce  rheumatism.  His  transmuta- 
tion experiments  with  streptococci  and  pneumococci  of  many  ditt'crent  strains, 
in  which  he  has  converted  each  to  one  or  more  other  types,  including  streptococci 
to  pneumococci  and  vice  versa,  indicate  that  widely  different  lesions  as  pneumonia, 
arthritis,  erysipelas,  scarlet  fever,  tonsillitis,  empyema  and  others  are  due  to  the 
same  organism  varying  in  properties  under  differing  circumstances. 

It  is  a  fact  worthy  of  note  that  the  introduction  of  many  pathogenic  micro- 
organisms into  the  body  will  result  in  endocarditis  and  artliritis,  but  these  states 
are  not  true  acute  articular  rheumatism. 

Morbid  Anatomy. — The  changes  produced  by  an  attack  of  acute  rheumatic 
fever  are  not  pathognomonic.  On  the  contrary,  the  condition  of  the  .synovial 
membranes  is  one  of  more  or  less  intense  hyperemia  with  the  efl'usion  of  Huid  into 
the  surrounding  tissues  and  into  the  joint  itself.  The  synovial  liquid  is  turbid 
and  contains  leukocytes  and  some  small  flakes  of  fibrin.  The  secondary  changes 
produced  by  the  disease  are  vegetative  endocarditis,  acute  pleuritis,  and  pericarditis, 
but  there  is  nothing  about  these  lesions  which  is  peculiar  to  this  specific  infection. 
A  mediastinopericarditis  is  not  rare.  (See  Endocarditis.)  In  certain  cases  there 
can  be  no  doubt  that  myocarditis  of  a  grave  degree  is  often  present.  Sometimes 
peritonitis  occurs.  Thus  in  100  cases  of  Poynton,  Agassiz  and  Taylor  it  occurred 
.5  times. 

Symptoms. — The  symptoms  of  acute  articular  rheumatism  are  usually  suddcti 
ill  niimi.  With  or  without  premonitory  signs  of  illness  the  patient  awakes  to  find 
that  one  or  more  of  his  larger  joints  is  acutely  inflamed  so  that  any  mo\ement  causes 
great  pain,  and  the  part  may  be  so  sensitive  to  the  touch  as  to  prevent  any  thorough 
examination  by  ])alpation  being  made. 

The  .s7,//(  over  the  affected  part  is  usually  dusky  red  in  hue,  and  quite  puffy  in 
ai)i)earance  because  of  the  presence  of  subcutaneous  exudation,  and  the  inflamed 
area  is  much  more  hot  to  the  touch  than  adjacent  tissues.  Sometimes,  however, 
no  local  redness  is  seen,  but  in  its  place  swelling  and  a  peculiar  sodden  and  livid 
hue  of  the  skin.  With  the  development  of  this  arthritis  a  distinct  febrile  movement 
begins,  and  the  fever  may  reach  102°  or  10-3°  on  the  first  day  in  many  eases.  This 
level  of  temj^eratiire  is  not  usually  exceeded,  but  the  variations  in  its  course  are 
very  marked  in  that  it  is  subject  to  great  remission,  particularly  if  the  sweating 
is  proftwe.    The  fever  ultimately  falls  by  lysis. 

The  tongue  is  coated,  the  bowels  are  usually  confined,  and  the  skin  is  hot  and 
dry,  or  at  times  bathed  in  a  profuse  sweat.  This  sweat  breaks  out  in  paroxysms 
and  is  exceedingly  acid,  possessing  a  peculiar  acid  odor.     It  is  probably  an  effort 


ACUTE  RIUiUMATlC  FKVEH  177 

at  elimination,  but  it  does  not  develop  in  all  cases,  'i'hc  vrine  is  nearly  always 
scanty  and  concentrated,  highly  acid,  and  on  standing  deposits  urates  in  excess. 

Acute  articular  rheumatism  is  characterized  by  the  speedy  spread  of  the  arthritis 
to  joints  in  other  parts  of  the  body.  In  some  instances  the  involvement  of  a  second 
joint  is  followed  by  diminution  of  the  inflanunation  in  the  joint  first  affected,  but 
in  many  instances  the  patient  suffers  from  a  progressively  developing  arthritis 
which  soon  involves  almost  all  the  larger  joints.  This  fugitive  character  of  the 
inflammation,  wandering  from  joint  to  joint,  is  so  very  characteristic,  that  the 
presence  of  a  monoarticular  inflammation  is  a  point  against  the  disease  being  true 
rheumatism.  The  smaller  joints,  such  as  the  fingers  and  toes,  usually  escape, 
but  they  are  often  apparently  affected  by  reason  of  the  fact  that  the  swelling  of 
the  tissues  extends  from  the  large  joint  above  so  that  it  covers  the  smaller  ones. 
In  other  instances,  however,  the  joints  escape  severe  infection,  and  the  synovial 
coverings  of  the  tendons  suffer  chiefly,  so  that  parts  near  the  joint  may  be  swollen, 
and  the  swelling  is  purely  periarticular.  The  vertebral  and  clavicular  joints  are 
verj^  rarely  affected. 

There  is  no  form  of  acute  arthritis  which  seems  to  give  the  same  amount  of 
severe  pain  as  does  that  of  this  disease,  and  the  close  of  the  attack  usually  leaves 
the  general  system  of  the  patient  considerably  shattered  because  of  the  se\-erity 
of  his  suffering,  his  marked  anemia,  and  the  exhaustion  caused  by  the  sweats  and 
the  lack  of  sleep.  The  pain  is  also  peculiarly  trying  because  the  state  of  the  joints 
is  such  that  movement  is  impossible  and  the  patient  gets  bed-sore  and  bed-frantic. 

In  some  cases  a  subacute  type  of  the  disease  develops  in  which  all  the  symptoms 
in  the  joints  at  least,  are  very  mild,  but  these  cases  are  very  prone  to  manifest 
cardiac  complications  later  on.     This  is  particularly  true  in  children. 

One  attack  usually  predisposes  to  another.  It  certainly  in  no  way  protects 
the  patient  from  subsequent  attacks. 

Duration. — The  disease  may  run  its  course  in  a  week  or  be  continued  over  a 
very  long  period  of  time,  lasting  a  month  and  causing  great  discouragement  of 
both  the  physician  and  patient.  In  some  instances,  the  arthritic  state  merges 
by  degrees  into  one  of  chronic  arthritis  without  fever,  and  the  patient  never  fully 
recovers  the  free  use  of  his  joints,  but  this  is  fortunately  very  rarely  the  case.  Even 
when  the  amount  of  inflammatory  exudate  seems  very  large  gradual  and  complete 
absorption  usually  occurs. 

Complications. — The  complications  of  acute  articular  rheiunatism  are  the  means 
by  which  it  produces  fatal  results,  and  they  are  most  frequently  found  in  the  heart 
muscle,  in  the  cardiac  valves,  or  in  the  pericardium.  Indeed,  cardiac  lesions  are 
almost  as  characteristic  of  acute  rheumatism  as  is  arthritis.  The  infection  attacks 
the  pericardium  with  great  constancy,  and  even  in  those  cases  in  which  the  arthritic 
changes  are  slight,  it  often  plays  the  greatest  havoc  in  the  heart,  so  that  we  fre- 
quently see  young  persons  with  grave  cardiac  lesions  who  have  presented  such  mild 
articular  symptoms  that  the  presence  of  rheumatism  has  been  overlooked.  Of 
842  cases  of  acute  articular  rheiunatism,  all  of  which  were  first  attacks,  valvular 
heart  lesions  were  present  in  420,  or  50  per  cent.  Of  these  lesions,  390  were  mitral, 
16  aortic,  and  14  mitral  and  aortic.  The  following  table  arranged  from  the  statis- 
tics of  Church  at  St.  Bartholomew's  Hospital  illustrates  not  only  the  frequency  of 
cardiac  complications  but  also  the  age  incidence  as  well: 

Number  of       Number  in  which  Percentage  of 

Age.  cases.  heart  was  affected,  heart  affection. 

Under  10  years  ......  25  20  80.0 

10  to  20  years 244  170  69.16 

20  to  30  years 241  124  51.1 

30  to  40  years 115  35  30.0 

40  to  50  years 41  9  21.39 

Over  .50  years 17  7  41.03 

683  365  53.44 

12 


ITS  DJSKASliS  DUE  TO  A  SPECIFIC  INFECTION 

The  al)()\c'  tahic  iiicludt's  pericarditis  as  well  as  valvular  lesions. 

It  is  generally  recognized  as  a  fact,  that  heart  lesions  arise  less  frequently  in 
the  old  than  in  the  young,  and  tiierefore  the  percentage  of  41.03  given  for  cases 
o\er  fifty  in  this  table  is  ])rol)al)ly  excessive. 

Tiiese  lesions  are  rarely  lethal  during  their  acute  stage.  They  dcNclop  into 
subacute  or  chronic  lesions,  and  days,  weeks,  or  years  after  the  patient  has  recoverefl 
from  the  acute  illness  become  active  agents  in  flestroying  life  or  incapacitating 
him  for  work.  The  reason  for  this  lies  in  a  continuation  of  the  oulocnrditi.s,  in  a 
■vibacidc  or  chronic  form,  for  days  or  weeks  after  the  acute  symptoms  have  passed 
by,  with  the  result  that  the  valves  become  shrunken,  and  so  are  unable  to  perform 
their  proper  functions;  or  they  become  glued  together,  and  in  this  way  their  action 
is  interfered  with.  Acute  articular  rheumatism  with  cardiac  complications  may 
therefore  cause  death  many  months  or  years  after  the  acute  attack.  (See  Endo- 
carditis.) 

Pericarditis  is  by  no  means  as  frequent  as  endocarditis.  It  is  usually-  of  the 
fibrinous  or  serofibrinous  type,  and  occasionally  it  is  purulent,  particularly  in  the 
case  of  children.     In  rarer  instances  a  myocarditis  develops. 

It  is  of  the  greatest  importance  that  the  physician  in  charge  of  a  case  of  acute 
articular  rheumatism  be  continually  on  the  lookout  for  cardiac  complications. 
He  can  do  something  toward  preventing  these  by  following  the  directions  given 
under  Treatment,  and  by  insisting  upon  absolute  rest.  The  vast  majority  of 
cases  of  acute  articular  rheumatism  manifest  sometime  during  their  course  a  more 
or  less  well-defined  mitral  murmur,  and  sometimes  a  pericardial  friction  .sound. 
In  many  instances,  instead  of  these  lesions  increasing  in  se\'erity,  they  disappear 
with  the  subsidence  of  the  joint  symptoms. 

Pulmonary  complications  are  not  exceedingly  common.  Stephen  Mackenzie 
found  that  pneumonia,  or  pleurisy,  occurred  in  about  10  per  cent,  of  3433  cases. 
Not  infrequently  slight  pulmonary  congestion  of  the  bases  occurs. 

The  nervous  complications  in  acute  articular  rheumatism  arise  from  three  causes: 
the  high  fever,  the  profound  toxemia,  and  the  nervous  irritation  and  exhaustion 
produced  by  many  hours  of  suffering.  Delirium  is  not  commonly  met  with.  An 
active,  noisy  delirium  sometimes  develops  as  a  result  of  the  administration  of  large 
doses  of  the  salicylates.  Such  mental  disturbance  is  said  to  not  infrequently 
complicate  the  development  of  rheumatic  pericarditis.  Sometimes,  too,  excessively 
high  temperature  is  associated  with  delirium. 

Meningitis  occurs  as  a  very  rare  complication. 

The  relationship  between  chorea  and  rheumatism  is  not  clear.  There  can  be 
no  doubt  that  they  bear  some  relationship  one  to  another,  but  whether  rheumatism 
is  to  be  regarded  as  an  etiological  factor  in  chorea  is  undecided. 

The  skin  lesions  of  acute  articular  rheumatism  consist  chiefly  in  the  dc\elopment 
of  urticaria  and  erythema.  Purpuric  rashes  sometimes  appear,  hence  the  somewhat 
old-fashioned  term  "purpura  rheumafica;"  but  it  is  probable  that  these  extravasa- 
tions under  the  skin  are  due  to  an  associated  infection  rather  than  to  the  rheumatism 
itself.  Another  very  interesting  lesion  occurring  as  a  sequence  of  acute  articular 
rheumatism  consists  in  rheumatic  jwdules  which  vary  in  size  from  a  small  pinhead 
to  a  large  i)ea,  and  develop  chiefly  on  the  hands  and  wrists  and  about  the  elbows  and 
knees,  and  sometimes  upon  the  back  over  the  spine.  They  often  last  for  months, 
and  are  seen  more  frequently  in  children  than  in  adults.  Indeed,  they  are  so 
characteristic  in  children  that  they  may  be  regarded  as  a  positive  sign  that  rheuma- 
tism has  at  some  time  been  present.  They  are  not,  however,  pathognomonic 
of  rheumatism  in  all  cases,  for  they  appear  in  gouty  and  rheumatic  subjects  who 
have  ne\-er  sutt'ered  from  the  acute  form  of  the  disease  (see  lieiow). 

Iritis  is  commonly  met  with,  and  it  is  probable  that  it  is  due  to  the  presence  of 
the  Micrococcus  rheumalicus  in  the  fine  vessels  of  the  muscle  fibres  of  iris.     This 


ACUTE  RHEUMATIC  FEVER  179 

organism  may  also  induce  the  muscle  soreness  in  some  cases  in  wliicli  tlie  joints 
escape. 

Diagnosis. — The  diagnosis  of  acute  articular  rheumatism  is  by  no  means  easy 
in  all  cases,  but  the  presence  of  fever  with  progressive  involvement  of  one  joint 
after  another  is  very  indicative.  The  great  difficulty  lies  in  separating  the  various 
nearly  related  forms  of  septic  arthritis  from  true  rheumatism.  If  there  is  present 
a  pre-existing  septic  focus  from  which  septicemia  may  arise,  the  probability  is 
that  the  malady  is  not  the  specific  disease  we  are  discussing.  Thus,  a  multiple 
arthritis,  with  or  without  fever,  often  follows  or  complicates  gonorrhea,  and  follows 
scarlet  fever,  tyj^hoid  fever,  and  dysenter\',  or  any  disease  which,  by  pro\iding  a 
source  of  infection,  exposes  the  joints  to  the  invasion  of  micro-organisms. 

The  chief  conditions,  aside  from  gonorrheal  rheumatism  and  ordinary  septic 
arthritis,  that  we  must  carefully  exclude  are  acute  osteomyelitis,  which  usually 
affects  the  femur,  and  which  if  it  is  not  recognized  early  may  destroy  the  i)atient's 
life;  monoarticular  inflammation,  which  is  often  due  to  syphilis,  and  acute  gout, 
in  which  case  the  history  of  previous  attacks  of  pain  in  the  smaller  joints  will  be 
present  and  the  inflamed  area  will  probably  be  in  the  ball  of  the  thumb  or  in  the 
joint  of  the  great  toe.  In  children  an  acute  arthritis  with  little  fever  sometimes 
develops  and  soon  suppurates.  It  is  undoubtedly  due  to  septic  infection.  Finally, 
let  it  be  borne  in  mind  that  the  mere  presence  of  heat,  pain,  swelling  and  fixation 
in  a  joint  should  not  be  called  acute  articular  rheumatism  until  all  other  possibilities 
are  excluded.  Perhaps  no  more  frequent  error  occurs  than  the  calling  of  all  forms 
of  acute  arthritis  "acute  rheumatism." 

Prognosis. — Death  very  rarely  ensues  as  a  result  of  acute  articular  rheumatism 
without  any  complications.  This  is  well  shown  by  the  follo^\'ing  statistics.  In 
8431  cases  of  acute  articular  rheumatism  collected  from  the  official  reports  of 
several  American  and  English  hospitals  there  were  127  deaths,  which  gives  a 
percentage  of  1.5.  From  the  years  1880  to  1903,  1524  cases  were  treated  in  the 
Pennsylvania  Hospital  with  only  14  deaths,  a  mortality  of  0.9  per  cent.  AYhile, 
therefore,  acute  rheumatism  rarely  causes  death  during  its  presence  in  the  active 
stage  it  is  nevertheless  true  that  no  other  acute  disease  causes  death  so  frequently  in 
after  years  because  of  secondary  changes  in  the  heart. 

The  prognosis  as  to  the  development  of  a  valvular  lesion  as  a  result  of  this  infec- 
tion is  unfaA'orable.  The  great  majority  of  patients  develop  an  endocarditis 
during  the  attack,  particularly  children,  and  in  this  class  the  lesion  is  often  perma- 
nent. When  rheumatic  subcutaneous  nodules  are  present  the  heart  almost  always 
sufl'ers  se\-erely,  probably  because  they  aft'ord  sources  of  repeated  infection.  About 
50  per  cent,  of  the  cases  which  develop  endocardial  signs  during  the  attack  possess 
these  signs  permanently.  Care  must  be  taken  to  separate  the  soft  murmurs  due 
to  myocardial  disease  from  those  due  to  valvular  disease.  A  decision  that  the 
lesion  is  going  to  be  permanent  cannot  be  fairly  reached  until  several  months 
ha^-e  elapsed  after  the  acute  illness.  Taking  a  prolonged  rest  of  weeks  or  months 
after  the  attack  aids  materially  in  making  a  favorable  prognosis. 

Treatment. — The  treatment  of  acute  articular  rheumatism  is  at  times  eminently 
satisfactory  and  at  others  equally  disappointing.  In  a  certain  proportion  of 
cases,  in  which  treatment  fails  to  produce  good  results,  the  condition  is  perhaps 
maintained  by  the  presence  of  associated  infections  which  help  to  produce  the 
arthritis.  While  no  true  specific  exists  for  acute  articular  rheumatism,  the  salicy- 
lates act  in  some  cases  with  a  degree  of  celerity  which  is  most  gratifying,  and  therefore 
they  are  always  to  be  considered  as  the  most  important  remedies  when  the  ph^ysician 
is  called  upon  to  treat  a  case  of  this  disease.  The  chief  objects  of  the  physician 
under  these  circumstances  are  the  alleviation,  modification,  and  shortening  of  the 
disease,  and,  second,  the  protection  of  the  heart  from  the  secondary  affections  of 
its  endocardium,  its  muscle,  and  its  pericardium.     For  the  relief  of  the  pain  and 


180  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

of  the  inflammatory  processes  in  the  joints  the  best  remedy  is  the  salicylate  of 
strontium  in  the  dose  of  15  to  20  grains  from  three  to  six  times  a  day.  It  siiould 
be  given  in  capsules  and  followed  l)y  a  copious  draught  of  water  or  milk  to  prevent 
it  from  irritating  the  stomach.  Sometimes  a  few  swallows  of  the  emulsion  of  sweet 
almonds  may  be  taken  to  protect  the  stomach  from  irritation. 

If  full  doses  of  the  salicylates,  sufficient  to  produce  distinct  physiological  symp- 
toms, such  as  fulness  in  the  head  and  some  deafness,  do  not  produce  signs  of  improve- 
ment in  the  course  of  five  or  six  days,  they  will  probalily  fail  to  cure,  and  had  better 
be  discontinued,  as  after  this  time  they  are  apt  to  increase  the  discomfort  of  the 
patient,  to  disorder  his  stomach,  and  to  increase  the  sweats.  In  their  place  the 
patient  may  receive  10  minims  of  the  wine  of  colchicum  root  and  15  grains  of  iodide 
of  potassium  three  times  a  day.  While  the  salicylates  are  being  gi\'en  it  is  always 
advisable  to  give  not  less  than  40  to  60  grains  of  sodium  bicarbonate  or  bicarbonate 
of  potassium  in  each  twenty-four  hours.  The  sodium  bicarbonate  seems  to  aid 
the  stomach  in  \\'ithstanding  the  salicylates,  and  provides  the  body  Anth  a  certain 
amount  of  alkali  which  is  advantageous. 

Recently  a  preparation  called  "rheumatism  phylacogen,"  which  is  practically  a 
filtrate  from  a  multiple  culture  of  infectious  organisms,  containing  an  excess  of 
the  Micrococcus  rhevmaficus,  has  been  introduced  as  a  valuable  remedy.  It  has 
been  theoretically  condemned.  I  have  seen  it  produce  excellent  results  when 
the  salicylates  have  failed. 

Copious  draughts  of  water  are  always  to  be  gWen  in  rheumatism  for  the 
purpose  of  flushing  the  kidneys. 

For  the  prevention  of  endocarditis  and  pericarditis  from  four  to  six  small  fly- 
blisters  may  be  placed  over  the  precordium,  and  their  influence  as  pre\'entive 
measures  is  thought  to  be  aided  by  the  free  use  of  the  sodium  bicarbonate  just 
named.  If  pericarditis  dcA'clops  and  the  action  of  the  heart  is  very  excessive, 
small  doses  of  aconite  may  be  cautiously  given  to  act  as  a  cardiac  sedative.  But 
this  drug  is  not  to  be  used  if  the  patient  is  markedly  depressed.  Sometimes  an 
ice-bag  placed  over  the  heart  acts  equally  well. 

The  joints  are  best  treated  by  anointing  them  with  ichthyol  and  lanolin  in  equal 
parts,  applying  an  excess  of  this  ointment,  and  then  wrapping  them  in  cotton- 
batting.  When  the  patient  suffers  pain  because  of  the  twitchings  of  his  muscles, 
which  in  turn  move  his  inflamed  joints,  some  relief  and  comfort  can  be  given  by 
applying  a  splint  to  produce  fixation  of  the  joint. 

The  acute  inflammatory  process  in  the  joint  is  usually  severe  enough  to  make 
the  patient  content  to  remain  in  bed.  But  it  not  infrequently  happens  that  as  the 
pain  in  the  joint  diminishes  the  patient  is  most  anxious  to  get  about  and  return 
to  his  usual  pursuits.  Nothing  can  be  more  dangerous  than  the  pursuance  of  such 
a  policy.  A  very  large  proportion  of  cases  of  valvular  heart  disease  are  due  to 
the  fact  that  the  patient  has  suffered  from  rhemuatism,  and  has  returned  to  his 
occupation  before  the  endocarditis  produced  by  the  rheumatic  poison  has  entirely 
disappeared.  For  a  time  he  may  be  able  to  perform  his  customary  duties,  but  the 
increased  labor  thrown  upon  his  heart  by  exercise  causes  a  delay  in  the  healing  of 
the  lesions  in  his  endocardium,  and  as  a  result  he  suffers  from  a  degree  of  mitral 
stenosis  or  mitral  regurgitation,  or  both,  which  sooner  or  later  will  make  him  a 
cardiac  invalid.  Even  if  these  symptoms  are  not  manifested  for  some  time  after 
the  attack  of  rheumatism  has  been  present,  they  may  ne\ertheless  become  danger- 
ously active  when  with  advancing  years  cardiac  compensation  is  lost.  The  physician 
should  therefore  impress  upon  every  patient,  with  acute  articular  rheumatism,  who 
insists  upon  rising  as  soon  as  he  feels  well,  the  fact  that  he  is  taking  his  life  in  his 
hands  by  so  doing.  Even  after  all  articular  symptoms  are  passed  by,  the  patient 
should  remain  in  his  bed  for  at  least  two  or  three  weeks,  and  this  advice  holds  good 
even  if  during  the  attack  no  signs  of  an  endocardial  murmur  have  been  manifest. 


CHOLERA  181 


CHOLERA. 


Definition. — The  word  cholera  when  strictly  applied  is  used  to  designate  a  disease 
which  is  characterized  by  profuse  serous  purging,  cramps,  vomiting,  and  extreme 
prostration,  and  which  is  due  to  an  infection  of  the  bowels  by  the  specific  micro- 
organism of  this  disease,  called  the  Spirillum  cholerm  asiaticce,  which,  as  it  is  often 
broken  into  short,  curved  rods,  is  frequently  incorrectly  termed  the  "comma 
bacillus."  When  it  is  desired  to  indicate  that  the  true  disease  is  present  the  term 
"Asiatic  cholera"  is  used  to  distinguish  the  malady  from  other  forms  of  serous 
diarrhea  of  a  severe  type,  such  as  cholera  morbus  or  cholera  infantum. 

History. — Prior  to  1817  cholera  was  confined  to  certain  parts  of  India  and  never 
infected  districts  far  removed  from  them.  It  is  probal)le  that  the  disease  has 
occurred  for  many  centuries,  but  it  is  a  noteworthy  fact  that,  unlike  most  epidemic 
diseases  of  pronounced  characteristics  and  high  mortality,  no  clear  description  of 
its  presence  was  placed  on  record.  Since  1817,  when  an  epidemic  of  unusual 
severity  broke  out  in  India,  it  has  been  known  to  be  constantly  present  in  endemic 
form  in  some  parts  of  that  country,  and  it  has  from  time  to  time  been  carried  thence 
along  well-travelled  routes  by  pilgrims  and  travellers,  or  by  their  possessions, 
until  many  parts  of  the  earth,  removed  thousands  of  miles  from  the  original  focus, 
have  suffered  from  it.  Seven  distinct  invasions  of  Europe  have  occurred  since 
1817,  and  the  last  one  from  1891  to  1895.  The  disease  was  first  introduced  into 
America  by  emigrants  who  landed  in  Quebec  and  New  York  early  in  the  decade 
of  1830  to  1840. 

Distribution. — The  geographical  area  of  origin  has  already  been  described.  The 
disease  may  occur  in  any  part  of  the  world  to  which  the  specific  germ  may  be  con- 
veyed. 

Etiology. — The  cause  of  epidemic  cholera  is  the  spirillum  which  was  first  isolated 
by  Koch.  It  is  spiral-shaped  or  assumes  the  form  of  segments  of  a  spiral,  or  short 
curved  rods  and  S  forms. 

The  degree  of  curve  varies  greatly;  sometimes  the  organism  is  almost  straight, 
at  other  times  it  forms  a  partial  circle.  Bizarre  forms  also  occur.  It  is  active, 
motile,  and  flagellate.  The  bodies  described  by  Hueppe  as  spores  have  not  been 
so  considered  by  other  observers. 

Cholera  is  distinctly  a  water-borne  disease  in  the  vast  majority  of  epidemics. 
The  specific  organism  gains  access  to  the  body  through  contaminated  drinking 
water  or  soiled  food.  In  the  Hamburg  cholera  epidemic  of  1892,  about  18,000 
persons  were  stricken,  and  of  this  number  8000  died.  In  the  city  of  Altona,  which 
is  really  a  part  of  Hamburg,  and  which  also  derives  its  drinking  water  from  the 
Elbe,  there  were  only  about  500  cases  of  cholera  in  a  population  of  150,000.  Ham- 
burg had  no  filtration  plant  at  the  time,  while  Altona  had  a  sand  filtration  plant. 
It  is  only  by  water  and  food  that  cholera  can  be  transmitted,  except  that  if  choleraic 
stools  are  desiccated,  and  the  dust  is  blown  on  food  or  into  the  mouth,  it  is  conceiv- 
able that  the  infection  may  occur.  Aside  from  the  rarity  with  which  this  accident 
takes  place,  the  fact  that  the  bacillus  speedily  dies,  when  dried,  militates  against 
it  being  active  under  those  circumstances.  A  more  possible  and  indeed  probable 
method  by  which  the  infecting  agent  may  reach  the  food  is  its  carriage  by  flies, 
for  in  the  body  of  the  common  house-fly  the  specific  organism  may  exist  for  twelve 
days. 

Hot  weather  favors  the  spread  of  the  disease.  As  in  all  infectious  maladies, 
all  causes  which  decrease  vital  resistance,  such  as  alcoholism,  exposure,  convales- 
cence from  other  diseases,  and  even  profound  mental  depression,  distinctly  increase 
the  susceptibility  of  the  patient. 

Prevention. — It  is  evident  from  what  has  been  said  that  there  is  no  reason  why 
cholera  cannot  be  prevented,  and  it  may  be  said  of  deaths  from  cholera,  as  it  is 


1S2  DISEASES  DUE  TO  A  SPECIFIC  IXFECTIOX 

said  of  deaths  from  typlioid  fever,  that  every  one  is  preventahle  if  proijer  care  is 
taken  to  destroy  all  the  specific  organisms  the  moment  they  escape  from  the  hody 
of  a  patient  snH'erinn;  from  the  malady.  That  they  arc  not  destroyed  in  cholera 
is  all  the  more  to  he  condemned  by  reason  of  the  fact  that  they  escape  only  in  the 
stools,  whereas  in  typhoid  fever  the  specific  bacillus  escapes  by  the  feces,  urine, 
the  skin,  and  perhaps  the  saliva.  The  cholera  sjiirillum  is  exceedingly  susceptible 
to  bactericides  and  particularly  to  acids,  under  fa\()ralilc  circumstances  succumbing 
to  such  weak  acids  as  vinegar. 

All  dejecta  from  cholera  patients  should  be  destroyed  by  heat  or  by  the  action 
of  chlorinated  lime,  or  formaldehyde,  or  of  corrosi\e  sublimate,  contact  with  a 
solution  of  which  should  be  complete  and  prolonged  for  at  least  one  hour,  for  in  the 
latter  instance  the  mercury  salt  may  combine  with  the  albumin,  or  be  decomposed 
by  the  gases  in  the  stools. 

During  the  presence  of  an  epidemic  no  food  should  betaken  in  the  raw  state, 
and  it  should  be  cooked  immediately  before  it  is  eaten,  in  order  that  there  may 
lie  no  time  for  it  to  become  infected  after  it  is  cooked.  With  these  precautions 
the  danger  to  physicians  and  nurses  is  reduced  to  a  minimum.  When  there  is  a 
possibility  of  negligence,  a  valuable  prophylactic  is  the  use  of  dilute  sulphuric 
acid  in  the  dose  of  .5  to  10  drops  in  water  three  times  a  day  after  food.  This  does 
good,  by  reason  of  the  fact  that  dilute  acids  kill  the  cholera  spirillum,  and  again 
because  this  acid  acts  as  an  astringent  remedy  in  diarrhea.  Care  should  be  taken 
during  an  epidemic  that  bad  food  and  exposure  are  avoided,  as  this  may  prepare 
the  way  for  infection. 

Through  the  researches  of  Haffkine  in  India,  Kolle,  and  Strong  in  the  Philippines, 
it  would  seem  that  it  is  possible  to  immunize  human  beings  against  cholera,  but 
this  plan  of  inoculation  is  of  no  value  when  the  disease  has  once  developed. 

During  the  years  1894  and  1895  Hafl'kine  inoculated  3951  individuals  with  his 
anticholera  vaccine.  Of  this  number,  33,  or  a  little  less  than  1  per  cent.,  contracted 
the  disease,  whereas,  of  9335  individuals  who  were  uninoculated  and  similarly 
exposed  to  the  infection,  210,  or  2.24  per  cent.,  were  stricken.  These  ob.servations 
were  made  in  India. 

In  July,  1902,  an  epidemic  of  cholera  broke  out  in  the  prefecture  of  Nagasaki, 
Japan,  and  preventive  inoculations  were  at  once  begun.  Of  21,334  persons  who 
were  inoculated,  110  contracted  the  disease.  In  previous  epidemics  the  number 
of  persons  aft'ected  ran  well  up  into  the  thousands,  but  it  is  but  fair  to  state  that 
in  this  epidemic  only  741  cases  occurred  in  that  prefecture  among  the  uninoculated. 
As  the  number  of  uninoculated  inhabitants  is  not  stated,. we  cannot  judge  of  the 
real  value  of  the  plan. 

Ilaffkine's  conclusions  as  to  the  result  of  anticholera  inoculations  are  as  follows: 

1.  The  inoculation  produces  an  effect  within  four  days. 

2.  During  these  four  days  a  difference  in  susceptibility  shows  itself  in  favor 
of  the  inoculated. 

3.  After  the  expiration  of  the  four  days  and  during  a  pcriofi  of  at  least  fourteen 
months,  a  high  degree  of  resistance  to  attack  is  observed  in  the  inoculated. 

4.  The  proportion  of  deaths  to  cases  is  not  influenced  by  the  inoculation. 

The  objection  to  Ilaffkine's  prophylactic  is  the  severe  reaction  it  causes. 
Strong's  ])roi)liylactic  lacks  this  effect,  but  has  not  been  sufficiently  tested  as  \'et. 

Pathology  and  Morbid  Anatomy. — After  death  from  cholera  postmortem  rigidity 
comes  on  ^■c^y  rajiidly,  and  is  persistent  to  such  a  degree  that  distortit)ns  of  the 
limbs  and  body  may  be  ])resent.  In  typical  cases  the  entire  body  ajjpears  shrunken 
and  wasted  and  the  dependent  portions  rapidly  become  livid.  Xot  rarely  a  post- 
mortem rise  of  temperature  takes  place. 

When  the  body  is  incised  the  tissues  are  foimd  to  be  devoid  of  their  normal 
moisture,  and  the  blood  in  the  great  vessels  is  thick  and  dark  in  hue.     The  stomach 


CHOLERA  183 

is  empty,  its  mucous  membrane  is  congested,  and,  in  some  instances,  ecciiymoses 
may  be  present. 

The  chief  changes  are  to  be  found,  however,  in  the  lower  part  of  tiie  small  bowel. 
Its  mucous  membrane  is  boggy  or  sodden,  and  covered  by  a  glutinous  material 
which  is  readily  detached.  Not  rarely  the  mucous  membrane  is  stripped  off  in 
patches  or  shed  in  flakes.  These  changes  may  extend  as  high  as  the  duodenum, 
and  in  the  lower  ileum  Peyer's  patches  and  the  solitary  glands  are  found  to  be 
swollen  and  congested.  There  may  be  present  a  diphtheroid  exudate,  which  is 
adherent  in  part,  and  in  part  is  fleecy  or  flocculent  in  appearance.  Deeper  ulcera- 
tions and  perforations  are  exceptional.  Hemorrhages  may  also  be  found  in  the 
mucous  membrane  at  this  place. 

Notwithstanding  the  active  purgation,  the  large  bowel  in  cholera  is  not  as  much 
altered  as  is  the  ileum,  the  only  change,  as  a  rule,  being  an  acute  catarrh  of  the 
mucous  membrane. 

It  is  important  to  the  student  to  recall  the  fact  that  cholera  is  characterized 
by  changes  in  the  small  bowel,  whereas  dysentery  is  chiefly  characterized  by  changes 
in  the  colon. 

The  intestines  are  contracted,  their  coats  thickened,  and  the  peritoneum  possesses 
a  peculiar  rosy  hue.     The  mesenteric  glands  are  enlarged  and  infiltrated. 

Granular  changes  in  the  large  glandular  viscera  are  present  in  a  certain  percentage 
of  cases,  and  a  complicating  nephritis  is  occasionally  seen.  The  kidneys  ^ay  be 
enlarged  and  the  vessels  congested.  Under  the  microscope  the  uriniferous  tubules 
are  seen  to  be  filled  with  granular  casts,  but  the  tufts  are  not  materially  changed. 
The  great  loss  of  fluid  by  the  serous  discharges  and  the  lessened  absorption  of 
liquids  causes  concentration  of  the  blood  and  greatly  interferes  with  the  excretion 
of  poisons  by  the  kidneys. 

The  liver  is  not  enlarged  but  rather  shrunken,  and  its  cells  show,  under  the 
microscope,  cloudy  swelling,  with  patches  of  fatty  degeneration.  The  spleen  is 
usually  small.     The  heart  is  flaccid  and  the  lungs  shrunken. 

The  cholera  organism  is  found  in  immense  numbers  in  the  contents  of  the  bowels 
and  in  the  discharges  of  patients  suffering  from  this  disease,  but,  unlike  the  typhoid 
bacillus,  it  is  not  usually  widely  disseminated  through  the  body  (Figs.  43  and  44). 

Symptoms. — The  symptoms  of  cholera  develop  in  from  a  few  hours  to  ten  days 
after  infection  has  occurred.  The  average  period  of  incubation  is  usually  three  to 
six  days. 

The  earliest  symptom,  aside  from  a  feeling  of  depression,  is  the  onset  of  icatery 
diarrhea,  which  may  be  associated  with  pain.  The  patient  sufl'ers  from  the  iveakness 
and  deipression  characteristic  of  ordinary  watery  diarrhea,  and  if  the  passages  are 
very  profuse  there  may  be  great  feebleness  and  even  collapse.  In  the  majority  of 
cases,  however,  the  onset  of  the  disease  is  more  abrupi  than  that  just  described. 
With  almost  no  indication  of  impending  illness  the  patient  is  seized  by  active  vomiting 
and  purging,  by  severe  cramps  in  the  extremities  and  trunk,  and  passes  into  collapse. 
The  stools,  as  soon  as  all  the  ordinary  intestinal  contents  have  been  washed  out, 
are  rice-water  in  character,  that  is,  on  standing  they  separate  into  two  laj'ers,  the 
upper  clear  and  opalescent,  the  lower  full  of  flakes  of  mucus  and  exfoliated  necrotic 
mucosa. 

The  amount  of  serum  lost  by  the  purging  is  very  large,  and  it  is  expelled  with 
considerable  force.  Because  of  the  large  quantities  of  fluid  lost  by  this  means 
the  urine  becomes  scanty  and  suppressed.  This  loss  of  fluid,  combined  with  the 
changes  in  the  kidneys,  results  in  uremja,  which,  of  course,  aids  greatly  in  increasing 
the  toxemia  of  the  disease.  The  vomiting  is  not  only  violent,  but  persistent  retching 
may  greatly  exhaust  the  patient.  The  cramps  in  the  muscles  are  due  to  the  rapid 
abstraction  of  fluid  from  their  tissues  and  perhaps,  in  part,  to  the  toxemia  of  the 
disease. 


184  DISEASES  DUE  TO  A  SPECIFIC  IXFECTION 

In  about  half  the  cases  recovery  l)egins  to  take  phice  at  this  stage  by  a  gradual 
modification  of  the  symptoms,  but  if  the  patient  is  too  ill  to  recover,  the  second 
stage,  or  that  of  collapse  and  jjrofoimd  asthenia,  now  develops.  This  stage  may 
last  from  a  few  hours  to  two  days.     As  it  proceeds  the  patient  becomes  so  feeble 


Cholera  spirilla  in  the  fundus  of  a  gland  of  Licbrrkuhn  in  the  small  bowel,  in  a  case  of 
Asiatic  cholera.     (Kast  and  Rumpler.) 

that  the  respirations  become  shallow.  The  fluid  stools  pass  from  the  bowel  invol- 
untarily, escaping  rather  by  relaxation  of  the  sphincter  than  by  the  conscious 
act  of  the  patient.  Feeble  attempts  at  emesis  may  still  persist,  and  the  cramps 
may  be  more  severe  than  before. 


As  the  exhaustion  deepens  the  imlse  becomes  a  mere  thread  at  the  wrist,  and 
may  even  be  imperceptible  in  the  great  vessels.  The  heart  sounds  become  more 
and  more  indistinct,  and  occasionally  soft  murmurs  are  heard. 

The  face  bears  the  Ilippocratic  expression,  the  nose  is  pivched  and  pointed,  the 


CHOLERA  185 

eyes  sunken  and  surrounded  by  dark  rings,  the  mouth  is  partly  open,  the  teeth 
covered  with  sordes,  the  skin  of  the  entire  body  is  hvid  and  often  bedewed  witli  a 
cold  sweat.  The  voice  is  whispering,  the  thirst  excessive,  and  the  mind  clouded. 
Toward  the  close  of  life  stupor  or  cmna  mercifully  relieves  sufl'ering.  Finally, 
with  a  continued  fall  of  bodily  temperature,  death  takes  place. 

When  the  stage  of  reaction  develops,  before  these  grave  symptoms  threaten 
death,  the  pulse  becomes  a  little  stronger,  the  passages  are  less  frecjuent  and  less 
copious,  and  the  respirations  grow  deeper.  Bodily  heat  is  gradually  restored, 
and  the  patient  recovers,  unless  some  of  the  complications  mentioned  farther  on 
ensue. 

Variations  from  the  Ordinary  Course. — The  patient  may  have  so  mild  an  infection 
as  to  be  but  slightly  ill  and  never  forced  to  go  to  bed.  In  other  instances  the 
serous  diarrhea  is  excessive,  but  the  urine  is  not  suppressed,  and  the  general  debility 
does  not  become  marked.  These  cases  are  sometimes  called  cases  of  "cholerine." 
They  may  speedily  recover  or  rapidly  proceed  to  the  fully  developed  malady. 
In  still  another  class  the  toxemia  of  the  disease  exceeds  all  other  symptoms.  The 
diarrhea  may  be  absent,  and  the  patient,  overwhelmed  by  the  poison,  sinks  into 
unconsciousness  and  death.     This  is  called  "cholera  sicca." 

The  degree  of  stupor  varies  greatly.  In  some  patients  the  mind,  at  the  well- 
developed  stage  of  the  disease,  is  remarkably  clear;  in  other  instances  it  is,  almost 
from  the  first,  stupid  from  toxemia. 

In  some  instances  high  fever  develops.  This  is  a  very  unfavorable  sign.  In 
others  an  urticaria  or  erythema  is  seen. 

Complications  and  Sequelae. — Aside  from  the  grave  complications  of  urinary 
suppression  followed  by  uremia,  the  profound  infection  may  result  in  localized 
gangrene  of  the  toes  and  fingers.  Edema  of  the  lungs  often  causes  death,  and  infec- 
tious arthritis  and  parotitis  may  develop.  Profound  weakness  and  feebleness  may 
persist  for  a  long  time  in  convalescence,  and  secondary  nephritis  may  ultimately 
cause  death. 

Diagnosis. — The  diagnosis  of  cholera  is  not  difficult  if  the  well-developed  type 
of  the  disease  is  present,  but  in  the  early  stages,  or  in  the  aberrant  forms  just 
described,  the  determination  of  the  cause  of  the  illness  may  not  be  easy.  True 
cholera  is  to  be  separated  from  cholera  nostras  or  cholera  morbus,  but  in  the  presence 
of  an  epidemic  of  Asiatic  cholera  this  may  be  impossible  without  bacteriological 
tests,  for  severe  cholera  morbus  may  not  only  be  manifested  by  purging  and  vomit- 
ing, but  by  collapse  as  well,  and  even  cramps  may  appear  in  the  more  severe  types. 
Cholera  must  also  be  separated  during  an  epidemic  from  the  profuse  watery  purging 
sometimes  met  with  in  cases  of  Bright's  disease,  when  the  purging  is  due  to  an 
effort  at  elimination.  Various  poisons  may  also  cause  choleraic  diarrhea,  notably 
antimony.  Indeed,  it  is  impossible  to  separate  acute  antimonial  poisoning  from 
cholera  during  an  epidemic  of  the  latter  disease,  because  the  symptoms  are  identical. 
Nothing  but  a  chemical  analysis,  on  the  one  hand,  or  a  bacteriological  test,  on  the 
other,  can  determine  this  question. 

It  is  important  to  remember  that  while  the  presence  of  the  spirillum  of  cholera 
is  characteristic  of  cholera,  that  inability  to  discover  it  in  the  discharges  is  not 
positive  proof  that  cholera  is  not  present,  because  in  rare  instances  it  may  be 
temporarily  undemonstrable.  A  very  valuable  method  of  diagnosis  is  the  test 
of  agglutination  of  cholera  bacilli  by  the  blood  of  the  patient  in  a  manner  similar 
to  that  of  the  Widal  test  in  typhoid  fever. 

Prognosis. — The  prognosis  in  cholera,  whenever  the  symptoms  are  well  developed 
is  always  grave,  for  the  mortality  in  most  epidemics  is  about  50  per  cent.  In  the 
old  and  very  young  the  outlook  is  worse  than  in  a  well-developed  person  in  the 
prime  of  life. 

There  are  three  facts  aside  from  the  severity  of  the  disease  which  increase  the 


186  DISEAfiES  DUE  TO  A  SPECIFIC  IXFECTIOX 

gravity  of  the  prognosis  very  materially,  namely,  alcoholism,  renal  disease,  and 
disease  of  the  liver.  In  addition,  it  must  he  remembered  that  any  pre-existing 
disease  which  decreases  vital  resistance  increases  the  gra\ity  of  the  case. 

In  respect  to  the  disease  itself,  it  may  be  said  that  al)ruptness  of  onset,  early 
hebetude,  and  rapid  development  of  signs  of  collapse  are  the  three  facts  that  promise 
evil  tendencies.  If  to  these  is  added  renal  inactivity,  pulmonary  edema,  or 
an  alinormally  low  temperature,  the  case  is  to  be  regarded  as  almost  hopeless. 
Contrariwise,  there  are  several  signs  of  good  omen,  namely,  the  presence  of  a  good 
pulse  and  the  maintenance  of  bodily  heat,  the  return  of  a  fecal  color  to  the  stools 
and  the  absence  of  the  great  emaciation  and  wasting  which  severe  cases  usually 
manifest. 

Treatment. — The  three  most  important  details  in  the  treatment  of  cholera  are 
the  control  of  the  diarrhea,  the  maintenance  of  strength,  and  the  conservation 
of  body  heat.  All  persons  who  have  anj-  tendency  to  diarrhea,  during  a  cholera 
epidemic  should  at  once  be  treated  by  astringent  mixtures,  which  should  lie  increased 
in  their  efficiency  by  the  addition  of  a  few  drops  of  sulphuric  acid.  By  this  method 
of  treatment  the  development  of  cholera  can  be  probably  pre\ented  in  a  cons  iderable 
number  of  persons.  The  use  of  an  astringent  and  acid  substance  like  sulphuric 
acid  is  far  more  advantageous  than  the  employment  of  opium,  because  the  acid 
is  destructive  to  the  micro-organism,  and  it  does  not  interfere  with  other  functions 
of  the  body  as  does  opium.  If  the  diarrhea  is  already  active  10  to  15  drops  of 
aromatic  sulphuric  acid,  with  double  that  quantity  of  spirit  of  camphor',  should  be 
administered,  well  diluted  with  water  or  with  brandy,  e\'ery  three  hours,  and 
counter-irritation  in  the  form  of  a  mustard  plaster,  or  sinapisms,  or  capsicum  drafts 
should  be  applied  over  the  abdomen.  If  these  cannot  be  obtained  a  turpentine 
stupe  may  be  used  with  advantage. 

It  seems  scarcely  necessary  to  add  that  even  in  mild  cases  the  patient  should  be 
kept  in  bed  and  the  greatest  possible  amount  of  rest  enforced.  If  \-pmiting  is 
an  active  symptom  it  may  be  necessary  to  avoid  all  medication  by  the  mouth  and 
give  stimulants  hypodermically.  Under  these  circumstances  2  grains  of  camphor 
dissolved  in  sterilized  olive  oil  may  be  given  by  means  of  the  hypodermic  needle 
every  eight  hours.  Such  a  method  of  treatment  will  usually  do  much  toward  the 
maintenance  of  active  circulation,  but  should  the  circulation  fail  the  physician 
must  employ  not  only  the  camphor  injections  named,  but  give  atropine  and  strych- 
nine hypodermically,  and  more  important  still,  for  the  purpose  of  compensating 
for  the  loss  of  much  fluid  by  the  bowel,  hypodermoclysis  should  be  resorted  to. 
It  is  best  to  employ  "concentrated  sterile  saline,"  one  ounce  of  which  when  added 
to  a  cjuart  of  pure  water  makes  normal  salt  solution.  But  if  this  cannot  be  obtained 
ordinary  common  salt  in  the  proportion  of  a  drachm  to  the  pint  may  be  injected 
by  hypodermoclysis.  This  fluid  should  of  course  be  first  sterilized  by  boiling, 
and  the  injection  should  be  made  slowly,  the  fluid  being  at  the  temperature  of  100°. 
It  is  quite  remarkable  how  rapidly  the  thirsty  tissues  will  absorb  this  fluid,  which 
not  only  com])eusates  for  the  loss  l)y  purging,  but  also  aids  in  overcoming  su])pres- 
sion  of  urine  by  supplying  the  bloodvessels  with  fluid.  Tlicrc  c:\\\  be  no  doubt 
that  hypodermoclysis  is  a  most  valuable  life-sa\ing  nicnsurc  in  the  trciilmcnt  nf 
this  di.sease. 

Rogers  has  shown  that  in  the  stage  of  collapse  there  is  a  loss  of  one-half  to  two- 
thirds  of  the  blood  serum  and  of  the  chlorides  as  well.  To  a\ert  this  loss  intraven- 
ous injections  of  hypertonic  salt  solution,  Locke's  modification  of  Ringer's  formula, 
should  be  resorted  to.  (This  is  on  the  drug  market  of  the  world  under  the  name 
Concentrated  Sterile  Saline,  P.  W.  &  Co.)  If  this  formula  cannot  be  quickly 
obtained  use  two  drachms  of  sterile  sodium  chloride  to  the  pint  of  freshly  distilled 
water.  This  fluid  should  be  injected  whenever  the  Idood  pressure  is  as  low  as  80 
nun.  of  Ilg.  in  Kuropeans  or  when  the  specific  gravity  of  the  blood  is  above  lOoG. 


YELLOW  FEVER  187 

The  specific  gravity  can  be  obtained  by  mixing  glycerine  and  water  in  difl'erent 
proportions  so  that  small  bottles  contain  solutions  varying  in  specific  gravity  from 
]()5()  to  1070.  A  drop  of  blood  from  a  capillary  tube  is  dropped  in  eacli  bottle. 
If  it  sinks  in  one  bottle  and  floats  in  another  it  is  evident  that  its  specific  gravity 
is  greater  than  the  first  and  less  than  the  other.  Thus  if  it  sinks  in  the  mixture 
at  1056  it  has  a  specific  gravity  in  excess  of  normal;  then  intra\'enous  injections 
should  be  given. 

To  destroy  the  toxin  in  the  intestine  Rogers  gives  a  solution  of  calcium  perman- 
ganate, which  is  somewhat  less  astringent  than  the  potassium  salt  and  at  the  same 
time  stronger,  as  it  is  divalent.  This  drug  is  given  to  drink  ad.  lib.  in  a  solution 
of  6  grains  or  more  to  the  pint.  It  is  usually  advisable  to  dilute  it  further  at  first 
until  the  patient  gets  accustomed  to  the  taste,  and  then  gradually  increase  its 
strength  as  much  as  possible.  In  addition,  the  potassium  salt  is  given  in  pills, 
being  more  conveniently  used  in  this  form,  as  it  is  much  less  hygroscopic  than  the 
calcium  permanganate: 

Potassium  permanganate 2  grains. 

Kaolin q-  s. 

Make  a  pill  and  coat  with  salol  or  keratin,  so  that  it  will  pass  through  the  stomach 
and  dissolve  in  the  small  intestine,  where  the  action  is  desired.  Two  pills  are 
given  every  quarter  of  an  hour  for  the  first  three  hours,  and  then  two  every  half 
hour  until  the  stools  become  green  and  less  copious,  which  usually  occurs  within 
about  twelve  hours.  The  pills  are  then  discontinued,  but  a  course  of  eight  pills 
is  given  at  the  beginning  of  the  second  and  third  days  under  treatment,  to  pre\'ent 
relapses.  In  children  smaller  amounts  must  be  given.  Any  pills  which  are  vomited 
are  replaced  by  others. 

If  the  temperature  at  the  stage  of  reaction  rises  above  103.5  or  104°  active  anti- 
pyresis  by  cold  bathing  or  cold  rectal  injections  is  to  be  resorted  to.  To  combat  the 
collapse,  hypodermoclysis  is  used  and  camphor,  pituitrin,  adrenalin,  digitalis,  stro- 
phanthus  or  caffeine  given  to  stimulate  the  circulation. 

To  aid  in  the  restoration  of  renal  activity  a  hot  compress  may  be  placed  under 
the  loins. 

As  a  rapidly  acting  diffusible  stimulant  in  conditions  of  marked  collapse  Hoff- 
mann's anodyne  in  the  dose  of  a  drachm  every  hour  may  be  given  hypodermically 
or  by  the  mouth  with  shaved  ice.  A  drachm  of  spirit  of  camphor  may  also  be  used 
with  advantage  for  this  purpose.  Aromatic  spirit  of  ammonia  may  also  be  given 
by  the  mouth,  but  is  not  so  valuable. 

YELLOW   FEVER. 

Definition. — ^Yellow  fever  is  an  acute  infectious  disease  occurring  chiefly  in 
tropical  or  semi-tropical  regions,  and  characterized  by  fever,  yellow  discoloration 
of  the  skin,  black  vomit  in  some  cases,  and  a  tendency  to  oozing  hemorrhages 
from  the  mucous  membranes.  The  early  development  of  albuminuria  is  also  a 
noteworthy  symptom. 

History,  Etiology,  and  Prevention. — The  earliest  history  of  yellow  fe^■e^  records 
its  occurrence  among  the  followers  of  Columbus,  and  before  that  time  it  never 
attacked  Europeans.  It  is,  therefore,  a  disease  indigenous  to  the  Western  Hemi- 
sphere. As  early  as  1648  the  inhabitants  of  St.  Kitts,  and  in  1655  those  of  Jamaica, 
were  attacked  by  it. 

Since  then  yellow  fever  has  devastated  North  and  South  America  many  times. 
It  has  extended  its  ravages  all  the  way  from  Quebec  to  Montevideo,  and  on  the 
western  coast  of  the  Western  Hemisphere  has  been  almost  equally  widely  distrib- 
uted.   In  the  latter  part  of  the  eighteenth  century  it  destroyed  10  per  cent,  of 


188  DISEASES  DUE  TO  A  SPECIFIC  IXFECTION 

the  population  of  Pliiladelpliia.  On  more  than  one  occasion  it  has  brougiit  military 
expeditions  to  defeat  by  the  frightful  mortality  which  it  has  caused  among  the 
troops.  During  the  Frencji  exjjedition  to  Ilayti,  in  1802,  22,000  out  of  25,000  men 
died  from  it  in  one  season,  and  the  various  attempts  which  were  made  by  Spain 
to  subjugate  Cuba  were  practically  frustrated  by  the  mortality  from  yellow  fever 
among  the  Spanish  troops.  Davidson  states  that  out  of  a  po]5ulation  of  9000 
persons  at  Gilbraltar  in  1800  only  28  escaped  infection.  In  1878  the  financial 
loss  in  the  Mississippi  Valley  produced  by  a  single  epidemic  amounted  to  over 
§15,000,000.  Out  of  a  population  of  19,500  in  Memphis  there  were  17,(300  cases 
and  6000  deaths. 

For  one  hundred  and  fifty  years  Havana  was  recognized  as  the  focus  in  which 
yellow  fever  was  practically  constantly  present,  and  from  this  focus  many  i)ortions 
of  the  civilized  world  were  again  and  again  infected.  It  was  not  until  the  I'nited 
States  Army  took  possession  of  Havana  and  its  medical  officers  instituted  sani- 
tary measures  that  any  real  attempt  was  made  to  discover  the  means  of  propaga- 
tion of  yellow  iever  or  to  limit  its  de\'elopment  in  that  city.  ^Yhen  the  brave, 
skilful,  and  scientific  labors  of  these  officers  were  completed  one  of  the  most  bril- 
liant medical  discoveries  in  the  history  of  the  world  was  annoimced. 

Under  proper  sanitary  directions  the  death  rate  in  Havana  fell  from  91  and  a 
fraction,  under  Spanish  rule  in  1898,  to  33  and  a  fraction  in  1899  under  American 
rule,  to  24|  in  1900,  and  to  22  and  a  fraction  in  1901,  but  there  was  not  a  simul- 
taneous diminution  in  the  frequency  or  mortality  of  yellow  fever.  Indeed,  at  that 
period  there  was  an  actual  increase  in  the  disease  notwithstanding  the  fact  that 
all  other  maladies  were  decreasing.  It  was  under  these  circumstances  that  a 
commission  was  appointed  by  the  Surgeon-General  of  the  United  States  Army 
for  the  purpose  of  studying  yellow  fever.  The  chairman  of  the  commission  was 
the  late  Dr.  Walter  Reed,  a  major  in  the  United  States  Army,  and  associated  with 
him  were  acting  assistant  surgeons  James  Carroll,  Jesse  W.  Lazear,  and  Aristides 
Agramonte. 

The  medical  profession  should  never  cease  to  do  honor  to  the  members  of  this 
commission,  who  faced  one  of  the  most  horrible  and  fatal  diseases  with  the 
greatest  bravery,  and  thereby  have  succeeded  in  saving  the  li\"es  of  himdreds  of 
thousands  of  individuals.  Dr.  Lazear,  who  was  one  of  the  most  enthusiastic 
members  of  the  commission,  allowed  himself  to  be  bitten  by  an  infected  mosrjuito. 
He  was  not  infected  by  this  bite,  but  several  days  after  he  was  accidentally  bitten, 
and  lost  his  life  from  the  consequent  attack  of  yellow  fever.  Another  member, 
Dr.  Carroll,  allowed  himself  to  be  bitten,  was  also  attacked  by  the  disease,  and 
narrowly  escaped  death. 

The  fact  that  Ross  and  others  had  proved  that  the  transmission  of  malarial 
fever  was  by  the  mocpiito,  and  that  Dr.  Carlos  Finlay,  a  physician  of  Havana,  a 
graduate  of  the  Jefferson  iNIedical  College,  of  Philadelphia,  had  asserted  as  long 
ago  as  1881  that  a  certain  species  of  mosquito  in  Havana  was  guilty  of  trans- 
mitting yellow  fever  from  person  to  person,  led  the  Army  Board  to  direct  their 
attention  to  the  investigation  of  this  question,  and  they  soon  found  that  if  a  female 
mosquito  of  the  species  Sfegomyia  caloims  were  allowed  to  bite  a  yellow  fever 
patient  during  the  first  three  days  of  the  disea.se,  and  then,  from  turire  to  twenty 
days  later,  permitted  to  bite  a  non-immune,  the  latter  almost  in\ariably  developed 
yellow  fever.  I  repeat:  If  the  mosquito  bites  a  non-immune  earlier  than  the  twelfth 
day  after  biting  a  patient  suffering  with  the  disease  it  is  not  transmitted.  The 
male  insect  does  not  bite.  The  female  bites  most  ^•iciously  about  dusk  and  about 
dawn.  This  insect  is  found  everywhere  around  the  globe  between  38  degrees 
north  and  38  degrees  south  latitude. 

That  the  disease  is  never  carried  by  fomites  was  also  proved  by  these  investi- 
gators, who  had  a  number  of  \oung  non-immunes  sleep  for  tweiity  consecuti^•e 


YELLOW  FEVER  189 

nights  in  a  room  which  was  hung  with  articles  soiled  by  black  vomit,  bloody  fecal 
discharges,  and  urine,  from  fatal  and  other  cases  of  yellow  fever.  These  persons 
also  packed  and  unpacked  these  articles  night  and  morning  from  boxes  in  which 
they  were  placed.  Other  non-immunes  actually  slept  in  garments  and  between 
sheets  that  had  covered  fatal  cases  of  yellow  fever,  but  in  not  a  single  instance 
was  the  disease  contracted,  although  as  soon  as  these  non-immunes  were  exposed 
to  mosquitoes  several  of  them  developed  yellow  fever. 

The  practical  result  of  proving  that  the  mosquito  is  the  cause  of  the  transmission 
of  the  infection  has  been  the  complete  clearance  of  Ha^^ana  of  yellow  fever.  AH 
cases  of  yellow  fever  were  protected  by  mosquito  netting  so  that  mosquitoes  could 
not  carry  infection  from  them  to  others.  All  pools  and  gutters  containing  water 
upon  which  mosquitoes  could  breed  were  removed,  and  the  destruction  of  mos- 
quitoes was  carried  on  actively,  with  the  result  that  it  was  possible  in  a  year  to 
diminish  the  number  of  deposits  of  mosquito  larvse  in  the  city  of  Havana  from 
26,000  to  300.  As  a  result,  the  death  rate  from  malaria  fell  from  344  in  1900  to 
151  in  1901,  and  up  to  July,  1902,  it  was  only  47;  while  the  diminution  in  the 
number  of  mosquitoes  caused  so  great  a  decline  in  the  prevalence  of  yellow  fever 
that  by  September  28,  1901,  new  cases  ceased  to  occur  in  Havana.  After  that 
time,  according  to  Dr.  Gorgas,  of  the  United  States  Army,  from  whose  reports 
much  of  this  information  is  taken,  not  a  single  case  originated  in  that  city 
until  the  latter  part  of  1905,  when  relaxed  vigilance  allowed  the  disease  again  to 
reappear. 

The  conclusions  of  the  commission  are  so  important  that  they  are  given  ver- 
batim : 

1.  The  mosquito — Stegomyia  fasciata  cahpus — serves  as  the  intermediate  host 
for  the  parasite  of  yellow  fever. 

2.  Yellow  fever  is  transmitted  to  the  non-immune  individual  by  means  of  the 
bite  of  the  mosquito  that  has  previously  fed  on  the  blood  of  those  sick  with  this 
disease. 

3.  An  interval  of  about  twelve  daj'^s  or  more  after  contamination  appears  to  be 
necessary  before  the  mosquito  is  capable  of  conveying  the  infection. 

4.  The  bite  of  the  mosquito  at  an  earlier  period  after  contamination  does  not 
appear  to  confer  any  immunity  against  a  subsequent  attack. 

5.  Yellow  fever  can  also  be  experimentally  produced  by  the  subcutaneous  in- 
jection of  blood  taken  from  the  general  circulation  during  the  first  and  second 
days  of  this  disease. 

6.  An  attack  of  yellow  fever,  produced  by  the  bite  of  the  mosquito  confers 
immunity  against  a  subsequent  attack  of  the  non-experimental  form  of  this  disease. 

7.  The  period  of  incubation  in  thirteen  cases  of  experimental  yellow  fever  has 
varied  from  forty-one  hours  to  five  days  and  seventeen  hours. 

8.  Yellow  fever  is  not  conveyed  by  fomites,  and  hence  disinfection  of  clothing, 
bedding,  or  merchandise,  supposedly  contaminated  by  contact  with  those  sick 
with  this  disease,  is  unnecessary. 

9.  A  house  may  be  said  to  be  infected  with  yellow  fever  only  when  there  are 
present  within  its  walls  contaminated  mosquitoes  capable  of  conveying  the  para- 
site of  this  disease. 

10.  The  spread  of  yellow  fever  can  be  most  effectually  controlled  by  measures 
directed  to  the  destruction  of  mosquitoes,  and  the  protection  of  the  sick  against 
the  bites  of  these  insects. 

11.  While  the  mode  of  propagation  of  yellow  fever  has  now  been  definitely 
determined,  the  specific  cause  of  this  disease  remains  to  be  discovered.  It  has 
later  been  shown  that  the  organism  causing  this  disease  is  ultramicroscopic  in  size 
and  it  passes  through  the  pores  of  a  Pasteur-Chamberland  B.  filter. 

Attention  has  already  been  called  to  the  fact  that  the  infectious  agent  of 


190  DISEASES  Dili  TO  A  SPECIFIC  IXFKCTIOX 

yellow  fever  is  conveyed  by  mosquitoes  from  i)atieiit  to  i)iitieiit.  It  is  there- 
fore essential  that  all  cases  of  yellow  fever  should  he  kc])t  under  mosciuito  netting 
so  that  they  may  not  be  bitten  by  mosquitoes,  and  it  is  also  wise  for  those 
who  are  well  to  jjrotect  themselves  at  night  from  mosquitoes  by  similar  means. 
For  scrcenini;;  those  who  arc  ill,  a  gau'.e  of  not  less  than  twenty  meshes  to  the  inch 
should  be  used,  otherwise  the  mosquito  may  jjuss  tJirough  it.  An  active  crusade 
against  all  mosquitoes  and  the  destruction  of  their  breeding-places  should  also  be 
instituted,  and  it  is  important  to  bear  in  mind  that  these  breeding  places  are  not 
sunlit  streams  but  shaded  cisterns,  old  bottles,  vases  in  cemeteries  and  rain  gut- 
ters tliat  do  not  drain,  themselves  thoroughly.  Swampy  places  should  be  drained 
and  all  high  grass  cut  down.  Stickle-back  minnows  placed  in  pools  feed  on  the 
larvae  and  crude  petroleum  may  be  distributed  over  the  surface  of  tJie  pool  for 
their  destruction. 

Pathology  and  Morbid  Anatomy. — One  of  the  most  marked  changes  produced 
in  tlic  body  by  the  infection  of  yellow  fever  is  that  which  takes  place  in  theljlood,  a 
decided  anemia  developing.  Many  of  the  red  cells  are  crenated  and  some  of  the 
white  cells  are  granular.  Free  hemoglobin,  hemin,  and  hematin  are  found  in  it 
owing  to  the  destruction  of  the  red  corpuscles. 

The  heart  is  soft  and  flabby,  and  minute  ecchymoses  in  its  muscular  tissue  may 
be  present.  The  pericardium  may  contain  an  excess  of  blood-stained  fluid,  and 
its  membrane  may  be  dotted  with  petechia?. 

The  stomach  shows  changes  with  great  constancy.  It  usually  contains  black 
fluid  due  to  altered  exuded  blood;  its  mucous  lining  is  congested  in  patches  and 
is  marked  by  ecchymosis  or  even  softened.  When  placed  under  the  microscope, 
sections  of  the  stomach  show  the  bloodvessels  engorged  and  their  walls  under- 
going fatty  degeneration.  The  intestinal  t;anal  also  contains  broken-down  blood 
passed  from  the  stomach,  and  its  contents  may  be  acid.  Fatty  degeneration  of 
Peyer's  patches  and  the  glands  of  Lieberkuhn  is  present. 

The  li\'er  is  often  pallid  or  yellow  in  hue,  and  its  cells  also  may  undergo  fatty 
change.  Councilman  states  that  associated  with  these  signs  of  fatty  degeneration 
areas  of  necrosis  can  be  demonstrated  in  every  case  that  comes  to  autopsy. 

As  in  many  acute  and  severe  infections,  the  kidneys  show  signs  of  acute  diffuse 
nephritis  with  fatty  degeneration  of  the  cells  lining  the  tubules. 

Small  hemorrhagic  spots  are  sometimes  found  in  the  meninges  of  the  brain 
and  cord,  and  fatty  degeneration" of  the  cells  of  the  solar  plexus  has  been  described. 

Symptoms. — A  very  noteworthy  fact  in  connection  with  the  symptomatology 
of  yellow  fe\'er  is  that  in  a  majority  of  cases  its  onset  is  most  abrupt.  There  may 
be,  for  a  few  hours  before  the  well-defined  symptoms  show  themselves,  a  sense  of 
malcme  and  headache  or  vertigo.  The  first  symptom  of  prominence  is  the  appear- 
ance of  a  rifior,  or  rigors,  which  may  be  moderate  or  severe,  but  Bemiss  states 
that  chills  are  rare.  In  addition  the  patient  suft'ers  from  .severe  lumbar  and  mu.s- 
cvlar  pains,  headache  and  ci/eachc,  and  marked  pallor.  There  is  often  cpifia.stric 
di.stre.ss.     In  children  the  disease  may  be  ushered  in  l)y  ronriilsioii.f. 

After  the  stage  of  onset  the  skin  of  the  face  becomes  flushed  and  turgid;  the 
mind  may  wander,  but  as  the  disease  develops  it  is  usually  remarkably  clear  and 
alert,  so  that  the  patient  watches  those  about  him  with  the  same  degree  of  atten- 
tion as  is  often  seen  in  acute  peritonitis.  The  expression  is  anxious.  The  tevi- 
perafvre  rapidly  rises  so  that  it  reaches  its  acme  of  from  103°  to  107°  by  the  end 
of  twenty-four  or  thirty-six  hours. 

If  the  case  is  a  very  mild  one  the  febrile  movement  may  cease  as  early  as  the 
end  of  the  first  day  or  on  the  morning  of  the  second  day,  but  usually  the  acme 
of  the  temi)erature  is  maintained  for  from  two  to  three  days,  during  which  time 
there  may  be  slight  morning  and  evening  variations.  In  cases  which  are  moder- 
ately severe  the  fever  usually  begins  to  fall  after  this  tune  and  reaches  a  point 


YELLOW  FI'JVER  1!H 

near  the  normal  in  iVoin  twonty-fonr  to  seventy-two  hours.  That  is,  the  fiiil  is 
by  lysis. 

After  tlie  temperature  has  reaehed  normal,  that  is  when  the  .itugn  of  rctiiisxlon 
about  to  he  described  has  become  well  marked,  a  secondary  ferer  develops  which, 
like  that  of  the  stage  of  on.set,  lasts  from  two  to  three  days  and  falls  by  lysis.  In 
cases  which  are  likely  to  be  fatal  this  fall  may  not  occur. 

The  resiyiration  and  jmhe  rate  are  at  first  increased  in  frequency  and  the  indi- 
vidual pulse  beat  is  increased  in  volume,  but  these  circulatory  conditions  speedily 
undergo  a  marked  change  with  the  approach  of  the  period  of  remission.  On  the 
second  or  third  day,  even  if  the  temperature  remains  as  high  as  before,  the  pulse 
rate  begins  to  fall,  or  falls  even  while  the  temperature  is  still  rising,  so  that  a  pulse 
rate  which  early  in  the  onset  was  as  high  as  110  may  now  be  as  low  as  75. 

After  the  fever  begins  to  fall  owing  to  the  beginning  of  convalescence  the  pulse, 
as  in  many  cases  of  ordinary  catarrhal  jaundice,  may  fall  still  farther  till  it  reaches 
45  a  minute.  It  is  the  slowing  of  the  pulse  in  the  stage  of  onset,  while  the  tem- 
perature is  still  high,  that  is  particularly  worthy  of  note. 

The  iongue  is  covered  with  a  white  fur  save  at  its  edges,  which  are  red;  the 
hoioels  are  constipated,  and  there  may  be  epigastric  distress  followed  by  the  vomiting 
of  acid  mucus. 

The  urine  is  scanty  and  it  may  be  distinctly  albuminous  as  early  as  the  third 
day.  This  early  albuminuria  is  considered  by  yellow-fever  experts  to  be  a  \ev\ 
important  aid  to  diagnosis. 

Hemorrhages  usually  do  not  develop  before  the  third  day  and  begin  as  a  bleed- 
ing of  the  gums  and  epistaxis.  Menorrhagia  may  develop.  Hematemesis  is  seen 
as  a  rule  only  in  severe  cases. 

By  the  third  day  a  very  marked  remission  in  the  symptoms  may  occur.  The 
pains  and  aches,  the  rapid  pulse,  the  high  temperature,  and  the  flushing  of  the 
face  all  become  modified.  The  gastric  symptoms  abate,  but  the  conjunctivae  may 
begin  to  be  jaundiced  and  the  skin  of  the  body  may  also  begin  to  show  a  yellow  hue. 
This  is  the  critical  period  of  the  disease,  for  the  patient  is  now  "  at  the  parting  of 
the  ways."  One  path  leads  to  rapid  recoA^ery  with  marked  amelioration  of  all 
the  symptoms;  the  other  leads,  after  a  remission  of  from  twelve  to  forty-eight 
hours,  to  a  recurrence  of  all  the  dangerous  symptoms  in  an  aggravated  form. 

If  the  way  is  evil  there  is  ■precordial  and  epigastric  distress,  persistent  vomiting 
of  clear  liquid  with  flakes  of  broivn,  reddish-looking  material,  which  speedily  in- 
creases in  amount  until  the  well-known  black  vomit  presents  itself.  The  uritie  is 
more  scanty  and  more  albuminous  than  ever,  and  the  general  state  of  the  patient 
is  that  of  profound  illness.  The  temperature  in  some  cases  rises  as  it  did  in  the 
stage  of  onset,  but  it  may,  and  this  sign  is  of  grave  import,  fall  below  normal. 
Even  yet  it  is  possible  for  recovery  to  occur  by  a  gradual  amelioration  of  all  the 
symptoms,  but  usually  the  symptoms  continually  get  worse.  The  grave  depres- 
sion increases,  the  yellow  skin  develops  a  greater  degree  of  yellowness,  and  petechise 
are  formed.  The  vomiting  of  black  material  is  more  severe  and  profuse,  and 
hemorrhages  may  occur  from  other  mucous  membranes  than  that  of  the  stomach. 
The  scene  closes  with  hiccough,  profound  asthenia,  suhsultiis  tendinum,  the  Hip- 
pocratic  face,  and  in  exhaustion  and  coma,  due  in  part  to  the  direct  effect  of  the 
infection  and  in  part  to  the  uremia  produced  by  the  intense  renal  lesions. 

While  these  may  be  considered  the  symptoms  of  yellow  fever  in  many  cases, 
in  others  they  are  very  different.  In  the  so-called  apoplectiform  type  the  patient 
is  seized  with  vertigo,  stupor,  unconsciousness,  and  convulsive  attacks.  He  speedily 
becomes  more  and  more  deeply  depressed,  his  circulation  fails,  the  bowels  and 
bladder  are  involuntarily  emptied,  and  Xvith  the  development  of  multiple  hemor- 
rhagic extravasations  he  dies. 

In  another  severe  type  the  symptoms  are  algid,  the  patient  speedily  passing 


192  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

into  profound  collapse  with  a  subnormal  temperature  and  ])rofuse  hemorrhages, 
death  coming  on  in  a  few  hours.  In  still  another  type  the  violent  vomiilny,  purg- 
ing, and  collapse  may  cause  the  case  to  resemble  one  of  cholera. 

Diagnosis. — It  is  stated  by  all  physicians  of  exijerience  that  in  some  eases  it  is 
almost  impossible  to  make  a  diagnosis  of  yellow  fever  in  its  early  stages,  chiefly 
because  it  has  few  pathognomonic  signs,  and  these  are  of  value  only  when  asso- 
ciated and  not  when  they  appear  singly.  Again,  many  cases  of  yellow  fever  pursue 
a  very  aberrant  course,  so  that  several  days  elapse  before  the  diagnosis  can  be 
made. 

\ellow  fever  must  be  separated  from  dengue,  pernicious  malarial  fever,  from 
malarial  hemoglobinuric  fever,  and  from  relapsing  fever.  The  dift'erentiation  of 
yellow  fever  from  dengue  has  given  rise  to  much  bitter  contro\-ersy,  and  even  at 
the  present  time  physicians  of  wide  experience  with  both  maladies  are  by  no 
means  agreed  about  the  separation  of  these  diseases  in  their  early  stages. 

Guiteras  asserts  that  there  are  three  notable  symptoms  of  yellow  fe\'er  which  are 
of  service  in  this  connection.  First,  the  facial  expression  of  the  yellow-fever  j)atient 
is  characteristic  because  in  no  other  disease  is  it  so  flushed,  the  eyes  so  injected, 
nor  the  conjunctiva  so  icteroid  after  a  few  hours  of  illness.  Second,  the  develop- 
ment of  albuminuria  as  early  as  from  the  first  to  the  third  day,  which  may  be 
transient  and  slight,  or  persistent  and  profuse.  The  third  differential  point  is  the 
change  in  the  pulse  already  noted  as  occurring  on  the  second  or  third  day  of  the 
disease,  during  the  continuance  of  fever. 

The  jaundice  of  dengue  rarely  appears  as  early  as  the  third  day. 

The  history  of  the  patient  as  to  exposure,  the  presence  of  the  estivo-autumnal 
parasite  in  the  blood,  and  the  enlarged  spleen  of  malarial  infection  point  to  per- 
nicious malarial  fever.  A  porter-colored  urine,  the  blood  infection,  and  the  en- 
larged liver  point  to  hemoglobinuric  fever,  while  the  discovery  of  the  spirillum  of 
Obermeier  in  the  blood  will  demonstrate  the  presence  of  relapsing  fever.  (See 
Relapsing  Fever.)  While  all  these  facts  may  aid  greatly  in  distinguishing  yellow 
fcA^er,  it  is  not  to  be  forgotten  that  the  absence  of  some  of  them  does  not  prove 
that  the  yellow  fever  is  not  present.  Thus  in  some  cases  the  albuminuria  does  not 
appear  very  early,  in  others  the  failure  to  discover  the  estivo-autumnal  parasite 
may  be  due  to  the  lack  of  skill  of  the  observer  or  to  the  well-known  difficulty  of 
its  discovery  even  by  the  most  practised  observers.  Again,  it  is  possible  for  the 
malarial  parasite  to  be  present  when  yellow  fever  is  present,  the  two  diseases  exist- 
ing simultaneously. 

Prognosis  and  Mortality. — In  a  disease  which  is  so  variable  in  its  manifestations, 
prognosis  must  always  be  guarded.  If  the  febrile,  gastric,  and  renal  symptoms 
are  mild  in  the  stage  of  onset,  the  outlook  is  more  favorable  than  if  they  are  severe. 
If  the  period  of  remission  is  not  well  marked  and  hemorrhagic  tendencies  are  well 
develo])ed,  the  prognosis  is  bad.  The  great  majority  of  cases  terminate  by  the 
ninth  day  but  death  rarely  occurs  before  the  third  day. 

The  mortality  \-aries  very  greatly  in  different  epidemics,  as  already  shown  in 
the  discussion  of  the  history  of  the  disease.  Sometimes  it  is  as  low  as  1.5  per  cent., 
again  as  higli  as  85  per  cent.  It  is  apt  to  be  lower  in  i)rivate  than, in  hospital  prac- 
tice. Some  authors  have  made  the  interesting  statement  that  the  mortality  is 
in  inverse  ratio  to  the  morbidity.  The  av-erage  mortality  may  be  stated  at  about 
30  per  cent.  Thus,  in  25,220  cases  of  yellow  fever  occurring  in  the  West  Indies, 
Central  and  South  America,  Mexico,  and  the  United  States,  8020  cases  were 
fatal,  a  percentage  of  31.8. 

Treatment. — In  the  treatment  of  yellow  fe\er  it  is  essential  that  the  patient 
shall  have  a  plentiful  supply  of  fresh  air  and  sunshine,  with  absolute  rest  and 
proper  sanitary  surroundings.  Bad  hygienic  surroundings  always  greatly  increase 
the  mortalitv  of  the  disease. 


YELLOW   FI'JVLIi  HW 

As  soon  as  the  patient  is  suspected  to  he  suH'ering  from  yellow  fever,  he  should 
be  put  to  bed  and  required  to  remain  there  until  convalescence  has  been  com- 
pleted, for  physical  and  mental  unrest  distinctly  predispose  the  patient  to  a  fatal 
issue.  During  the  whole  period  of  the  disease  the  patient  should  not  be  allowed  to 
sit  up  in  bed,  since  sudden  cardiac  failure  may  occur.  All  the  food  and  medica- 
tion should  be  given  to  the  patient  when  in  the  recumbent  position,  and  the  con- 
tents of  the  bowels  and  bladder  emptied  into  a  bed-pan.  The  patient  should  be 
lightly  covered,  and  the  use  of  heavy  blankets  or  quilts  should  be  discouraged. 

Cleanliness  of  the  mouth  should  be  carefully  maintained,  since  otherwise  soft- 
ening and  ulceration  of  the  gums  not  infrequently  occur. 

Active  medication  for  the  treatment  of  the  disease  itself  is  unwise.  The  physi- 
cian should  give  remedies  only  when  they  are  very  distinctly  indicated,  as  for  the 
relief  of  a  failing  heart,  with  the  hope  of  increasing  the  activity  of  the  kidneys, 
and  for  the  prevention  of  profound  asthenia.  In  some  portions  of  the  world  where 
yellow  fever  frequently  occurs,  it  is  customary  to  employ  hot  mustard  foot-baths 
and  even  hot  packs  during  the  early  stages  of  the  disease,  but  they  are  unwise 
after  the  malady  is  once  well  developed.  For  the  relief  of  the  fever  cool  sponging 
with  alcohol  and  water,  or  even  with  ice-water,  may  be  employed,  an  ice-bag 
being  applied  to  the  head.  The  employment  of  the  coal-tar  products  is  never 
advisable,  and  they  are  particularly  contra-indicated  when  the  depression  is 
marked.  Many  practitioners  have  employed  emetics  in  the  early  stages  of  yellow 
fever,  but  these  are  certainly  not  required  unless  it  is  known  that  the  patient's 
stomach  is  overloaded  with  food,  when  10  to  20  grains  of  ipecac  may  be  given. 

Many  years  ago  former  Surgeon-General  Sternberg  advised  the  employment 
of  bicarbonate  of  soda,  corrosive  sublimate,  and  water  in  the  treatment  of  yellow 
fever,  but,  although  this  method  of  treatment  has  been  widely  employed,  it  has 
now  largely  gone  out  of  use,  although  large  quantities  of  bicarbonate  of  soda  are 
given  freely  by  many  practitioners  as  a  matter  of  routine. 

As  in  most  infectious  diseases,  the  bowels,  if  constipated,  should  be  moved 
by  means  of  calomel,  which  in  turn  may  be  followed  by  one  of  the  saline  purges 
or  by  castor  oil.  Purgation  may  be  resorted  to  every  twenty-four  or  fortj^-eight 
hours,  in  order  to  keep  the  bowels  thoroughly  evacuated.  To  aid  the  purgatives 
and  for  the  purpose  of  washing  toxic  materials  from  the  large  intestines,  copious 
irrigations  of  the  colon  with  normal  salt  solution  are  advisable.  The  patient 
should  be  urged  to  drink  freely  of  water  in  order  to  flush  the  kidneys,  and  alkaline 
mineral  waters,  such  as  Vichy,  ApoUinaris,  or  Seltzer,  or  plain  water,  to  which 
bicarbonate  of  soda  has  been  added  in  small  quantities,  may  be  used  with  advan- 
tage to  neutralize  the  acidity  of  the  gastric  contents  and  to  act  as  diuretics. 

For  the  arrest  of  excessive  vomiting,  cocaine  has  been  highly  recommended, 
but  there  is  no  reason  to  believe  that  it  exercfees  any  better  anti-emetic  prop- 
erties in  this  disease  than  in  other  diseases  in  which  vomiting  is  present.  One  or 
2  minims  of  creosote  or  carbolic  acid  are  equally  valuable. 

For  the  purpose  of  stimulating  the  heart  and  circulatory  system,  digitalis  in 
the  dose  of  5  minims  of  the  tincture,  or  strychnine  in  the  dose  of  4ij5-  of  a  grain,  or 
caffeine  in  the  dose  of  1  or  2  grains,  may  be  given  three  or  four  times  a  day,  and 
if  collapse  is  threatened  the  strychnine  may  be  given  hj^Dodermically  with  atropine, 
or  Hoffmann's  anodyne  may  be  given  by  the  mouth  or  by  the  hypodermic  needle. 
Strong  black  coffee  may  also  be  employed  by  the  mouth  or  by  the  rectum,  for  the 
purpose  of  rallying  the  patient. 

For  persistent  hiccough,  sipping  very  hot  water  is  often  advantageous. 

From  the  beginning  to  the  end  of  the  attack  it  is  the  duty  of  the  physician  to 

carefully  watch  the  condition  of  the  kidneys  by  making  daily  examinations  of 

the  urine,  since  uremia  is  one  of  the  greatest  dangers  which  can  beset  the  patient. 

After  the  kidneys  have  once  become  so  inactive  that  the  urine  is  exceedingly 

13 


194  DISI'JAS/'JS  DIE   ro  .1    Sl'KClFlc   I S FEi'TKiS 

scanty  it  is  often  absolutely  impossible  to  stiniuUite  them  to  activity,  whereas 
much  can  be  done,  if  from  the  very  first,  renal  activity  is  maintained.  For  this 
purpose  calomel  may  be  given  as  a  diuretic  in  the  dose  of  2  or  '^  grains  every  few- 
hours  for  one  or  two  days  at  a  time,  or  one  of  the  diuretic  potassium  salts,  such 
as  the  citrate  or  acetate,  in  large  amounts  of  water.  Ilypodermoclysis  with  nor- 
mal salt  solution  may  be  employed.  Renal  congestion  may  be  overcome  by  the 
application  of  mustard  plasters  and  dry  cups  over  the  kidneys. 

During  the  acute  stage  of  the  illness  the  condition  of  the  stomach  is  such  that 
tile  administration  of  food  is  almost  impossible,  but  milk  diluted  one-half  with 
\'ichy  water  or  with  water  containing  bicarbonate  of  sodium  may  be  given. 

During  convalescence  the  greatest  possible  care  must  be  exercised  that  the 
patient  does  not  take  food  in  too  large  quantities.  No  solid  food  .should  be  per- 
mitted before  the  end  of  a  week,  and,  if  the  patient  has  been  very  will,  not  for  two 
weeks.  In  the  meantime  the  diet  should  consist  of  partially  pc]it(inizcHl  milk, 
milk-toast,  broths,  and  eggs. 

As  in  all  exhausting  diseases,  the  physician  must  insist  upon  the  jiatient  remain- 
ing in  bed  until  the  heart  muscle  has  entirely  recovered  from  the  profound  depres- 
sion of  the  disease.  Bitter  tonics,  such  as  iron,  quinine,  and  strychnine,  may  be 
given. 

PLAGUE    (BUBONIC   PLAGUE). 

Definition. — Plague  is  an  acute,  specific,  infectious,  and  contagious  disease 
caused  by  the  Bacillus  j^esfis.  It  occurs  in  widespread  epidemics,  is  character- 
ized by  fever,  inflammation  of  various  glandular  groups,  and  profound  depression. 
The  course  of  the  disease  is  exceedingly  rapid  and  the  mortality  extremely  high. 

History  and  Distribution. — In  ancient  times  plague  occured  in  pandemics,  spread- 
ing o\'er  the  whole  known  world.  Most  of  the  old  world  epidemics  about  the 
beginning  of  the  Christian  era  have  been  described  as  plague  on  wholly  insufficient 
evidence.  Hirsch  dates  the  first  recognizable  epidemic  in  the  second  century,  B.C. 
Following  this,  historical  descriptions  do  not  satisfactorily  identify  the  di.sease 
until  the  pandemic  which  persisted  for  nearly  sixty  years,  during  which  time  it 
ravaged  the  whole  of  Europe  (.\.D.  542).  Following  this  epidemic,  known  in  hi.s- 
tory  as  the  i)lague  of  Justinian,  the  disease  appeared  from  time  to  time,  but  only 
twice  to  so  great  a  degree.  The  first  of  these  two  extensions  was  during  tlie  four- 
teenth century,  during  wliich  it  is  estimated  that  25,000,000  persons  died  in  all 
Europe  and  England,  and  \Yales  lost  2,500,000  or  iialf  its  population;  the  second 
pandemic,  known  as  the  Great  Plague  of  London,  began  in  1()()4  and  lasted  until 
1679.  During  the  first  year  of  this  epidemic  one-sixth  of  the  total  population  of 
London  perislied.  The  advance  of  sanitary  science  since  that  time  has  gradually 
forced  plague  out  of  Euro])e  and  limited  the  area  of  its  extension.  During  the  last 
three  decades  it  has  lingered  in  Southeastern  Europe. 

We  are  now  in  the  presence  of  what  must  be  considered  a  world-wide  extension 
of  the  disease,  limited  onl\-  by  effectixe  preventive  measures.  Tiie  ])resent  epi- 
demic began  in  Hong  Kong  in  1S94.  In  lSfl()  it  reached  the  Presidency  of  Bombay, 
and  since  that  time  it  has  spread  through  nine  British  ])rovinces  and  fifty-one 
native  States,  the  cases  increasing  in  spite  of  all  restrictive  efforts.  It  is  estimated 
that  to  the  middle  of  the  year  1903  two  million  persons  perished  in  the  Deccan. 
In  the  city  of  Bombay  over  one  hundred  thousand  persons  died,  and  in  the 
Presidency  of  Bombay  alone  during  January,  1903,  the  deaths  averaged  eighty 
thousand  w^eekly.  Later,  the  disease  appeared  in  Japan,  Madagascar,  and  South 
Africa.  It  has  obtained  a  temporary  foothold  in  (ilasgow,  Lisbon,  and  Oporto. 
In  1900  it  reached  Sydney,  Australia.  On  the  American  continent  it  ajipeared 
in  Brazil  and  the  Argentine  Republic.  In  1SS9  it  established  a  foothold  in  San 
Francisco,  in  which  cit\-  rigorous  measures  have  limited  it  to  a  very  great  degree. 


PLAGUE  H)5 

During  the  year  1902  the  disease  ajipeared  in  Peru,  ^Mexico,  and  Ahiska.  In  19(14, 
1,141,300  persons  died  of  phvgue  in  British  India  notwithstanding  acti\e  efforts 
on  the  part  of  the  government  to  arrest  the  disease,  and  tlie  deaths  from  tliis 
disease  in  India  in  the  five  years  and  four  months,  ending  April  .30,  1907,  reached 
over  4,500,000  or  almost  the  total  population  of  Greater  New  York  and  Philadel- 
phia combined. 

Etiology. — Plague  is  caused  by  Banllus  j>estifs,  a  specific  micro-organism  dis- 
covered by  Kitasato  and  Yersin  in  1894,  during  tlie  epidemic  in  Hong  Kong. 
This  organism  is  a  short,  oval,  non-motile,  coccobacillus  resembling  the  bacillus 
of  chicken  cholera.  It  occurs  singly,  joined  in  pairs,  and  occasionally  in  long 
chains.  It  is  found  in  large  numbers  in  the  pus  of  plague  buboes  and  in  smaller 
numbers  in  the  viscera  and  blood.  It  has  been  cultivated  from  all  the  accessible 
tissues  of  the  body  during  life,  and  from  all  the  excretions  except  the  sweat.  It 
has  also  been  recovered  from  the  floors  and  soil  in  the  houses  of  patients  sick  with 
plague. 

The  bacillus  stains  with  all  the  ordinary  staining  reagents  and  is  decolorized 
by  Gram's  method.  It  takes  up  the  stain  much  more  strongly  at  its  poles.  Some- 
times a  capsule  is  observed,  but  there  is  no  spore  formation.  It  grows  best  at  the 
body  temperature  and  on  all  the  ordinary  media.  In  fluid  culture  media,  overlaid 
with  a  film  of  bland  cocoanut  oil,  the  bacillus  grows  in  the  form  of  long  stalactites 
hanging  from  this  oily  layer,  that  are  considered  characteristic  of  this  organism. 
Its  vialaility  is  rather  low.  If  kept  moist  and  cool,  it  may  keep  alive  and  virulent 
for  months,  but  if  dried  at  the  room  or  body  temperature  it  dies  in  from  three  to 
four  days.  Exposure  to  direct  sunlight  destroys  it  in  a  few  hours.  The  bacillus 
is  pathogenic  for  nearly  all  domestic  animals.  Indeed,  most  of  them  are  subject 
to  plague  and  aid  in  its  dissemination.  Sheep,  calves,  pigs,  ducks,  and  fowls 
readily  contract  the  disease,  and  the  bacilli  may  be  recovered  from  their  viscera 
and  excretions.  The  disease  also  occurs  in  bats,  and  the  common  rat  is  peculiarly 
susceptible  to  it.  The  great  mortality  among  rats,  preceding  and  often  signalizing 
an  epidemic  of  plague,  is  an  observation  that  was  well  known  to  the  ancients. 

The  Chinese  long  ago  recognized  the  association  between  the  death  of  the  rats 
in  a  house  and  the  development  of  plague  a  few  days  later.  Finally,  the  fleas 
that  infest  rats  and  the  flies  in  infected  houses  also  serve  to  carry  the  contagion. 

The  method  of  conveyance  to  man  has  been  established  with  a  fair  degree  of 
certainty.  Inoculation  experiments  in  man  and  animals  have  shown  that  when 
A-irulent  bacilli  are  introduced  into  the  tissues  plague  develops.  Thus  at  Cairo  in 
1835  plague  blood  was  used  to  inoculate  two  criminals,  but  though  they  dcA-eloped 
the  disease  both  reco^'ered.  The  list,  too,  of  physicians  and  laboratory  workers, 
who  ha^'e  contracted  the  disease  from  accidental  inoculation  and  dissection  wounds, 
is  a  large  one.  Among  them  may  be  mentioned  Whyte,  who,  in  1802,  infected 
himself  and  perished,  and  Aoyama  and  his  assistants  who  contracted  plague  from 
dissection  wounds. 

In  1898  three  deaths  occurred  in  Vienna  as  a  result  of  laboratory  inoculations, 
one  in  1899  in  Lisbon,  and  one  in  1902  in  Berlin,  w^hile  13  cases  resulting  from 
accidental  inoculations  in  postmortem  examinations  have  been  collected  in  India. 

In  rare  cases  man  is  infected  by  the  inhalation  of  the  germ.  That  infection 
takes  place  through  air  and  food  has  not  been  substantiated.  The  disease  enters 
through  the  skin,  by  direct  infection  through  slight  wounds  or  abrasions,  or  through 
the  bite  of  suctorial  insects.  It  has  been  shown  that  rats  suffer  more  intensely, 
perhaps,  than  any  other  animal  from  plague.  The  rats  are  infested  with  fleas, 
which  are  also  infected,  and  the  disease  is  transmitted  from  rat  to  rat  and  finally 
from  rat  to  man  by  the  bite  of  these  insects.  Wherry,  of  the  U.  S.  Public  Health 
and  Marine  Hospital  Service,  has  also  shown  that  plague  aft'ects  ground  squirrels 
and  that  the  disease  may  be  transferred  by  the  fleas  which  infest  them.    As  fleas 


19G  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

iiuiy  be  transferred  from  place  to  place  in  litters,  baf;gaf,'c,  or  clotliinf;,  they  may 
readily  spread  the  disease.  The  supposition  that  rat  fleas  attack  man  when  there 
is  a  great  mortality  among  their  chief  hosts  is  well  borne  out  by  the  occurrence  of 
human  plague  following  closely  upon  ei)idemics  among  rats. 

Fox  believes  the  actual  transmission  of  the  l)acilli  by  the  flea  is  by  means  of 
its  infected  feces.  These  are  deposited  on  tlie  skin  at  the  time  of  biting  and  are 
carried  into  the  wound  by  the  mandible  of  the  insect  or  by  later  scratching  of 
the   site    by   the   host. 

The  possibility  of  infection  taking  place  directly  into  wounds  and  alirasions  from 
infected  soil  must  be  admitted.  Calvert  reports  an  interesting  case  where  the 
disease  was  acquired  in  sexual  intercourse,  and  one  case  where  the  bite  of  an  in- 
fected rat  caused  a  fatal  infection.  Direct  transmission  from  patient  to  patient, 
while  always  possible,  occurs  very  rarely.  This  is  borne  out  by  the  observations 
in  Bombay,  Hong  Kong,  and  other  places,  that  cases  are  extremely  rare  among  the 
physicians,  nurses,  quarantine  guards,  and  disinfection  laborers,  who  are  con- 
stantly in  intimate  contact  with  plague  cases. 

The  disease  principally  attacks  the  poorer  classes  of  the  native  population, 
those  who  live  in  the  slums  under  poor  hygienic  surroundings.  Lack  of  personal 
cleanliness  and  deficient  light  and  ventilation  in  living  rooms  are  predisposing  causes. 

Frequency. — Plague  afl'ects  all  ages  and  both  sexes  equally.  Neither  geographical 
location,  character  of  soil,  nor  elevation  have  any  influence  on  its  spread.  It  pre- 
vails at  all  seasons  of  the  year,  although,  generally  speaking  it  is  least  active  in 
the  seasons  of  greatest  heat  or  cold. 

Epidemics  begin  slowly.  The  common  history  is  that  in  the  beginning  a  few 
isolated  cases  develop,  the  epidemic  slumbering  along  in  this  way  for  a  year  or 
more  before  rapid  extension  takes  place.  It  declines  in  the  same  way.  Not  only 
do  the  number  of  cases  grow  less,  but  their  virulence  notably  diminishes.  It  creeps 
slowly  from  town  to  town,  following  the  routes  of  travel.  Its  extension  from  one 
country  to  another  over  sea  is  due  to  the  presence  of  infected  rats  on  the  ships  ply- 
ing between  them.  Thus  the  epidemic  in  Peru  was  shown  to  ha\'e  spread  from  the 
rats  on  a  ship  carrying  grain  from  India. 

Prophylaxis. — Personal  prophylaxis  should  be  directed  in  the  first  place  to  avoid- 
ing too  close  contact  with  plague  cases,  although  direct  infection  is  very  rare. 
Wounds,  abrasions,  and  skin  eruptions  on  the  limbs  should  be  carefully  guarded, 
particularly  against  a  germ-carrying  finger-nail  and  fleas,  and  it  is  well  to  put 
kerosene  upon  the  feet  and  legs  to  drive  away  fleas.  Tight  leggings  or  gaiters 
should  be  worn  to  prevent  the  bite  of  fleas.  Attendants  should  wear  a  mask  to 
prevent  pneumonic  plague.  These  measures  combined  with  personal  cleanliness, 
a  good  water  supply,  and  abundant  ventilation  are  efficient. 

The  general  measures  to  be  taken  for  the  prevention  of  plague  are,  inoculation, 
evacuation  of  infected  houses,  and  the  extermination  of  fleas,  rats  and  mice  by 
trapping  and  poisoning. 

The  danger  from  contact  is  not  very  great.  Ex-posed  persons  should  be  disin- 
fected, given  a  jirophylactic  inoculation,  have  their  clothing  destroyed,  and  then 
be  released.  The  quarters  in  which  a  plague  patient  has  lain  should  be  thoroughly 
scraped,  disinfected,  and  repainted  or  whitewashed.  Better  still,  when  practical, 
they  should  be  burned.  The  evacuations  and  bedding  of  the  sick  should  be  cre- 
mated. 

In  spite  of  the  most  stringent  proph^•lactic  measures,  plague  is  \ery  diflicult 
to  control.  As  a  matter  of  fact,  where  it  has  once  attained  even  a  slight  foot- 
hold it  has  not  been  successfully  eradicated  by  any  of  these  measures.  Witness 
the  cases  in  San  Francisco,  where  after  several  years  of  eft'ort  the  disease  still 
persisted.  It  sees  likely  that  the  most  wc  can  expect  with  our  present  means  is  to 
hold  the  disease  m  check. 


PLAGUE  197 

Protective  Inoculation. — HafFkine  introduced  a  prophylactic  inoculation 
against  plague.  His  method  has  been  modified  by  Lustig  and  recently  by  Bes- 
redky.  Briefly,  these  methods  consist  in  injection  of  plague  cultures  killed  by 
heat.  Extensive  experience  has  shown  that  these  inoculations  confer  an  immu- 
nity against  plague,  beginning  in  twenty-four  hours  and  lasting  from  three  to  four 
months,  and,  according  to  Simpson,  three  or  four  years.  Simpson  has  shown  by 
statistics  based  upon  nearly  one  and  a  half  million  persons  inoculated  that  the 
mortality  ranges  from  0  to  57  per  cent.  Whereas  among  about  four  million  not 
inoculated  the  mortality  varied  from  2  to  100  per  cent.  Recent  studies  seem  to 
show  that,  given  during  the  period  of  incubation,  they  have  the  power  to  abort 
the  disease  in  many  cases.  This  system  of  protective  inoculation  was  being  tried 
on  an  extensive  scale  in  the  Punjab,  when  a  very  deplorable  accident  cut  the 
experiment  short.  After  more  than  100,000  persons  had  been  inoculated  without 
untoward  results,  nineteen  men  received  their  injection  from  the  same  package, 
developed  tetanus  on  the  fifth  day,  and  all  died.  This  unfortunate  afl'air  practic- 
ally stopped  prophylactic  work  in  India,  by  greatly  increasing  the  aversion  the 
natives  had  always  shown  to  it. 

Pathological  Anatomy. — The  visceral  lesions  of  plague  are  constant  and  uni- 
form. Punctate  hemorrhages  appear  not  only  on  the  skin,  but  throughout  the 
whole  gastro-intestinal  tract.  They  are  found  on  the  peritoneum,  pleura,  and 
pericardium,  as  well  as  in  the  capsules  of  the  spleen,  kidney,  and  li\er.  The  cerebro- 
spinal system  is  congested  and  there  is  an  increase  of  its  fluid.  The  liver  and 
kidneys  are  hj-peremic  and  the  spleen  very  much  enlarged.  In  pneumonic  cases 
the  bronchi  are  injected  and  swollen  and  there  are  small  areas  of  consolidation 
scattered  throughout  the  lung.  Thip  pleural  cavities  frequently  contain  moderate 
quantities  of  seropus. 

The  glandular  system  shows  constant  involvement.  In  the  bubonic  form  the 
glands  appear  on  section  as  large,  diffused  masses,  with  extensi^'e  hemorrhages 
into  their  substance.  This  appearance  is  not  confined  to  one  group  of  glands, 
but  extends  along  the  lymphatic  trunk  and  invades  the  glands  in  the  immediate 
proximity  to  the  main  buboes. 

Microscopically,  intense  hyperemia  with  hyperplasia  is  found  not  only  in  the 
glandular  but  also  in  the  periglandular  structure.  Before  the  glands  break  do-mi 
the  bacillus  pestis  is  found  alone;  after  suppuration  is  established  other  organisms 
are  found  with  it. 

In  the  septicemic  and  pneumonic  cases,  or  in  those  cases  dying  before  marked 
bubo  formation  has  taken  place,  the  gross  changes  in  the  IjTnphatic  system  are 
not  so  apparent,  but  there  is  always  enlargement  of  one  or  more  groups  of  glands 
or  slight  tumefaction  and  congestion  of  the  entire  Ijnnphatic  system.  The  patho- 
logical process  is  identical  in  all  the  tj-pes,  only  that  in  the  bubonic  form  the  inten- 
sity of  the  affection  is  expended  on  one  gland  or  group  of  glands,  while  in  the  other 
form  the  adenitis  and  lymphangitis  are  diffuse. 

Symptoms. — Clinically,  plague  may  be  divided  into  four  varieties: 

1.  Bubonic  plague,  pestis  bubonica,  malignant  adenitis. 

2.  Septicemic  plague,  pestis  siderans. 

3.  Pneumonic  plague. 

4.  Larval  plague,  pestis  minor,  pestis  ambulans. 

Bubonic  Plague. — This  is  by  far  the  commonest  type,  averaging  80  per  cent, 
of  all  cases.  The  incubation  period  varies  from  two  to  eight  days,  averaging  four 
days. 

The  attack  begins  with  fever,  lassitude,  severe  headache,  and  pain  in  the  limbs. 
Rigors  may  or  may  not  be  present,  but  vomiting  is  usual  in  this  stage.  There 
is  drowsiness,  vertigo,  and  extreme  anxiety.  After  lasting  from  twelve  to  twenty-four 
hours,  fever  begins  and  the  temperature  rises  rather  quickly  to  103°  to  107°.    There 


198  DISEASES  DIE  TO  A   SPECIFIC  ISFECTIOK 

is  now  hurried  pulse  and  respiration.  The  face  is  heavy,  swollen,  and  flushed; 
the  tongue  is  coated  with  a  hea\y  lilack  fur;  the  teeth  are  covered  with  sordes. 
]\)initni<i  is  often  persistent  and  diarrliea  may  develo]).  The  i)atient  is  most 
profoinidly  depressed,  the  depression  heiufj  out  of  all  jjrojjortion  to  the  duration 
of  the  disease,  and  a  low  mutterin<i;  delirium  is  present.  Death  may  occur  in 
this  stage,  accompanied  by  convulsiun.s-  and  collapse  or  by  uremic  coma  with  total 
suppression  of  urine. 

In  from  twenty-four  to  seventy  hours — that  is,  from  tin-  third  t(i  tlic  fifth  day 
of  the  disease — the  characteristic  (ilanduUn  swclliiuis  rlevelo]).  The  glands  in\'(ilvod 
are  in  the  groin  in  60  per  cent,  of  the  cases,  the  axilla  in  oo  per  cent.,  and  the  neck 
and  angle  of  the  jaw  in  5  per  cent.  The  buboes  are  usually  single  and  arc  much 
more  common  on  the  right  side  than  on  the  left.  Occasionally  they  are  bilateral, 
rarely  multiple.  In  size  they  vary  from  a  pigeon's  egg  to  the  size  of  a  fist.  They 
are  frequently  painful  and  always  exquisitely  tender. 

Coincident  with  the  development  of  the  buboes,  small  areas  of  (jaiuircnr  of  ihe 
skin,  carbuncles,  or  generalized  pustular  skin  lesions  may  de\-elop. 

The  buboes  increase  in  size  for  three  or  four  days  and  then  become  stationary. 
In  a  small  pro])ortion  of  cases  gradual  resolution  takes  place.  In  the  larger 
proportion  softening  and  suppuration  occur  and  the  bubo  is  opened  or  ruptured 
and  discharges  a  foul-smelling  pus.  At  this  stage  free  suppuration  is  usually 
a  good  omen.  If  the  pus  continues  scanty  and  sanious  the  disease  remains 
A'irulent. 

In  free  suppuration  the  bacilli  disappear  from  the  pus  in  a  very  few  days  and 
convalescence  is  rapidly  established.  In  the  cases  that  terminate  favorably  a 
marked  amelioration  is  observed  with  the  development  of  the  glandular  swelling, 
and  usually  about  the  seventh  day  the  temperature  falls  and  the  jirofound  depres- 
sion disappears. 

Septicemic  Pl,\gue. — In  this  form  the  symptoms  are  much  more  severe  and 
the  stage  of  bubo  formation  is  lacking.  That  is,  there  is  no  one  gland  or  group 
of  glands  conspicuously  involved,  but  the  whole  glandular  si/stem  is  engorged  and 
swollen.  The  essential. difl'erence  seems  to  lie  in  that  the  infection  is  more  severe 
both  quantitatively  and  cjualitatively.  There  is  a  marked  bacteriemia.  Clinically, 
these  cases  differ  from  the  former  in  the  more  profound  depression,  more  moderate 
fever  (100°  to  102°),  and  the  greater  tendency  to  hemorrhages. 

Pnei;moxic  Pl.\gi'e. — This  form  begins  suddenly  with  rigors  and  all  the  symp- 
toms of  acute  pulmonary  inflammatiou.  Respiration  is  rapid  and  labored  and  there 
is  a  painful  harrussing  cough.  So  far  the  symptoms  resemble  an  ordinary  lobar 
jnieunionia.  The  sputum,  instead  of  being  scanty,  tenacious,  and  of  the  usual 
prune-juice  color,  is  copious,  watery,  and  spotted  and  streaked  with  bright  blood. 
Physical  examination  shows  areas  of  consolidation  scattered  throughout  the  lungs. 
An  entire  lobe  is  rarely  involved.  This  form  of  the  disease  is  the  most  fatal  of 
all,  patients  rarely  surviving  after  the  third  day.  In  these  cases,  too,  although  it 
is  not  clinically  apparent,  postmortem  examinations  show  general  in\-olvement 
of  the  glandular  sy.stem.  Pneumonic  plague  is  more  common  in  cliildrcii  than  in 
adidts,  and  at  the  beginning  of  epidemics  than  at  the  end. 

Hemorrhages  occur  in  all  the  various  clinical  types  of  plague,  more  commonly 
pcrha])s  in  the  se])ticemic.  They  ai)pear  in  the  skin  as  petechia!  and  eeehyiiioses. 
There  may  be  epista.ris,  hematuria,  and  hemorrhage  from  the  stomach  or  boirel. 
IIenio])tysis  is  a  very  sinister  symj^tom. 

The  urine  is  diminished  and  commonly  contains  large  quantities  of  allnnnin 
with  more  or  less  kidney  structure.  Albuminuria  is  ne\er  absent  in  severe  or  fatal 
cases. 

The  blood  changes  are  not  characteristic.  There  is  a  marked  leukocytosis,  \ary- 
iug  from  20,000  to  50,000,  with  moderate  reduction  of  the  hemoglobin. 


PLAGUE  199 

Relapses  occur  in  a  small  percentage  of  eases  and  are  always  grave.  Convales- 
cence may  be  very  much  prolonged  by  indolent  ulcers  and  burrowing  sinuses  at 
the  seat  of  the  buboes. 

Larval  Plague,  Pestis  Minor. — Cases  of  this  type  occur  in  all  epidemics 
and  are  very  common  toward  their  close.  In  larval  plague  the  Uj[>ical  buboes 
develop  with  few  prodromata.  The  constitutional  reaction  ma>-  be  very  mild, 
the  fever  is  slight,  and  the  patient  is  but  little  annoyed  by  the  disease.  Some 
epidemics  are  characterized  by  large  proportions  of  such  cases. 

Diagnosis. — In  the  presence  of  plague  in  epidemic  form,  the  rapid  onset  of  the 
disease,  the  profound  depression,  the  glandular  swelling  can  hardly  suggest  any- 
thing else  than  this  disease.  The  identification  of  the  BaciUns  pestis  in  the  blood, 
in  fluid  from  the  buboes,  or  in  the  sputum  assures  the  diagnosis.  Inoculations 
and  culture  experiments  are  important  in  the  early  stages  of  an  epidemic  with 
large  numbers  of  atypical  cases  of  plague.  The  best  routine  method  of  diagnosis 
is  the  microscopic  examination  of  a  drop  or  two  of  the  fluid  obtained  from  the 
buboes  by  means  of  a  hypodermic  syringe.  The  few  drops  of  bloody  lymph  col- 
lected in  this  manner  contain  large  numbers  of  bacilli.  The  diagnosis  of  the  pneu- 
monic form  can  be  made  only  by  demonstrating  the  micro-organism  in  the  sijutum. 

Prognosis. — Varying  in  different  epidemics,  the  average  mortality-  runs  from  70 
per  cent,  to  95  per  cent.  The  variations  depend  on  the  stage  of  the  epidemic, 
the  proportion  of  pestis  minor  cases,  and  the  race  and  hygienic  conditions  of  the 
patients.  In  the  Hong  Kong  epidemic  the  average  mortality  was  93  per  cent, 
among  the  Chinese,  88  per  cent,  among  the  Indians,  60  per  cent,  among  the  Jap- 
anese, and  18  per  cent,  among  the  Europeans.  This  gradation,  as  INIanson  has 
remarked,  is  "in  general  correspondence  with  the  social  and  hygienic  conditions 
of  these  different  nationalities." 

The  influence  of  the  type  of  the  disease  on  mortality  is  shown  in  the  following 
figures  from  an  analysis  of  13,145  cases.  In  the  bubonic  cases  the  mortality  was 
77.25  per  cent.,  in  the  pneumonic  cases  96.69  per  cent.,  and  in  the  septicemic 
cases  89.62  per  cent. 

The  number  of  the  buboes  and  their  location  has  no  bearing  on  the  mortality. 
Visceral  hemorrhages  are  always  unfa^'orable  symptoms,  while  free  suppuration 
of  the  buboes  must  be  considered  as  a  very  favorable  omen. 

Pregnancy  complicating  plague  is  also  very  unfavorable.  Abortion  invariably 
occurs  and  death  is  almost  certain. 

Treatment. — Treatment  of  plague  is  wholly  symptomatic.  For  the  fever, 
headache,  and  delirium  nothing  is  so  effective  as  cold  sponging.  Cantlie  recom- 
mends initial  purging  with  calomel  in  large  doses,  followed  by  salines.  This 
remedj^  frequently  checks  vomiting  and  permits  nourishment  to  be  taken. 

For  the  pain  and  restlessness  there  is  no  remedy  so  effective  as  morphine,  given 
hypodermically,  in  small  doses.  In  the  profound  depression  and  collapse,  diffusible 
stimulants  are  indicated;  ammonia  to  the  nose,  mustard  to  the  skin,  and  ether  or 
camphor  subcutaneously.  Alcohol  should  be  given  freely,  particularly  in  a  septi- 
cemic form. 

Suppuration  of  the  buboes  should  be  hastened  by  poultices  and  hot  fomen- 
tations. When  fluctuation  occurs  they  should  be  opened  freely  and  dressed 
antiseptically. 

Thomson  reports  excellent  results  in  the  epidemic  in  Hong  Kong  from  the 
internal  use  of  carbolic  acid  in  large  doses.  He  gave  144  grains  daily  in  doses  of 
12  grains  every  two  hours  in  a  mixture  of  syrup  of  orange  and  chloroform-water. 
One  patient  took  over  2500  grains  of  pure  carbolic  acid  before  his  blood  was  free 
from  plague  bacilli.  Beyond  a  few  cases  of  carboluria  no  toxic  .symptoms  de\'el- 
oped.    He  considers  this  the  most  hopeful  method  at  our  disposal. 

Yeserin,   Calmette,   and  Borrell  have  developed  an   antitoxic  serimi   by  the 


200  DISEA.SES  DUE  TO  A   SI'ECIFIC  IXFECTIOX 

injection  of  ascending  doses  of  cultures  killed  by  heat  into  susceptible  animals. 
Experimentally,  plague  in  animals  has  been  arrested  by  this  means.  Clinically 
the  results  with  the  antitoxic  sera  have  been  most  contradictory.  \Yhile  they  have 
not  entirely  fulfilled  the  hoi)e  that  they  first  seemed  to  hold  out,  later  experience 
in  this  direction  is  more  encouraging.  The  antitoxin  needs  further  study,  and 
particularly  needs  standardization. 

CLIMATIC   BUBO. 

Definition. — Climatic  bubo,  tropical  huho,  tropical  adenitis  (non-venereal),  is  a 
subacute  inflammation  of  the  lymphatic  glands  of  the  groin,  attended  by  a  fever 
remitting  in  type  and  persisting  from  three  to  four  weeks.  The  disease  is  widely 
distributed  in  tropical  climates.  It  occurs  on  the  coast  of  Africa  and  Asia,  and 
is  common  enough  in  the  Philippines,  Japan,  Malaya,  the  West  Indies,  and  the 
Mediterranean. 

The  disease  commonly  affects  individuals  living  together  under  the  same 
hygienic  conditions,  as  sailors  and  soldiers,  and  occurs  in  small  epidemic  out- 
breaks. There  is  some  eA'idence  to  show  that  its  origin  is  due  to  the  entrance  of 
bacterial  infection,  either  through  minute  wounds  in  the  legs  and  genitals  or  the 
bites  of  insects.  It  has  been  described  as  due  to  tropical  heat  and  to  paludism, 
as  a  sequel  to  dysentery,  and  even  as  a  form  of  bubonic  plague  (pestis  minor). 
Bacterial  evidence  disposes  of  the  last  theory,  but  in  the  presence  of  epidemic 
plague  these  cases  demand  careful  study. 

Symptoms. — They  begin  with  moderate  swelling,  redness,  and  tenderness  of  the 
inguinal  or  crural  glands  of  one  or  both  sides.  At  the  outset  there  is  usually  a 
chill,  femr  of  a  remitting  type,  headache,  and  backache.  The  buboes  slowly  increase 
until  they  attain  the  average  size  of  a  hen's  egg,  after  which  the  fever  gradually- 
diminishes.  After  persisting  from  one  to  two  months  or  longer  they  gradually 
disappear.  In  the  large  majority  of  cases  the  inflammation  is  limited  to  the  gland 
structure  proper.  The  periglandular  tissues  and  skin  are  not  invoh-ed  and  there 
is  very  little  pain  or  tenderness.  In  from  .3  per  cent,  to  5  per  cent,  of  all  cases  the 
inflammation  spreads  to  the  periglandular  tissues.  The  skm  becomes  adherent 
over  the  glands  and  they  finally  suppurate.  In  these  cases  the  constitutional 
symptoms  are  intensified  and  the  pain  and  tenderness  are  very  great.  The 
abscesses  tend  to  burrow  freely.  After  a  period  of  free  suppuration  deep,  sharp- 
edged,  indolent,  painful  ulcers  remain.  The  average  duration  of  the  suppurating 
cases  is  from  two  to  three  months. 

Treatment. — The  febrile  condition  is  not  severe  enough  to  demand  special  treat- 
ment. Iodine  and  ichthyol  may  be  applied  to  the  skin  over  the  gland,  and,  after 
acute  symptoms  subside,  mercurial  ointment  and  elastic  pressure  should  be  used. 
When  suppuration  takes  place  the  gland  must  be  laid  open.  Rife  advises  calomel 
as  a  dusting-powder  to  control  the  severe  pain  in  the  chronic  ulcers. 

DYSENTERY. 

Definition. — Dysentery  is  a  condition  characterized  by  diarrhea,  abdominal 
pain,  and  the  presence,  as  a  rule,  of  considerable  quatities  of  mucus  in  the  stools. 
When  the  condition  becomes  chronic  it  is  often  interrupted  by  periods  in  which 
constipation  supplants  the  diarrhea.  Dysentery  is  to  be  separated  from  the 
diarrhea  due  to  indigestion  and  to  catarrh  of  the  small  bowel  by  the  facts  that 
tenesmus  is  usually  marked,  the  lesions  are  chiefly  in  the  large  bowel,  and  the 
stools  may  be,  in  the  early  part  of  the  attack,  rather  scanty  and  consist  of  mucus 
and  blood. 


DYSENTERY  201 

It  is,  moreover,  to  be  distinctly  understood  that  dysentery  is  not  a  single  disease, 
but  that  this  term  is  applied  to  the  conditions  and  symptoms  which  de\^elop  as  the 
result  of  several  distinct  causes,  although  at  present  there  is  much  confusion  as 
to  the  causes  of  the  various  forms.  Strictly  speaking,  amebic  dysentery  should  be 
classed  among  the  diseases  due  to  animal  parasites,  but  it  is  best,  from  tlie  clinical 
stand-point,  to  discuss  it  here. 

At  the  present  time  at  least  five  well-defined  tj^pes  of  dysentery  are  recog- 
nized, namely,  that  which  is  known  as  hacillary  dysentery,  which  is  due  to  infection 
with  the  specific  bacillus  of  Shiga,  or  a  bacillus  nearly  related  to  it.  Second,  cnt- 
amebic  dysentery,  intestinal  amebiasis  (Musgro^'c  and  Clegg'),  wliich  is  due  to  the 
entamebic  dysenteriw.  This  form  is  found  in  all  parts  of  the  world,  but  is  much 
more  frequent  in  the  tropics,  whence  most  of  the  cases  seen  in  this  country 
come.  Strong,  of  the  United  States  army,  reports  561  cases  of  entamebic  dysen- 
tery out  of  1328  cases  of  dysentery  in  his  service.  A  third  form  is  that  due  to  the 
Balaniidium  coli  and  is  also  tropical  in  origin.  Fourth,  catarrhal  dysentery,  which 
is  apparently  not  due  to  a  definite  infection,  but  to  acute  congestion  of  the 
mucous  membrane  of  the  colon,  and  finally,  fifth,  diphtheritic  dysentery,  which  is 
not  due  to  the  Klebs-LoefHer  bacillus,  but  is  characterized  by  a  yellowish  exudate 
on  the  mucous  folds  of  the  bowel  with  areas  of  ulceration  and  necrosis.  A  form 
of  catarrhal  dysentery  sometimes  also  develops  as  the  result  of  renal  disease. 

Bacillary  Dysentery. — Epidemics  of  bacillary  dysentery  ha^e  occurred  since 
the  earliest  times,  and  Herodotus  mentions  one  which  attacked  the  army  of  Xerxes 
in  the  year  480  B.C.  During  the  first  part  of  the  Christian  era  the  disease  raged  in 
France,  Germany,  and  England.  It  has  existed  in  Europe  in  pandemic  form  on  at 
least  two  occasions,  namelj',  in  the  years  1538  and  1779. 

In  the  year  1729  an  epidemic,  in  which  5000  persons  died,  occurred  in  Holland, 
Friesland,  Guilders,  and  Liege.  More  than  2000  of  Napoleon's  soldiers  died  from 
it  during  the  expedition  to  Egypt,  and  4000  cases  occurred  in  the  English  army 
during  the  Crimean  war.  About  one-fourth  (288,000)  of  all  cases  of  sickness  among 
the  soldiers  of  the  War  of  the  Rebellion  were  said  to  be  cases  of  dj^sentery.  In  the 
year  1890  an  epidemic  broke  out  in  the  province  of  Tuhuoka,  Japan.  This  province 
had  a  population  of  1,231,387,  of  which  25,272  were  attacked.  Of  these  25,272 
cases  4742  proved  fatal.  Smaller  but  equally  fatal  epidemics  of  the  disease  have 
repeatedly  occurred  on  crowded  ships  and  in  periods  of  famine.  Further  than 
this  it  has  long  been  recognized  that  this  epidemic  form  of  dysentery  was  distinctly 
infectious,  and  it  can  even  be  spread  from  one  continent  to  another  by  infected 
ships,  as  in  the  great  outbreak  in  the  United  States  from  1846  to  1856,  when  it  was 
probably  conveyed  by  emigrants  from  Ireland,  where  the  disease  was  rampant. 

Marshy  lands  seem  to  have  a  pronounced  predisposing  influence.  Water  which 
has  been  contaminated  by  those  who  are  ill  with  the  disease  is  an  important  factor 
in  its  spread.    Milk  and  solid  food  may  also  carry  the  infection. 

Dysentery  in  its  various  forms  is,  in  a  large  proportion  of  cases,  the  result  of 
bad  sanitation  both  as  to  surroundings  and  diet.  It  is  much  less  frequent  at  present 
than  in  times  past,  and  rarely  ravages  modern  institutions  or  armies  as  it  did  fifty 
years  ago. 

Epidemic  dysentery  being  exceedingly  prevalent  in  Japan  in  1897,  Shiga,  a 
Japanese  investigator,  became  interested  in  its  bacteriological  study,  and  isolated 
from  the  stools  of  36  patients  suffering  from  this  disease  a  slightly  motile  bacillus 
having  rounded  ends  and  decolorizing  by  Gram's  method.  When  brought  into 
contact  with  the  blood  serum  of  patients  suffering  with  dysentery  this  bacillus 
usually  agglutinates  (as  does  the  typhoid  bacillus  in  the  Widal  test),  although  in 
a  few  mild  cases  the  reaction  fails  to  take  place.  Flexner,  Strong,  Kruse,  'N'edder, 
and  Duval,  Vallard,  Musgrave,  Craig  and  Dopter,  Spronck,  Rosenthal,  and  other 
investigators  have  isolated  in  such  cases  organisms  which  they  consider  closely 


202  DISEASES  DUE  TO  A  SPECIFIC  LXFECTIOX 

related  to  or  identical  with  the  one  obscr\ed  In-  Sliif;a,  and  wJiich  tlie.v  heiicve  to 
he  tlie  Ciuise  of  a^^-ute,  epidemic,  sporachc,  and  institutional  dysentery. 

Dmal  and  Bassett  in  1902  obtained  a  similar  orf,fanisin  t'roin  the  stools  of 
cliiidrcn  suft'erini;  from  dysentery  or  the  summer  diarrhea  of  infants.  Still 
more  recently  (1903)  Wolfstein,  Park,  Dunham,  and  Carey  have  not  only  eon- 
firmed  these  findings,  but  have  shown  that  at  least  two  bacilli  are  present  in 
cases  of  cholera  infantum  and  dysentery.  One  of  these  corresponds  to  Shiga's 
liacilhis,  but  they  believe  that  in  all  ])robal)ility  several  clo.sely  allied  pathogenic 
l)acilli  will  be  found  res]K)nsible  in  different  epidemics.  The  bacilli  arc  found  in 
numbers  ])roportionatc  to  the  severity  of  the  illness,  but  often  are  not  demonstrable 
in  the  stools  until  the  latter  are  typical  of  the  disease,  and  usually  only  after  the 
lapse  of  five  to  seven  days  of  illness.  Chantemesse  and  Widal  assert  that  a  bacillus 
which  they  found  in  the  stools  of  five  dysentery  patients,  and  which  they  also 
recovered  from  the  mesenteric  glands  and  intestinal  wall  of  a  patient  who  died 
of  dysentery,  is  identical  with  the  Sliiga  bacillus,  and  as  their  observations  were 
made  in  1888,  ten  years  before  Shiga  published  the  results  of  his  work,  they  claim 
priority  of  discovery.  In  France  and  Italy  it  is  generally  conceded  that  they 
were  the  first  to  find  a  specific  organism  in  cases  of  dysentery. 

Amebic  DYcSENTERY. — Our  recognition  of  the  presence  of  ainrJicr  in  cases  of 
dysentery  dates  from  1859,  when  Lambl  first  discovered  an  ameba  in  the  stools 
of  this  tyjie  of  diarrhea.  Later  the  parasite  was  studied  by  Losch  (1875)  and 
Kartulis,  but  it  was  not  until  Osier  (in  1890),  Councilman,  and  Lafieur  (1891) 
reported  upon  its  presence  in  several  cases  of  dysentery,  and  in  the  ]3ast  decade, 
that  it  received  the  attention  that  it  deserves.  Leukart  has  placed  the  ^linrba 
dysenterioB  in  the  class  of  rhizopoda  of  the  Protozoa.  Schaudinn  called  it  Kiitamcha 
histolytica  or  Entameha  dysenieriw,  the  former  term  being  now  quite  commonly 
used.  Recent  investigations  indicate  that  the  Entameha  Irtnuiciia  of  \'iereck  is 
identical  with  the  histolytica. 

The  Entameba  histolytica  is  a  spheroidal  cell,  four  to  eight  times  the  size  of  the 
red  blood  cell.  It  consists  of  two  parts,  an  internal  part  called  the  endosarc,  or 
endoplasm,  and  an  external  part  called  the  ectosarc,  or  ectoplasm.  These  two 
parts  cannot  always  be  clearly  recognized  when  the  organism  is  at  rest,  but  they 
are  easily  identified  when  motion  is  present.  The  endosarc  makes  up  the  greater 
part  of  the  body  and  its  granules  may  be  fine  or  coarse.  In  this  portion  several 
vacuoles  are  not  rarely  found  and  a  distinct  nucleus  is  discernible  when  the  organ- 
ism is  stained.  As  in  ordinary  ameba^  the  histolytira  often  contains  foreign  bodies 
such  as  red  blood  cells,  and  even  bacteria.  The  ])scudopod,  or  arm,  which  is  pro- 
truded from  the  ameba  when  it  is  engaged  in  amclmid  mn\cnicnt,  is  of  the  hyaHnc 
ectosarc.    (See  Plate  IV.) 

The  parasite  is  found  in  the  stools  of  acute  and  chronic  dysentery,  in  the 
floors  of  the  intestinal  ulcers,  and  in  the  secondary  abscesses  which  it  is  prone  to 
l^roduce. 

Walker  and  Sellards  have  shown  liy  their  extcnsi\"e  feeding  experiments  with 
men  in  the  Phili])pines  that  the  ameha-  cultivable  on  Musgraxe  and  Clegg's  medium 
are  inca])ahle  of  living  parasitically  in  the  intestinal  tract  of  man,  that  they  are 
non-pathogenic,  and  that  they  play  no  role  in  the  etiology  of  endemic  tro])ical 
dysentery.  They  also  conclude  that  the  Entameha  hi.'^tdli/tlra  is  the  essential 
etiologic  factor  in  this  dysentery  and  that  an  accurate  lal)oratory  diagnosis  of  the 
disease  is  possible.  With  the  distinction  between  the  harmless  Entameha  coli 
and  the  pathogenic  Entameha  histolytica  established,  there  is  no  longer  a  rea.son 
for  indiscriminately  treating  all  persons  having  entameha^  in  their  stools. 

Amebic  dysentery  may  occur  at  any  age  from  infancy  to  senility,  but  it  is  must 
common  between  twentx'  ar.d  thirt.\'  years  of  age.  It  is  nnich  more  conuiion  in 
men  than  in  women. 


PLATE   IV 


^ 


_,.t!« 


^^ 


Amcsbae  from  Cases  of  Dysentery  and  Enteritis.     (Roemer.) 


DYSENTERY  203 

Balantidium  Dysentery. — Walker  concludes  from  recent  studies  that  every 
person  harboring  Balantidium  coli  is  sooner  or  later  liable  to  de\elop  balantidial 
dysentery.  He  finds  that  in  the  l*hiii])])incs  the  cliicf  source  of  infection  is  tlie 
domesticated  pig. 

The  Balantidium  coli  is  a  protozoon  found  inconstantly  in  the  feces  of  tlK)se  it 
infects,  and  is  often  present  without  causing  symptoms. 

Prevention. — Dysentery  in  all  its  forms  is  to  be  prevented  by  the  use  of  boiled 
water  and  cooked  foods,  by  the  establishment  of  proper  drainage,  and  by  the 
avoidance  of  cold  and  wet.  Persons  who  are  subject  to  catarrh  of  the  colon  and 
rectum  should  wear  a  flannel  binder.  When  the  disease  develops,  the  stools  of  the 
patient  should  be  thoroughly  destroyed  and  the  greatest  care  exercised  that  the 
food  and  drink  of  the  healthy  are  not  contaminated  by  his  discharges. 

As  Musgrave  has  shown  that  intestinal  amebiasis  may  occur  without  diarrhea 
it  is  evident  that  "ameba  carriers"  may  be  active  factors  in  spreading  the  disease 
and  in  the  presence  of  an  epidemic  this  factor  should  be  attended  to  among  other 
measures. 

The  conclusions  of  Walker  and  Sellards,  based  as  they  are  on  numerous  feeding 
experiments  with  50  volunteer  men,  are  most  valuable. 

1.  The  data  on  which  they  base  their  prophylaxis  are: 

(a)  Eniameba  histolytica,  the  essential  etiologic  agent  in  the  disease,  is  an  obliga- 
tory parasite  and  cannot  propagate  outside  the  body  of  its  host. 

(6)  The  motile  forms  of  this  entameba,  which  are  passed  in  the  bloody  mucous 
stools  in  acute  dysentery,  quickly  die  and  disintegrate  and  are  probably  incapable 
of  withstanding  passage  through  the  human  stomach. 

(c)  Owing  to  the  prevalence  of  chronic  and  latent  infections  and  the  frequent 
failure  of  treatment  to  kill  all  of  the  entamebse  in  the  intestine,  "carriers"  who  are 
constantly  passing  in  their  stools  large  numbers  of  the  resistant,  encysted  stage 
of  Entameba  histolytica  are  common  in  endemic  regions. 

2.  These  facts  make  it  probable  that  "carriers"  of  Entameba  histolytica  consti- 
tute the  chief,  if  not  the  sole,  agents  in  the  dissemination  of  the  disease.  Pro- 
phylactic measures  should  be  directed  toward  them  and  should  include: 

(a)  The  identification  of  "carriers"  by  the  examination  of  the  stools  of  con- 
valescents, servants,  and  other  suspects  whose  emploj'ment  make  them  particularly 
dangerous  to  the  public  health. 

(6)  The  sanitary  disposal  of  feces. 

(c)  The  treatment  of  all  "carriers." 

3.  The  most  efficient  personal  prophylaxis  is  frequent  stool  examinations,  as 
an  index  for  treatment,  of  all  persons  residing  in  endemic  regions. 

Shiga,  in  Japan,  has  used  a  polyvalent  serum,  made  by  the  use  of  the  Shiga- 
Kruse  and  Flexner  organisms,  combined  with  a  mixture  of  dead  bacilli  as  a  means 
of  preventing  the  occurrence  of  the  disease.  He  treated  1000  persons  and  although 
he  failed  to  materially  diminish  the  incidence  of  the  malady,  the  mortality  in 
those  attacked  was  reduced  from  the  average  20  or  30  per  cent,  to  almost  nothing. 
(See  Treatment.) 

Frequency. — Until  very  recently  it  was  generally  supposed  that  amebic  dysen- 
tery was  the  type  of  the  disease  most  commonly  met  with  in  the  United  States, 
but  now  that  Shiga's  bacillus  has  been  found  in  many  cases  of  sporadic  and  epi- 
demic diarrhea  in  this  country  it  must  be  regarded  as  the  less  frequent  form  of  the 
two.  Indeed,  it  would  seem  probable  that  many  of  the  cases  hitherto  regarded 
as  catarrhal  are  due  to  this  bacillus.    (See  also  Cholera  Infantum.) 

Pathology  and  Morbid  Anatomy. — In  bacillary  dysentery,  when  death  has  oc- 
curred in  the  first  week,  the  autopsy  reveals  the  mucous  membrane  of  the  colon 
to  be  intensely  corrugated  and  swollen,  so  that  its  natural  rugosities  are  greatly 
emphasized,  while  over  them  is  spread  an  easily  detached  layer  of  superficial  epi- 


204  DISEASES  DUE  TO  A  SPECIFIC  INFECT  I  OS 

theliuin,  which  has  undergone  necrotic  changes.  Numerous  spots  of  ecchyniosis,  or 
hemorrhage,  into  the  mucous  membrane  are  often  present,  but  ulcers  are  not  found, 
althougli  the  necrotic  process  just  named  may  be  so  severe  that  a  superficial  gan- 
grene may  be  present.  When  the  inflammation  is  very  intense  the  whole  thickness 
of  the  bowel  wall  may  be  indurated,  and  e\en  the  \isceral  peritoneum  may  be 
infected.  In  some  instances  an  associated  inflammation  of  the  small  bowel  is 
present,  somewhat  similar  changes  being  present  in  its  coats. 

Shiga  described  the  morbid  process  of  acute  bacillary  dysentery  as  a  catarrhal 
inflammation  proceeding  to  hemorrhagic,  diphtheritic,  or  ulcerative  inflammation. 
Kruse  also  observed  diphtheritic  memliranes  in  eight  cases  wliich  came  to  autopsy, 
and  Flexner  recognizes  the  tendency  to  their  formation,  although  he  did  not  find 
any  in  the  cases  which  he  examined  postmortem  in  the  Philijjpines. 

Craig  has  reviewed  the  morbid  anatomy  of  chronic  cases  of  infectious  or  bacillary 
dysentery,  recognizing  follicular,  diphtheritic,  and  gangrenous  stages.  In  the  first 
the  coats  of  the  colon  usually  are  thickened,  and  the  follicles,  particularly  of  the 
cecum,  ulcerated.  The  jnucosa  is  of  a  gray-slate  color,  and  shows  patches  of  acute 
congestion;  the  gut  is  narrowed,  but  there  are  areas  of  dilatation.  The  ulcers 
appear  at  the  summit  of  the  follicles  as  minute,  raggerl  erosions.  Later  the  necrotic 
areas  extend,  and  their  margins  appear  stamped  out,  but  undermined.  The  ulcers 
measure  |  to  J  cm.,  but  may  attain  diameters  of  1.5  cm.  and  extend  to  the  sub- 
mucosa  or  muscular  layer.  Cicatrized  and  open  ulcers  may  be  foimd  together. 
In  the  diphtheritic  stage,  which  may  be  implanted  on  the  follicular,  the  colon  is 
grayish  or  greenish-blue,  marked  by  red  or  dusky-brown  areas  and  greatly  thick- 
ened. The  mucosa  becomes  necrotic,  exfoliates  in  masses  or  irregular  patches 
composed  of  granular  detritus,  leukocytes,  and  innumerable  bacteria.  Ulceration 
practically  always  accompanies  the  formation  of  the  membrane.  The  gangrenous 
stage  seems  but  an  intensification  of  the  diphtheritic.  The  serosa  is  more  afl'ected, 
and  matted  adhesions  are  the  rule.  The  necrotic  colon  is  easily  torn,  greenish- 
black,  and  marked  by  inky-black  areas.  The  ileocecal  region  is  sacculated,  and 
the  sigmoid  flexure  and  rectum  dark  olive-green  in  color.  Tumefied,  purulent 
elevations  show  through  the  serous  coat.  Internally  the  mucosa  shows  an  inde- 
scribable admixture  of  necrotic  or  gangrenous  lesion,  with  purulent  suft'usion  of 
all  the  coats  of  the  colon.  In  each  of  the  foregoing  forms  parts  of  the  mucosa 
escape,  and  these  manifest  more  or  less  catarrhal  inflammation.  The  protean 
manifestations  of  bacillary  dysentery,  both  acute  and  chronic,  are  so  influenced 
by  the  pathogenicity  of  the  infecting  organism,  the  activity  of  mixed  or  asso- 
ciated infection,  susceptibility  of  the  patient,  duration  of  the  process  and  other 
factors  that  an  exact  description  is  impossible. 

The  noteworthy  dift'erence  between  the  lesions  produced  in  children  and  adults 
by  the  Bacillus  dysentericB  is  that  in  the  former  the  solitary  and  agminated  lym- 
phatic tissues  are  much  more  commonly  and  more  se\'erely  affected  than  in  adults. 

In  the  acute  type  of  bacillary  dysentery  the  entire  intestine,  large  and  small,  is 
affected  by  a  fibrinous  inflammation  with  only  superficial  ulceration.  In  the 
chronic  type,  which  has  lasted  from  a  month  to  a  year,  the  lesions  are  limited  to  the 
colon  and  occur  chiefly  in  its  lower  part.  These  lesions  consist  in  extensive  ser- 
piginous depressed  ulcers  and  are  found  in  a  greatly  thickened  bowel  wall. 

The  lesions  of  entamebic  dyseniery  are  quite  dift'erent  from  those  of  bacillary 
dysentery.  In  the  first  place  the  ulceration  is  confined  almost  entirely  to  the  large 
intestine,  although  tlie  lower  part  of  the  small  intestine  may  be  slightly  afl'ected. 
Tlic  submucous  tissues  become  infiltrated  and  swollen  in  ])atches,  which  project 
above  the  level  of  the  normal  nnicous  membrane.  These  infiltrated  areas  undergo 
necrosis  and  slough  away,  leaving  ulcers  which  may  be  superficial  or  deep,  and 
which  may  extend  as  far  as  the  peritoneal  coat  of  the  intestine,  but  perforation  is 
rare.    Tliey  are  often  very  large  and  extend  laterally  as  well  as  downward.    The 


DYSEiXTERY  205 

edge  of  the  ulcer  may  be  undermined  and  tlie  floor  honeycombed.  Not  rarely 
the  extension  laterally  takes  place  under  the  mucosa  or  dissects  the  muscle  coat 
so  that  there  is  only  a  small  opening  to  a  large  area  of  necrotic  tissue.  Occasionally 
the  submucosa  is  necrotic  without  evident  superficial  lesions.  The  ameha:  are  found 
in  the  ulcers  in  the  neighboring  lymph  spaces  and  sometimes  in  the  blood\-essels 
of  the  part,  but  there  is  an  extraordinary  lack  of  pus  when  the  se\-erity  of  the 
necrotic  process  is  considered. 

When  recovery  takes  place  fibrous  tissue  covered  by  epithelium  closes  the 
spaces  made  by  the  ulcers,  and  as  these  scars  contract  strictures  may  develop. 
The  colon  becomes  thickened  and  it  may  be  adherent  to  the  adjacent  structures, 
and  uneven  contractions  form  pockets  in  which  the  parasites  may  linger  after 
apparent  clinical  recovery.    The  appendix  may  be  involved. 

The  changes  in  the  liver  in  amebic  dysentery  consist  of  two  alterations.  The 
first  are  multiple  areas  of  local  necrosis,  and  secondly  abscess,  either  single  or 
multiple.  The  single  abscesses  are  usually  large  and  in  the  convexity  of  the  right 
lobe  or  else  in  the  concavity  of  the  liver  where  it  lies  nearest  the  large  bowel. 
Boston  has  collected  statistics  of  2340  cases  of  amebic  dysentery.  Of  these,  486, 
or  20  per  cent.,  suffered  from  hepatic  abscess.  (See  Hepatic  Abscess.)  The 
percentage  varies  from  60  per  cent.  (Kartulis)  to  21  per  cent.  (Councilman  and 
Lafleur.)  Roux  has  collected  639  cases  of  amebic  abscess  of  the  liver.  Of  these, 
435,  or  70.8  per  cent.,  were  in  the  right  lobe;  85,  or  13.3  per  cent.,  were  in  the 
left  lobe,  and  2,  or  0.3  per  cent.,  were  in  the  lobus  Spigelii.  The  multiple 
abscesses  are  usually  small  and  widely  scattered  and  often  near  the  surface.  It 
is  noteworthy  that  these  so-called  abscesses  do  not  contain  true  pus  unless 
secondary  infection  with  pus  organisms  has  occurred.  They  are  composed  of  a 
grumous  material  made  up  of  a  thick,  coarse,  irregular  reticulum,  in  the  meshes 
of  which  lie  the  semi-fluid  contents.  As  the  area  increases  in  size  the  fluid 
becomes  reddish,  brownish,  greenish-yellow,  or  chocolate  color,  and  is  mixed  with 
pieces  or  shreds  of  broken-down  hepatic  tissue.  Amebse  may  be  found  in  the 
contents  of  these  cavities. 

Abscess  of  the  liver  due  to  the  Eniameha  dysenterioe  nearly  always  develops  in 
the  first  few  weeks  of  the  disease.  Occasionally  one  of  the  larger  abscesses  ruptures 
into  the  right  lung.    (See  Complications.) 

A  valuable  contribution  to  the  subject  of  the  associated  lesions  of  dysentery 
has  been  made  by  Craig,  of  the  United  States  Army  Medical  Staff.  x\nalyzing 
120  cases  of  dysentery,  of  which  60  were  of  the  bacillary  and  60  of  the  amebic  t}-pe, 
he  found  that  in  nearly  every  instance  the  autopsy  revealed  an  increase  in  the 
cerebrospinal  fluid  and  edema  of  the  brain.  In  the  amebic  cases  an  intense  con- 
gestion of  the  cerebral  vessels  was  also  present,  and  in  50  per  cent,  minute  capiUary 
hemorrhages  were  present.  In  the  bacillary  cases,  on  the  other  hand,  the  brain 
seemed  unduly  anemic.  In  the  respiratory  system  bronchopneumonia  is  the  most 
common  lesion  in  the  bacillary  disease.  Craig  believes  that  fully  60  per  cent,  of 
the  cases  of  dysentery  seen  in  the  S'an  Francisco  Military  Hospital  have  coincident 
nephritis,  and  of  the  120  cases  already  cited  no  less  than  101  had  this  condition, 
usually  of  the  parenchymatous  type.  More  cases  of  nephritis  occiu-  in  the  entamebic 
than  in  the  bacillary  tj^pe. 

In  the  acute  catarrhal  form  there  is  a  free  production  of  mucus  which  coats  the 
surface  of  the  lower  bowel,  chiefly  in  the  sigmoid  flexure  and  rectum.  This  mucus 
is  filled  with  exfoliated  epithelium,  some  of  which  has  undergone  fatty  degenera- 
tion. Not  infrequentlj'  blood  cells  are  present  in  the  mucus.  When  the  inflam- 
matory process  is  severe,  marked  congestion  and  infiltration  of  the  mucous 
membrane  and  submucosa  may  be  present,  and  even  a  purulent  and  superficial 
ulceration  may  occur. 

The  diiMheritic  type  is  characterized  by  congestion  of  the  mucous  membrane 


-06  DISEASES  DIE  TO  A  SPECIFIC  IXFECTIO.X 

and  the  develupment  upon  its  surface  of  a  false  membrane.  The  connective  tissue 
under  it,  and  between  the  glands,  is  infiltrated  and  filled  with  fibrin  and  pus.  In 
cases  in  which  the  process  is  very  active,  the  inflammation  may  reach  not  only  the 
muscular  coats,  but  even  the  peritoneal  coat.  The  area  covered  by  the  false  mem- 
brane varies  greatly  in  different  cases.  In  some  only  the  rectal  mucous  membrane 
is  affected,  in  others  a  continuous  exudate  covers  the  entire  colon,  and  in  still  others 
it  appears  in  scattered  patches.  If  the  process  is  severe  healing  takes  place  by 
sloughing  of  the  necrotic  tissues,  wliich  may  reach  to  the  deeper  layers  of  the 
bowel,  leavmg  ulcers  which  gradually  undergo  cicatrization,  or  the  ulcers  remain 
granulating  surfaces  for  months  and  heal  only  under  direct  treatment. 

Symptoms. — The  s\Taptoms  of  all  the  various  forms  of  dysentery  are  closel>' 
similar.  The  oti-set  is  usually  sudden,  or  it  may  develop  in  the  course  of  a  grad- 
ually increasing  diarrhea,  which  at  first  is  thought  to  be  an  ordinary  attack  of 
looseness  of  the  bowels.  The  patient  suffers  from  wretchedness,  which  is  thought 
to  be  the  result  of  the  intestinal  disorder,  and  often  has,  in  the  earliest  stages,  a 
considerable  degree  of  griping  pain.  The  initial  diarrhea  soon  sweeps  the  bowels 
clean  of  their  normal  contents,  and  as  soon  as  this  is  accomplished  the  stools  be- 
come scanty  and  consist  largely  of  mucus  which,  not  rarely,  contains  blood.  The 
griping  pain  increases  in  violence,  and  there  is  marked  tenesmus  which  often  causes 
the  patient  to  break  out  in  a  profuse  sweat.  The  rectal  irritation  causes  a  con- 
stant desire  to  go  to  stool,  wliich  is  not  satisfied  by  the  small  evacuation  that 
occurs.  At  first  the  constant  irritation  of  the  anus  may  cause  spasms  of  the  sphinc- 
ters, but  later  when  the  disease  is  severe  the  sphincter  ani  may  become  relaxed, 
and  even  recial  prolapse  may  ensue.  The  centres  in  the  spinal  cord  controlling  the 
bladder  become  reflexly  irritated  and  difficult  urination  may  add  to  the  suffering 
of  the  patient. 

It  is  manifest  that  such  sxTuptoms  must  speedily  cause  grave  systemic  disturb- 
ance by  reason  of  the  loss  of  nutritive  material,  the  constant  pain,  the  less  of  sleep 
and  straining,  and  so  the  pulse  soon  becomes  rapid  and  feeble,  and  the  patient 
rapidly  emaciates  not  only  because  of  the  reasons  just  cited,  but  also  because  the 
local  lesion  in  the  bowels  soon  results  in  general  systemic  infection,  either  with 
the  specific  cause  of  the  attack  or  with  other  micro-organisms  which  gain  access 
to  the  general  system  through  the  diseased  intestinal  wall. 

The  tongue  is  ver\"  foul  and  the  secretions  of  the  mouth  scanty. 

If  the  disease  persists  the  scanty  mucous  stools  may  be  supplanted  by  more 
profuse  serous  discharges,  which  are  often  reddish  in  hue,  and  seem  to  contain 
small  particles  of  flesh  (probably  bloody  mucus  and  mucous  membrane).  This 
fluid  is  highly  albuminous.  The  debility  and  emaciation  of  the  patient  speedily 
becomes  profound,  as  the  loss  of  fluid  and  albumin  continues.  Whether  the 
stmjls  are  mucous  or  serous,  they  are  fetid  and  have  an  odor  \\hich  is  quite 
characteristic. 

Allien  examined  by  the  sigmoidoscope  the  appearance  of  the  bowel  is  fairly 
tx-pical  in  that  small,  superficial  ulcers  covered  by  grayish  mucus  which  is  easily 
wiped  off,  leaving  a  granular  surface,  are  numerous.  This  mucus  will  often  re\eal 
the  ameba  when  the  feces  are  negati^"e. 

In  that  form  of  dysentery  called  hacillary  the  fever  at  first  may  rise  as  high 
as  10:3°,  but  in  the  eniamchic  form  the  temperature  is  usually  not  greatly  disturbed 
unless  sec-ondary  abscess  develops.  It  rarely  rises  above  102°,  and  may  be  sub- 
normal after  the  stage  of  onset. 

AMien  the  infection  with  Shiga's  bacillus  is  very  \irulent,  death  from  toxemia 
and  exhaustion  may  occur  as  early  as  the  fourth  day.  but,  on  the  other  hand,  the 
case  may  last  for  much  longer  periods  before  the  fatal  result  ensues.  There  is 
sometimes  met  a  subacute  form,  which  lasts,  in  a  modified  type,  for  weeks  or  even 
months. 


DYSESTERY  2li^ 

Cases  of  entamebic  dysentery  may  fie  divided  into  three  typet:  (a)  A  mild  form 
in  which  the  general  health  remains  goorj.  althougli  the  number  of  stfjob  may  \»r\ 
from  two  to  six  in  a  day.  (6)  A  moderately  severe  form  in  which  the  general  health 
is  greatly  impaired  and  there  is  much  loss  of  flesh,  with  an  evening  rise  of  tempera- 
ture and  frequent  stooLs.  fc)  A  verj-  severe  tjpe  is  met  with  in  which  the  prostra- 
tion and  loss  of  weight  are  extreme,  the  stoob  are  bloody  and  verj-  frequent,  and 
the  extremities  cold.  In  all  these  cases  the  patient  may  without  any  apparent 
cause  pass  to  better  or  worse  with  extraordinan.'  speed.  <</>  A  c-hronic  form  of 
entamebic  dysentery  also  exists  which  lasts  for  months  and  has  temporary'  periods 
of  constipation.  These  periods  of  constipation,  if  abscess  does  not  develop,  give 
the  patient  an  opportunity  to  be  nourished,  and  so  he  may  be  able  to  retam 
strength  and  flesh. 

Entamebic  dysenterj-  may  cause  death  in  a  few  days  or  last  for  weeks,  and  may 
cause  death  finally  by  the  secondary'  abscess  in  the  liver.  Free  hemorrhages  from 
the  bowel  may  also  occur  in  this  form,  and  perforation  from  deep  ulcers  is  recorded. 

In  the  acute  catarrhal  form  of  dysenter.'  there  may  be  ferer  at  onset  and  scjba- 
lous  masses  wiU  often  be  found  mixed  with  the  mucus  which  is  expelled.  After 
an  illness  of  from  four  to  seven  days  the  quanthj"  of  blood  in  the  stocJs  is  decreased, 
and  they  become  less  frequent. 

Marked  abdominal  tenderness  over  the  course  of  the  large  bowel  b  usually 
present  in  all  cases. 

In  the  acute  diphtheritic  form  the  patient  is  usually  extremely  ill  from  the  reiy 
first.  The  systemic  depression  is  marked  and  profound  adynamia  is  quickly  devel- 
oped. The  belly  i.*  di^ended  and  painful  upon  pressure.  Bloody  mucus  is  not 
imcommonly  absent  from  the  stools.  Just  as  in  the  other  forms  so  in  this,  a  sub- 
acute or  chronic  tj-pe  b  met  with  in  which  the  abdtMninal  signs  are  mild  aod  the 
number  of  stixils  a  day  i;  as  low  as  four  or  five. 

Complications  and  Sequels. — Perforation  of  the  botcel  has  already  been  named 
as  a  possible  sequel  of  the  amebic  form  of  the  dbease.  In  other  instances  a  loeal- 
jiryrf  peritonitis  develops,  and  as  the  result  of  infection  of  the  tbsues  about  the  colon 
a  peritj-phlitb  or  periproctitis  comes  on.  Rupture  of  an  hepatic  abscess  b  a  very 
frequent  occiurence.  The  pus  finds  its  way  through  the  diaphragm  into  the  right 
limg  or  right  pleural  space.  Rarely  it  has  burst  into  the  duodenum  and  even  into 
the  vena  cava,  or  backward  and  downward  along  the  psoas  muscle,  or  into  the 
kidney.  Even  the  pericardium  and  the  bladder  may  be  perforated.  Strong  has 
called  attention  to  the  occurrence  of  profuse  intestinal  hanorrhage. 

In  many  epidemics  of  dj^sentery  there  b  associated  mild  or  seveie  malarial 
infection  which  renders  the  ease  difficult  of  treatment  in  that  two  infections  have 
to  be  controlled  simultaneously.  Septic  arthritis,  pericarditis,  and  endotarditis 
sometimes  occur  as  terminal  infections.     (.See  Pathology  and  Morbid  Anatomy. » 

Diagnosis. — ^The  diagnosb  that  the  patient  has  acute  inflammation  of  the  large 
bowel,  and  b  therefore  suffering  from  dysentery-  in  one  of  its  forms,  b  easily  made 
if  the  sjTnptoms  just  described  are  present.  It  b  not,  of  course,  so  easy  lo  deter- 
mine which  of  the  several  forms  of  dj'sentery"  b  present-  The  bacfllary  form 
is  separated  from  the  amebic  varietj'  by  the  presence  of  marked  fever,  which  b 
usually  absent  in  the  latter  disease:  by  the  discovery  of  the  q)ecific  bacillus  in  ihe 
stools,  which  discoverj".  however,  requires  special  training  in  searching  for  it; 
and  by  the  agglutination  test  of  the  bacillus  with  the  patient's  blood  serum,  which, 
as  in  the  case  of  the  ^Idal  test  of  the  blood  in  typhoid  f  evo-.  gives  us  much  valuable 
ioformation.  This  reaction  is  uncertain  in  the  first  week,  often  positive  after  the 
sLsth  day,  but  in  some  cases  it  does  not  occur  for  two  weeks.  For  thb  reason  it  does 
not  possess  great  diagnostic  importance  in  the  early  stages  of  the  disease.  To 
be  of  value  it  must  take  place  in  a  dilution  of  1  :  200.  The  percentage  of  poative 
reactions  according  to  Rosenberser  b  SOJ?. 


208  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

The  amebic  variety  can  be  recognized  during  life  only  liy  finding  the  ameba 
in  the  stools.  This  requires  some  practice  and  skill.  The  small  pieces  of  blood- 
stained mucus  are  the  parts  in  which  the  organism  is  to  be  sought  for,  first  with 
a  low-power  and  then  with  a  high-power  lens.  (See  Plate  IV.)  The  light  coming 
through  the  instrument  should  be  stopped  down  by  an  appropriate  diaj)hragm. 
Several  negative  examinations  do  not  exclude  entamebic  dy.sentery,  and  particularly 
in  chronic  cases  is  it  necessary  to  make  repeated  examinations.  In  such  cases 
acute  exacerbations  may  afl'ord  stools  relatively  rich  in  ameb?e  even  when  inter- 
current examinations  have  been  negative  several  times.  The  stools  should  be  as 
fresh  as  possible,  unmixed  with  urine,  and,  if  not  warm,  the  slide  examined  should 
be  warmed  gently  or  placed  on  a  warm  stage  so  as  to  induce  mo\'cments  of  the 
amebse.  If  an  organism  which  possesses  active  ameboid  movement  is  discovered 
and  if  it  contains  several  red  blood  cells  the  diagnosis  is  practically  assured. 

The  failure  to  discover  the  amebae  or  the  signs  of  the  presence  of  the  bacillus  of 
Shiga  should  cause  a  search  for  the  Balaniidium  coli.  This  is  essential  to  successful 
treatment.     (See  Treatment.) 

When  examining  the  stools  it  is  essential  to  bear  in  mind  that  a  multitude  of 
intestinal  bacteria  are  also  present  and  that  various  parasites  other  than  the  specific 
ameba  may  be  present.  Thus,  the  Trichoinonas  intesiinaUs  and  the  Cercomo7ias 
intesiinaUs  are  often  found.  Thayer  has  recorded  a  case  in  which  the  Strongyloides 
iniestinaUs  was  present  as  an  additional  parasite. 

The  diphtheritic  form  is  to  be  suspected  if  from  the  first  the  patient  seems  pro- 
foundly adynamic.  Typhoid  fever  is  to  be  separated  from  dysentery  by  the  fever, 
the  rose  rash,  and  the  Widal  test. 

Prognosis. — The  prognosis  in  dysentery  depends  to  some  extent  upon  the  variety 
of  infection  which  is  present,  and  upon  the  hygienic  surroundings  and  vitality  of 
the  patient,  for  even  the  mildest  types  may  be  fatal  if  the  patient  receives  bad 
food  and  is  exposed  to  excessive  heat  or  cold  or  wet.  When  the  bacillus  of  Shiga 
is  the  cause  the  prognosis  in  acute  cases  must  always  be  most  guarded,  both  as  to 
the  recovery  and  the  duration  of  the  illness.  The  mortality  ^•aries  greatly  in 
different  epidemics  in  different  parts  of  the  world.  Thus  m  Japan,  Shiga  found 
it  Aaried  from  22  to  55  per  cent.  In  this  country  the  mortality  has  been  as  low 
as  3  per  cent.  The  general  state  of  emaciation  and  depression  must  always  be 
considered.  If  the  stools  contain  gangrenous  sloughs,  the  outlook  is  of  course 
very  grave;  and  if  hiccough,  great  nervous  depression,  and  low  delirium  de\'elop 
the  outlook  is  probably  fatal. 

In  the  entamebic  type  the  development  of  abscess  in  the  liver  of  course  adds 
very  greatly  to  the  gravity  of  the  case;  but  even  when  ameliic  abscess  is  present 
and  ruptures  into  the  lung,  it  is  possible  for  recovery  to  take  place,  if  proper  surgical 
measures  of  relief  are  undertaken. 

Even  the  most  urgent  cases  may,  when  apparently  near  to  death,  reco\'er,  but 
convalescence  is  protracted. 

According  to  Duncan  prognosis  can  be  based,  to  some  extent  at  least',  on  the 
character  of  the  stools.  He  believes  a  good  result  can  be  foreshadowed  in  those 
cases  in  which  are  passed  mucus  with  minute  fecal  lumps,  stained  or  not  with  blood, 
and  in  which  the  blood  and  mucus  disappear,  after  which  the  ordinary  fecal  char- 
acters will  soon  manifest  themselves. 

The  prognosis  is  of  evil  omen,  according  to  Sir  Joseph  Fayrer:  (a)  in  the  cases 
in  which  pulpy  stools  without  blood  or  mucus  are  passed;  (?;)  where  fluid  fecal 
matter  is  from  time  to  time  passed  throughout  the  illness,  the  prognosis  is  unfavor- 
able, inasmuch  as  these  characters  of  the  stools  show  the  disease 'to  be  ex-tensive, 
and  affecting  chiefly  the  upper  part  of  the  large  as  well  as  in  some  cases  part  of 
the  small  intestine;  (c)  the  prognosis  is  of  the  worst  possible  character  where  the 
stools  consist  of  blackish-red  or  lilackish  fluid  with  a  horribly  putrescent  odor,  and 


DYSENTERY  209 

of  bits  of  gangrenous  tissue.  Duncan  iias  never  seen  a  patient  passing  tiiis 
character  of  stool  recover. 

Treatment. — In  all  forms  of  dysentery  the  following  rules  as  to  treatment 
apply:  So  far  as  diet  is  concerned  it  is  self-evident  that  the  food  sJKjulrl 
consist  of  those  substances  which  are  readily  digested  and  absorberl  from  tiie 
stomach  and  the  duodenum,  in  order  that  as  small  a  residue  as  possil)le  .may  pass 
on  downward  into  the  large  bowel.  Milk,  which  is  so  universally  resorted  to  in 
the  treatment  of  all  forms  of  diarrhea,  is  not  always  as  useful  a  form  of  nutriment 
as  it  is  thought  to  be;  for  not  uncommonly  it  will  be  found  that  when  milk  is  taken 
it  remains  undigested,  or  forms  curds  which  are  indigestible  because  of  the  feeble 
secretion  of  digestive  juice.  These  curds  pass  through  the  bowels  and  afford 
pabulum  for  micro-organisms  which,  in  turn,  are  injurious  to  the  mucous  membrane. 
If  it  is  given,  it  should  certainly  I)e  diluted  freely  with  lime-water,  barley-water, 
or  Vichy-water,  or  else  it  should  be  peptonized  in  order  that  its  digestion  may  be 
readily  performed;  and  it  is  of  vital  importance  in  this  connection  that  it  should 
be  given  in  small  quantities,  frequently,  rather  than  in  large  quantities.  .Solid 
food  is,  of  course,  contra-indicated,  but  semi-solid  foods  hke  milk-toast,  the  digestion 
of  which  is  aided  by  pancreatin  or  taka-diastase,  and  a  very  soft-boiled  egg,  will 
often  prove  a  better  diet  than  one  which  is  more  liquid,  but  less  nourishing,  since 
the  physician,  in  the  presence  of  dysentery,  is  faced  by  two  opposing  factors;  on 
the  one  hand  a  feeble  digestion,  and  on  the  other  hand  the  necessity  of  supporting 
vitality  to  the  highest  possible  point  by  the  administration  of  proper  foodstuffs. 

Musgrave  and  Sisson  state  that  the  routine  treatment  in  the  Philippine  General 
Hospital  which  has  given  the  most  satisfactory  results  in  bacillary  dysentery 
consists  in  the  following: 

First,  absolute  rest  to  save  the  strength  of  the  patient  and  to  prevent  the  involve- 
ment of  the  larger  segment  of  the  intestine. 

Secondly,  the  early  administration  of  some  mild  laxative,  preferably  sodium 
sulphate  or  magnesium  sulphate,  preceded  by  fractional  doses  of  calomel  in  order 
to  diminish  the  presence  of  infecting  material  in  the  gastro-intestinal  tract,  as 
well  as  to  get  rid  of  some  irritating  material  that  might  be  present  there.  The 
administration  of  simaruba  ofBcinalis  combined  with  some  opiate  is  highly  recom- 
mended, for  it  has  given  the  writers  the  most  satisfactory  results  in  comparison 
with  the  use  of  other  drugs.  As  an  adjuvant  to  this  treatment,  the  judicious  use 
of  normal  salt  solution  as  an  enema,  or  given  in  the  form  of  the  drop  method  per 
rectum  in  the  amount  of  1  liter  once  a  day,  is  sometimes  very  beneficial. 

When  the  acute  stage  of  the  disease  has  subsided,  enemata  of  hydrogen  peroxide 
in  a  weak  solution  (about  2.5  cubic  centimeters  in  500  cubic  centimeters  of  water) 
once  a  day  are  a  great  help  towards  prompt  recovery. 

The  use  of  astringents  and  the  so-called  gastro-intestinal  antiseptics  the  writers 
have  given  up  as  unsatisfactory.  Although  there  is  a  small  percentage  of  patients 
who  recover  under  this  treatment,  one  should  remember  that  there  are  cases  that 
get  well  even  without  any  medical  treatment,  and  these  writers  consider  it  problem- 
atical whether  or  not  the  usual  astringents  and  gastro-intestinal  antiseptics  are 
really  beneficial  in  the  treatment  of  this  disease.  The  fact  must  be  kept  in  mind 
that  most  of  the  astringents  and  so-called  intestinal  antiseptics,  such  as  bismuth, 
tannic  acid  preparations,  salol,  beta-napthol,  benzo-napthol,  benzoic  acid,  and 
others,  have  an  irritating  action  upon  the  stomach  and  intestines,  especially  if 
they  are  given  in  large  amounts  and  over  a  considerable  period  of  time. 

The  use  of  the  ice-bag  over  the  abdomen  is*a  great  help  in  diminishing  the  abdom- 
inal pain,  and  hot  turpentine  stupes  frequently  are  useful  for  the  same  purpose. 

The  essential  part  of  the  treatment,  however,  is  dietetic.  During  the  first 
twenty-four  hours  of  the  acute  stage  of  the  disease  food  must  be  withdrawn.  Pieces 
of  cracked  ice  may  be  given  to  allay  thirst.  At  the  end  of  twenty-four  hours,  the 
14 


210 


DISEASES  DUE  TO  A  SPECIFIC  INFECTION 


patient  is  allowed  albumin-water  or  rice-  or  barley-water  and  later  skimmed  or 
peptonized  milk.  When  improvement  has  begun,  milk,  broth,  beef  juice,  and 
orange  juice  may  be  given.  The  mouth  must  be  frequently  cleansed  with  an 
antiseptic  mouth  wash  to  prevent  the  frequent  complications  of  parotitis  and 
gastritis. 

The  serum  treatment,  first  recommended  by  Shiga  in  1898,  has  both  advantages 
and  disadvantages.  If  the  identification  of  the  bacillus  which  is  the  cause  of 
the  infection  can  be  carried  out  with  readiness,  as  well  as  with  accuracy,  this 
scientific  treatment  ought  to  yield  a  greater  percentage  of  cures  than  usually  is 
obtained.  For  practical  purposes,  however,  especially  in  those  cases  that  have 
to  be  treated  in  places  where  the  means  of  identifying  the  infecting  micro-organisms 
are  not  available,  it  is  a  failure  in  most  instances.  The  sera  of  patients  suffering 
from  one  form  of  bacillary  dysentery  will  not  agglutinate  other  varieties  of  Bacillus 
dvsenterise. 


)I«  1900 

n 

" 

1   I    1   1   1   {!    1 

1    J..nc| 

"^^j'we"^' 

Al 

^\ 

c 

3 

MF 

10 

u 

12 

13 

a 

15 

10 

17 

IS    10   20   il    22   2:1   21    2.)   26;  27 

2S 

20 

30 

.11 

1 

112 

( 

111 

30,000 

110 
100 

28,000 

i 

=. 

20,000 

=■ 

1/ 

103 

21,000 

s 

' 

', 

107 

22,000 

J 

r^ 

— 

100 

20,000 

' 

106 

13,000 

/ 

101 

10,000 

- 

\ 

/ 

\ 

103 

11,000 

1 

^ 

102 

12,000 

7^ 

, 

101  i    10,000 

/ 

, 

100      a,ooo 

\ 

. 

■■<, 

-'1 

•JO      o.ooo 

\j     \ 

' 

J 

- 

- 

_ 

_ 

i-                     i 

98   1     l.OOO 

— — V— 

J 

- 

^ 

-1 

- 

Ci 

- 

D 

D 

i;;^ 

'N/'^l 

07    1     2,000 

9G    ]     1,000 

.L 

1 

Effect  of  ipecacuanha  on  the  leukocyte  curve  and  temperature  in  amebic  hepatitis. 
Broken  line,  leukocytes. 


(Greig.) 


It  is  possible  that  Flexner's  polyvant  serum  might  be  used  for  any  acute  bacillary 
dysentery.  However,  streptococci,  staphylococci,  colon  bacillus,  and  others 
concerned  in  the  production  of  colitis  under  certain  circumstances,  will  make  the 
use  of  even  a  polyvalent  serum  unsatisfactory  in  many  instances. 

The  treatment  of  amebic  dysentery  may  be  divided  into  three  methods,  and  each 
one  of  these  plans  finds  ardent  advocates  among  those  of  tlie  profession  who 
have  had  sufficient  experience  to  make  us  feel  that  their  opinions  are  of  value. 
Before  discussing  these,  however,  it  may  be  stated  that  in  the  early  stage  of  the 
disease  the  bellyache  may  be  relieved  by  a  hypodermic  of  \  grain  of  morphine 
and  followed  by  castor  oil  and  laudanum  to  sweep  out  the  bowel. 

The  ipecac  plan  is  to  be  considered  the  first  of  these.  Leonard  Rogers  has  shown 
that  emetine  hvdrochloride  given  hypodermically  in  the  dose  of  §  grain  daily 
exercises  a  specific  healing  eft'ect  and  results  in  speedy  cure  in  many  ca.ses.  In 
severe  cases  the  emetine  sjiould  be  given  intravenousl.v.  This  type  of  treatment 
has  for  obvious  reasons  supplanted  the  use  of  ipecac  itself  but  if  emetine  is  not 
at  hand  ipecac  sliould  be  given  as  Woodhull  advises  as  follows: 

"The  stomach  must  be  empty  and  the  patient  recumbent.  About  twenty 
minutes  before  giving  the  ipecac  it  is  well  to  paint  the  epigastrium,  not  the  whole 


DYSENTERY  211 

abdomen,  with  tincture  of  iodine,  or  to  appij'  a  mild  sinapism  sufficiently  to  induce 
gentle  counter-irritation.  This  precaution,  however,  ma,y  sometimes  be  omitted, 
or  may  be  deferred  until  the  medicine  has  been  taken.  Ten  or  15  minims  of  lauda- 
num may  be  given,  always  on  an  empty  stomach,  to  be  followed  in  ten  or  twelve 
minutes  by  from  15  to  30  or  more  grains  of  ipecac  in  pill  form,  or  as  a  paste,  with 
a  very  small  quantity  of  water.  No  food  or  fluid  should  be  taken  for  at  least 
four  hours,  and  recumbent  rest  should  be  strictly  maintained.  If  the  ipecac  is 
administered  in  pill  or  capsule  the  laudanum  may  be  mixed  with  it  instead  of  given 
previously.  One  scruple  of  ipecac  and  1  grain  of  opium  can  be  made  into  four 
pills,  or  the  laudanum  can  be  put  in  the  pills.  When  pills  are  used  they  shoulil 
be  freshly  made.  Or  20  grains  of  ipecac  can  be  suspended  in  2  fluidrachms  of 
water  with  a  few  drops  of  an  aromatic  to  disguise  the  taste.  It  is  never  advis- 
able, on  account  of  the  popular  idea  associated  with  it,  to  disclose  the  name  of 
the  medicine,  and  the  patient  should  be  warned  to  resist  any  inclination  to  vomit. 
The  size  of  the  dose  should  be  in  proportion  to  the  gravity  of  the  case.  Just  as 
in  severe  colic  verj^  large  doses  of  opium  are  tolerated,  and  in  pernicious  h\ev 
enormous  quantities  of  quinine  are  indicated,  so  in  dysentery  surprisingly  large 
doses  of  ipecac  are  well  borne,  although  the  magnitude  of  the  dose  should  bear 
some  relation  to  the  severity  of  the  disease.  With  a  little  experience,  that  relation 
will  soon  be  determined.  Sixty  grains  is  not  a  maximum  dose  for  an  adult,  but 
with  the  ordinary  acute  dysentery  from  15  to  25  grains  at  a  time  should  suffice. 
If  the  first  or  any  subsequent  dose  is  rejected,  w'hich  rarely  happens  if  these  rules 
are  carefully  followed,  it  is  to  be  repeated  after  a  short  interval.  The  retching 
or  \'omiting  of  exhaustion  or  the  restlessness  of  delirium  is  no  bar,  but  rather  an 
inducement  to  this  treatment;  and  small  children  or  delicate  women  can  take  it 
with  impunity  in  proportionate  amounts. 

"The  common  course  in  acute  dysentery  is,  first,  the  relief  of  pain,  next  the 
■  subsidence  of  fever,  and  then  the  cessation  of  the  bloody  discharges.  The  usual 
sign  that  recovery  is  at  hand  is  a  painless,  copious,  semi-fluid  evacuation,  much 
the  color  of  the  ipecacuanha  powder,  not  black  as  has  been  stated.  The  medicine 
then  may  be  reduced  or  entirely  suspended.  In  acute  cases  these  resuUs  will 
follow  very  quickly.  In  chronic  dysentery  complete  reco^very  may  be  delayed  or, 
indeed,  may  fail  of  absolute  attainment,  but  great  amelioration  may  be  confidently 
anticipated.  That  the  powder  should  be  pure  and  comparatively  fresh  is  always 
essential." 

Walker  calls  attention  to  the  fact  that  the  ipecac  treatment,  while  very  efficient 
in  relieving  attacks  and  causing  the  entamebse  to  disappear  temporarily  from  the 
stools,  does  not  always  kill  all  of  them  in  the  intestine.  Treatment  should  there- 
fore be  controlled  by  stool  examinations  in  order  to  prevent  the  relapses  so  common 
in  dysentery. 

The  second  method  of  treatment  is  the  purgative  plan,  which  has  come  forward 
largely  within  the  last  few  years,  probably  because  of  increasing  experience  on 
the  part  of  American  and  English  surgeons  in  the  Philippines  and  in  South  Africa. 
Clinical  evidence  is  rapidly  accumulating  which  proves  beyond  all  doubt  that  in 
a  certain  proportion  of  cases  of  acute  dysentery  the  employment  of  sulphate  of 
magnesium  combined  with  aromatic  sulphuric  acid  is  a  most  advantageous  method. 
The  bowels  are  first  thoroughly  moved  with  Epsom  salts  or  with  Rochelle  salts, 
and  then  aromatic  sulphuric  acid  is  given  freely,  so  that  it  will  exercise  its  well- 
known  astringent  or  constipation  influence. 

The  third  plan  of  treatment  consists  in  the  administration  of  intestinal  antiseptics, 
of  which  perhaps  bismuth  salicylate,  benzonapthol,  and  salol  have  been  most 
commonly  employed.  Theoretically,  it  is  easy  to  conceive  that  these  substances 
may  be  advantageous,  but  practical  experience  has  shown  that  they  fail  to  exercise 
the  degree  of  antiseptic  influence  with  which  i;hey  are  credited,  and  they  are  not 


212  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

of  sufficient  importance  to  justify  their  eniploj-ment  to  the  exchision  of  the  ipecac 
or  saHnc  methods  which  have  just  l)een  descril^ed.  The  employment  of  calomel 
and  corrosive  sublimate  with  good  results  in  these  cases  rests  upon  the  fact  that 
they  increase  the  activity  of  the  liver,  both  in  destroying  toxic  material  and  in 
secreting  bile. 

Without  doubt  local  treatment  by  high  intestinal  irrigations  is  of  value.  Copious 
clysters  which  will  reach  far  up  into  the  descending  and  transverse  colon  are 
necessary.  In  a  number  of  instances  the  writer  found  that  injections  of  phenol- 
sulphonate  of  zinc,  in  the  proportion  of  20  grains  to  the  pint,  have  produced 
very  satisfactory  results,  the  zinc  acting  both  as  an  astringent  and  antiseptic. 
Other  practitioners  have  employed  copious  injections  of  weak  solutions  of  nitrate 
of  silver  of  the  strength  of  1  drachm  to  4  pints.  Rogers  has  obtained  the  best 
results  in  bacillary  dysentery  by  injecting  albargin  or  sih'cr  gelatose  in  the  strength 
of  1  to  500  of  water,  using  half  to  1  pint  as  an  injection  each  day.  The  tenesmus 
which  is  frequently  associated  with  the  dysenteric  condition,  or  on  the  introduction 
of  ths  soft  rectal  tube,  can  sometimes  be  a\'oided  by  the  use  of  a  10  grain  iodoform 
suppository  used  half  an  hour  before  the  injection  is  to  be  gi^'en.  This  suppository, 
by  its  local  anesthetic  effect,  is  of  service,  and  I  have  thought  that  the  absorption 
of  the  iodine  from  it  was  also  advantageous. 

The  method  of  giving  the  intestinal  lavage  is  of  considerable  importance.  It 
should  not  be  given  with  a  Davidson  or  other  pumping  syringe,  but  always  b\' 
means  of  a  fountain  syringe  or  surgical  irrigator.  The  hydrostatic  pressure  em- 
ployed should  ne\'er  be  greater  than  two  or  three  feet,  and  it  is  much  better  that  the 
injection  should  be  gently  given,  so  that  it  takes  fifteen  or  twenty  minutes  to  find 
its  way  up  into  the  intestine,  than  that  it  should  be  delivered  forcibly  enough  to 
produce  angry  contractions  of  the  bowel,  which  will  cause  great  agony  and  so 
much  irritation  that  the  treatment  makes  the  patient  worse. 

Where  great  irritability  of  the  bowel  exists  it  is  probably  better  to  emiiloy  two 
rubber  catheters  side  by  side,  one  being  for  the  intake  and  the  other  for  the  outflow, 
since  in  this  way  great  distention  of  the  liowel  is  avoided.  In  instances  in  which 
cold-water  injections  seem  inad\'isable  very  hot  water  may  be  emi)loyetl,  but  it  is 
distinctly'  disad\-antageous  to  employ  tepid  water,  which  has  a  relaxing  and  enervat- 
ing efi'ect,  and  does  not  possess  the  healthy  stimulant  effects  of  marked  cold  or 
high  heat.  Often  it  is  best  to  employ  normal  saline  solution,  since  by  this  means 
maceration  of  the  intestinal  mucous  membrane  is  avoided. 

The  use  of  Aaccine  of  Shiga's  bacillus  has  given  very  variable  results  in  the 
hands  of  different  clinicians.    It  seems  uncertain  and  not  very  safe. 

Another  form  of  specific  treatment  is  that  which  is  directed  to  combating  amebic 
dysentcri/  by  means  of  injecting  quinine  hisulphate,  in  tlie  strength  of  1:5000,  suf- 
ficiently high  in  the  rectum  for  it  to  exercise  its  fatal  effect  upon  the  ameba  coli. 
Thymol  1:2500  may  also  be  used  in  this  way  (Thomas).  Harris  has  highly 
recommended  hydrogen  peroxide  given  by  injections  as  a  parasiticide. 

The  complicating  hepatitis  or  hepatic  abscess  can  be  prevented  in  a  large  propor- 
tion of  cases  if  Leonard  Rogers'  advice  be  followed,  namely,  the  use  of  ipecac 
or  emetine  hydrochloride  as  soon  as  the  ameba  is  demonstrated  or  as  fever  and 
hepatic  tenderness  develop.  (See  earlier  part  of  Treatment.)  When  abscess  has 
develoj)ed  Rogers  has  shown  that  tlie  projier  treatment  is  puncture,  aspiration 
and  repeated  injection,  without  drainage,  of  quinine  solution.  Opening  such  an 
abscess  by  the  ordinary  means  con\erts  a  sterile  amebic  abscess  into  an  infected 
pus  cavity.  Usually  three  grains  of  the  quinine  at  one  injection  arc  sufficient, 
dissolved  in  water  1 :500.  One  to  tiirce  aspirations  and  injections  arc  all  that  are 
needed. 

Stimulants  well  diluted  with  water  or  with  nutritive  broths  should  be  gi\en  if 
needed,  and  strychnine  and  quinine  employed  in  convalescence  as  tonics. 


EPIDEMIC  GANGRENOUS  PROCTITIS  213 

For  the  control  of  diarrhea  when  excessive,  enemata  of  fleodorizwl  tincture  of 
opium  and  starch-water  are  very  useful. 

During  convalescence  it  is  needful  to  axoid  any  article  of  food  wiiicii  can  distiirh 
intestinal  digestion. 

Walker  has  shown  that  ipecac  and  emetine  are  practically  useless  in  tlie  dysentery 
due  to  the  Balanfidivm  coli.  Neither  do  arsenical  compounds,  or  quinine,  or  the 
aniline  dyes,  usually  destructive  to  the  protozoa,  do  much  good,  but  the  salts  of 
silver  and  mercury  are  very  active  and  it  would  seem  that  organic  compounds 
of  silver  like  argyrol  will  give  the  best  results  if  used  by  colonic  irrigations. 


EPIDEMIC  GANGRENOUS  PROCTITIS. 

Defmition. — Epidemic  gangrenous  proctitis  is  an  acute  contagious  disease  appear- 
ing as  a  rapidly  spreading  ulceration  of  the  anus  and  rectum,  with  prolapse  and 
gangrene  of  the  ulcerated  rectum  and,  in  a  large  proportion  of  cases,  death  in 
coma  or  convulsions. 

This  disease,  originally  believed  to  be  limited  to  narrow  areas  in  Central  and 
South  America,  is  now  known  to  occur  much  more  widely  throughout  the  tropical 
zones.  It  is  generallj'  distributed  in  tropical  South  America  and  in  Central  America. 
It  has  been  observed  in  the  Philippines,  the  Celebes,  and  New  Guinea. 

There  is  some  question  whether  this  affection  should  be  regarded  as  a  distinct 
disease  entity  or  not. 

Etiology. — Nothing  is  known  of  the  direct  cause  of  this  curious  condition.  Ackers, 
of  Curacao,  states  that  it  is  the  common  belief  of  the  natives  in  A'enezuela  that  the 
disease  is  caused  by  eating  unripe  maize,  of  which  the  children  are  particularly 
fond.  This  seems  hardly  probable.  The  disease  has  been  observed  in  countries 
in  which  maize  is  practically  an  unknown  food  product.  Kieffer  has  reported 
one  case  in  which  the  Bacillus  pyocyaneus  was  undoubtedly  the  active  organism. 
A  high  degree  of  humidity  seems  an  essential  condition  to  the  development  of  the 
disease.  Ackers  observed  this  disease  in  fowls  and  the  smaller  domestic  animals, 
occasionally  in  calves.  In  Venezuela  and  New  Guinea  the  disease  is  confined 
to  children,  particularly  those  of  the  poorer  classes,  and  in  the  rest  of  the  tropical 
world  it  also  holds  true  that  children  are  more  frequently  attacked  than  adults. 

Pathology. — The  rectum  and  anus  in  early  stages  are  affected  by  deep  ulcers 
overlaid  with  a  diphtheroid  pseudomembrane.  Two  forms  can  usually  be  distin- 
guished: the  low  form  with  limitation  of  the  lesions  to  the  rectum  between  the 
sphincters,  and  the  high  form  in  which  the  disease  extends  well  up  to  the  sigmoid. 

Symptoms. — The  disease  begins  with  local  symptoms  referred  to  the  anus  and 
rectum.  There  is  burning  and  intolerable  itching  followed  by  severe  dysenteric 
symptoms.  After  twelve  to  twenty-four  hours  there  is  more  or  less  constant  and 
severe  tenesmus. 

The  evacuations,  at  first  feculent,  become  mucoid  and  finally  consist  entirely 
of  mucus  and  blood.  The  distress  grows  urgent,  effort  and  pain  become  continu- 
ous, and  there  is  a  constant  flow  or  bubbling  out  of  slimy  mucus  stained  with  blood, 
or  almost  pure  frothy  blood.  The  evacuations  are  very  fetid.  As  the  disease 
progresses  there  is  profound  collapse.  Nervous  symptoms  appear  and  the  patients 
become  either  delirious  or  comatose.  In  children  there  may  be  convulsions. 
Emaciation  is  rapid  and  death  usually  occurs  in  convulsions  or  coma.  If  the 
patient  survives  this  stage  the  rectum  is  extruded  and  undergoes  rapid  necrosis 
and  sloughing. 

In  the  early  stages  the  diagnosis  between  epidemic  gangrenous  proctitis  and  dysen- 
teric lesions  in  the  descending  colon  can  only  be  made  by  examination  of  the  rectum. 
In  ad\'anced  cases  the  condition  is  self-evident.    The  mortality  is  very  high,  but 


214  nrSEASEsS  DUE  TO  A   SPECIFin  IXFECTIOX 

even  comatose  patients  need  not  be  dospairoil  of.     IlccoNcry  occasionally  occurs 
after  prolapse  and  slonKliiiiK  of  the  rectum. 

Treatment. — The  Venezuelan  treats  this  disease  by  introducinj;  lemon-juice 
or  diluted  ai/ininlinife  into  the  rectum.  When  extrusion  of  the  rectum  occurs 
he  keei)s  it  dry  by  dusting;  with  wood-ashes.  Indications  are  for  active  antisepsis 
of  the  rectum  with  diluted  creolin  or  hydroi^en  peroxide.  Opium  will  be  necessary 
for  the  control  of  ])aiii,  and  is  best  applied  directly  to  the  diseased  area.  If  pro- 
lapse occurs  no  effort  should  be  made  at  first  to  replace  it.  The  rectum  should  be 
dusted  with  an  antiseptic  powder  or  freshly  made  charcoal.  If  ganj^rene  occurs 
the  rectum  must  be  extirpated. 

HILL  DIARRHEA. 

Definition. — An  acute  morning  diarrhea  with  white  stools  and  attended  by 
marked  flatulency.  It  is  a  disease  of  the  acclimatized  and  not  of  the  new-comer 
in  the  tropics. 

Etiology. — The  etiological  factors  in  the  production  of  hill  diarrhea  are,  first, 
prolonged  residence  in  hot  countries  with  the  establishment  of  acclimatization, 
and  an  unaccustomed  altitude,  five  to  six  thousand  feet,  with  a  high  degree  of 
humidity.  The  dweller  in  the  low,  hot  plains  who  goes  to  the  hills  is  very  prone 
to  fall  a  victim  to  this  disease.  It  is  consequently  observed  when  business  or 
relaxation  takes  the  colonists  into  mountainous  portions  of  the  tropics.  It  is 
common  in  the  hill  sanatoria  of  tropical  countries,  particularly  in  India,  where 
it  was  named  hill  diarrhea,  Simla  diarrhea,  etc.  Hill  diarrhea  bears  a  very  close 
resemblance  to  sprue.  The  cardinal  symptoms  differ  only  in  degree,  but  the 
tendency  of  hill  diarrhea  is  so  constantly  to  recovery,  and  that  of  sprue  so  con- 
stantly downwarfl,  that  they  must  be  considered  separately. 

Pathology. — ^'c^y  little  is  known  of  the  pathology  of  this  peculiar  condition. 
It  seems  to  be  clear  that  there  is  a  temporary  suspension  of  function  of  the  liver 
and  pancreas.  This  is  probably  the  expression  of  exhaustion  resulting  from  the 
extra  strain  on  already  overworked  digestive  organs  seeking  to  adapt  themselves 
to  a  further  change  of  climatic  conditions.  Scheube  thinks  this  condition  depends 
on  an  atonic  state  of  the  colon  which  he  belic\es  to  lie  a  common  sequel  to  long 
residence  in  hot  countries,  and  that  the  diarrhea  is  due  to  chilling  of  the  abdomen 
in  the  unaccustomed  cold  and  dampness  of  the  early  morning  hours  of  the  mountain- 
ous region  of  the  tropics. 

The  tendency  in  the  vast  majority  of  cases  is  to  prompt  readjustment  and 
restoration  within  one  or  two  weeks.  A  small  proportion  of  cases  persist  and  may 
end  in  typical  sprue.  Crombie  reports  cases  in  which  cure  has  taken  place  only 
when  the  [jatients  returned  to  the  plains.  In  these  cases  every  visit  to  the  hills 
was  followed  by  this  diarrhea. 

Symptoms. — Shortly  after  arrival  in  the  mountains  the  patient  is  troubled  with 
(I i/s peptic  st/i)ipf(i)ii.s-  and  a  morninq  diarrhea.  On  the  succeeding  days  the  diarfhea 
becomes  more  troublesome  until  it  reaches  eight  to  ten  movements  daily.  It 
comes  on  in  the  early  morning,  at  or  near  dawn,  with  a  sudden  call  to  stool.  It 
continues  during  the  forenoon  and  ceases  ahrvpily  about  mid-day.  There  is  very 
little  pain  and  that  only  as  a  vague,  indeterminate  fliscomfort  o\-cr  the  colon, 
and  no  tormina  or  tenesmus.  The  movements  are  large  and  frothy,  they  are  devoid 
of  coloring  matter,  and  look  like  stirred  mortar  or  whitewash.  They  have  an 
unpleasant,  mawkish  odor.  Dyspeptic  symptoms  are  pronounced.  There  is 
distress  after  eatincj,  particularly  in  the  morning,  and  there  may  be  marked  tympanitic 
distention  of  the  abdomen. 

Treatment. — Treatment  is  directed  to  the  restoration  of  intestinal  digestion  and 
the  maintenance  of  a  relative  degree  of  rest  to  the  gastro-intestinal  tract  by  putting 


MALTA  FEVER  21') 

the  patient  on  liquid  or  milk  diet.  Small  doses  of  calomel  to  stimulate  the  ]ie])atic 
function  are  of  value.  Similarly  i)il()carpine  has  been  tried  with  tlie  idea  of 
increasing  the  flow  of  the  pancreatic  secretion.  Judicious  use  of  the  digestive 
ferments  should  be  made.  These  patients  should  be  advised  to  keep  to  their  beds 
during  the  morning  hours.  In  persistent  cases  it  may  become  necessary  to  send 
the  patients  down  to,  or  near,  the  sea  level. 


MALTA  FEVER. 

Definition. — Malta  fever,  or,  as  it  is  sometimes  called,  "undulant  fever,"  is  a 
disease  which  is  comparatively  common  in  the  island  of  Malta.  The  maladj' 
occurs  not  only  in  Malta,  but  along  the  shores  of  the  Mediterranean  Sea,  and  so 
is  sometimes  called  "Mediterranean  Fever."  When  it  occurs  at  Gibraltar  it  is 
called  "  Gibraltar  Fever"  or  "Rock  Fever,"  and  when  in  Italy,  "Neapolitan  Fever." 
It  is  endemic  in  Texas  all  through  the  goat-raising  districts  and  is  probably  often 
thought  to  be  typhoid  fever.  The  malady  is  due  to  an  infection  by  the  Micro- 
coccus melitensis.  Its  chief  clinical  characteristic  is  wa\'e-like  or  undulant  curves 
of  febrile  movement.  There  are  also  recurring  exacerbations  of  (eveT  with  profuse 
sweats,  pains  in  the  limbs,  swelling  of  the  joints,  and  enlargement  of  the  spleen. 

History  and  Geographical  Distribution. — Although  the  first  accurate  account 
of  this  disease  was  published  in  1861  by  J.  A.  Marston,  who  described  it  under 
the  name  of  Mediterranean,  remittent,  or  gastric  remittent  fever,  it  probably 
has  been  endemic  in  the  islands  and  along  the  shores  of  the  Mediterranean  Sea 
for  centuries.  Hippocrates  described  cases  of  continued  remittent  fever  which 
in  their  entire  symptom-complex  correspond  with  certain  manifestations  of  undulant 
fever,  and  references  to  a  protracted  form  of  fever  prevailing  in  Mediterranean 
countries  were  made  by  writers  of  the  eighteenth  century  and  by  Sir  William 
Burnett  and  Dr.  Hennon  early  in  the  nineteenth  century.  While  the  disease 
is  most  common  at  Malta,  Gibraltar,  in  the  Balearic  Islands,  in  Cyprus,  in  Crete, 
and  along  the  southern  coast  of  Italy,  evidence  is  constantly  being  produced  to 
show  that  it  has  a  wide  distribution  throughout  tropical  and  subtropical  regions. 
Cases  of  undoubted  authenticity  have  been  reported  from  China,  India,  Porto  Rico, 
and  the  Philippine  Islands,  and  a  fever  occurring  in  Venezuela  closely  resembles 
it  clinically,  although  no  cases  in  which  the  specific  organism  has  been  obtained 
in  that  country  are  on  record.  Investigations  have  revealed  its  presence  in  the 
United  States. 

To  Great  Britain  the  disease  is  of  great  importance  because  it  incapacitates 
so  many  of  the  troops  sent  to  garrison  the  Island  of  Malta.  Thus  from  1898  to 
1904  no  less  than  2229  cases  occurred  and  resulted  in  75,000  days'  sickness  per 
annum,  for  each  case  lasts  about  120  days. 

Etiology. — The  pathogenic  organism  of  Malta  fever  is  the  Micrococcus  melitensis, 
which  was  discovered  in  1887  by  David  Bruce,  who  isolated  it  in  pure  culture  from 
the  spleens  of  nine  patients  who  died,  and  found  it  in  two  instances  in  blood  drawn 
from  the  spleen  during  life.  This  microbe  is  a  minute,  round  or  oval  coccus, 
staining  readily  with  the  aniline  dyes,  but  not  by  Gram's  method.  It  grows  very 
slowly  in  bouillon,  agar-agar,  and  gelatin,  and  agglutinates  when  placed  in  blood 
serum  drawn  from  individuals  affected  with  the  disease.  A  joint  commission, 
appointed  by  the  British  Government,  has  proved  it  possesses  great  vitality,  for 
the  organism  was  found  alive  after  sixty-nine  days  in  dried,  sterilized  manured 
soil,  after  eighty  days  on  dried  fabrics,  after  seventy-two  days  in  damp  soil,  and 
after  thirty-seven  days  in  sterilized  water.  When  injected  into  monkeys  it  produces 
a  malady  similar  to  Malta  fever,  and  its  specific  action  in  the  human  subject  has 
been  demonstrated  by  several  cases  of  accidental  inoculation.     Monkeys  have 


216  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

been  infected  at  tlic  will  of  an  experimenter,  when  forecd  to  breathe  an  atmosphere 
laden  with  dust  containinfr  the  specific  organism. 

A  commission  was  aj^itointed  by  the  British  Admiralty  to  investigate  this  dis- 
ease the  report  of  which  pubhslied  by  the  Royal  Society  in  April,  1907,  showed 
that  the  specific  micrococcus  escapes  by  the  urine  and  the  milk,  l)ut  that  the  breath, 
saliva,  sweat  and  probably  the  feces  do  not  contain  it.  As  goats  are  very  prone  to 
the  disease  the  milk  of  this  animal  is  a  frequent  cause  of  its  spread.  Since  the  use 
of  goats'  milk  has  been  stopped  in  the  British  Army  and  Navy  the  disease  has  been 
almost  eradicated.  The  Commission  also  sliowed  that  the  infection  may  l)e  con- 
veyed by  flies  and  suggested  that  infected  women  may  transfer  the  disease  in  coitus. 

Malta  fever  is  a  disease  of  summer,  being  most  prevalent  in  June  and  July. 
Persons  of  all  ages  are  subject  to  it,  although  the  period  of  its  greatest  incidence 
is  said  by  Maltese  physicians  to  be  between  the  sixth  and  the  thirtieth  years. 
Sex  appears  to  be  without  influence  in  its  causation.  One  attack  appears  to  confer 
immunity,  at  least  for  a  number  of  years. 

Pathology. — ^The  gross  morbid  changes  observed  after  death  \ary  somewhat 
according  to  the  stage  of  the  disease  in  which  death  occurs.  In  those  cases  which 
die  during  the  first  four  weeks  of  the  attack,  the  spleen  is  inA'ariably  congested 
and  enlarged  and  often  is  so  soft  that  it  resembles  a  large  mass  of  clotted  blood. 
The  meninges,  the  liver,  the  stomach  and  intestines,  and  the  kidneys  are  also 
frequently  congested,  and  the  lungs  are  always  congested  at  their  bases,  while  in 
some  cases  lobular  consolidation  takes  place.  The  heart  occasionally  shows  granu- 
lar or  fatty  degeneration  and  in  a  few  instances  pericardial  effusion  occurs.  In 
cases  which  die  late  in  the  disease  there  is  evidence  of  a  prolonged  toxic  action 
upon  the  tissues.  The  liver  and  spleen  are  larger  than  normal  and  of  firm  consist- 
encj^  due  to  the  formation  of  fibrous  tissue,  and  the  heart  is  usually  pale,  its  walls 
are  thin  and  its  cavities  dilated.  The  spleen  is  the  only  organ  which  shows  charac- 
teristic microscopic  changes,  namely,  an  increase  in  lymphoid  tissue  and  the  jiresence 
of  large  numbers  of  the  specific  micro-organism.  Sections  of  the  liver  and  kidneys 
show  granular  or  fatty  degeneration.  As  to  blood  changes  there  is  a  reduction 
in  the  number  of  red  cells,  alterations  in  their  size  and  shape,  and  a  tleficieney  of 
heriioglobin.  The  white  cells  are  often  relatively  increased,  the  basophiles  being  in 
excess. 

The  incubation  period  is  from  three  to  tw-enty  days,  most  commonly  fifteen. 

Symptoms. — The  onset  of  the  typical  or  undulant  form  of  the  disease  is  gradual, 
and  is  attended  by  lassitude,  anorexia,  nausea,  headache,  insomnia,  and  slight  evening 
elevation  of  femjjerature.  As  the  morbific  process  advances  the  digesti\-e  and  nervous 
symptoms  become  intensified,  and  the  temperature  rises  slowly  day  by  day, 
remitting  somewhat  each  morning,  until  it  reaches  a  level  varying  from  103°  to  105°. 
Here  it  is  maintained  for  a  varying  period  of  time,  and  then  falls  slowly  with  pro- 
fuse sweating.  The  other  symptoms  abate  simultaneously.  Soon,  howe\er,  the 
temperatvre  rises  again  and  a  condition  similar  to  the  one  just  described  supervenes, 
constituting  a  relapse,  of  which  several  occur.  The  most  noteworthy  s.Miiiitom  of 
Malta  fever  is  therefore  the  persistent  recurrence  of  febrile  movements  which  are 
^\•ave-like  in  character,  and  which  last  from  scAcn  to  twenty-one  da\"S.  They  are 
followed  by  a  period  of  apyrexia  or  of  ^■ery  moderate  fe^"er,  which  lasts  for  a  few 
days,  when  the  febrile  mo\ement  returns  as  before.  In  this  manner  the  disease 
may  persist  for  months,  not  being  self-limited,  as  is  the  course  of  typhoid  fever. 
The  active  fever,  the  profuse  sweats,  and  the  pain  continuing  for  so  long  a  period 
produce  great  exhaustion  and  emaciation.  Sometimes  cardiac  or  pulmonary 
complications  arise  which  determine  a  fatal  issue  of  the  malady. 

In  the  majority  of  cases  of  this  type,  however,  convalescence  ensues,  but  it 
is  slow  and  often  attentled  by  neuralgic  and  rhemnatoid  symptoms,  and  occasionally 
by  orchitis. 


MALTA   FEVER 


217 


!>■ 


Variations  from  the  typical  form  of  the  disease  are  not 
at  ail  uncommon.  Some  cases  are  characterized  by  rapid 
onset  and  tlie  early  development  of  severe  constitutional 
symptoms,  which  usually  end  in  death,  while  other  cases 
run  an  extremely  mild  course  with  little  constitutional 
disturbance  other  than  general  malaise  and  slow  but 
progressive  anemia  and  emaciation.  In  this  form  the 
temperature  is  often  intermittent,  rising  several  degrees 
each  afternoon  and  falling  to  normal  or  nearly  normal 
the  next  morning. 

Diagnosis. — Accurate  diagnosis  of  Malta  fever  depends 
upon  the  agglutinative  serum  test  between  the  blood  and 
the  micrococcus,  which  should  be  made  whenever  possible. 
This  reaction  is  almost  always  obtainable  by  the  sixth 
day  after  the  development  of  pyrexia  and  often  as  early 
as  the  fourth.  F.  J.  A.  Dalton,  of  the  British  navy,  finds 
that  trustworthy  results  are  obtained  by  the  use  of  a 
dilution  of  1 :  50,  with  a  time  limit  of  half  an  hour. 

Clinically,  the  diagnosis  presents  many  difficulties,  for 
the  different  manifestations  of  the  disease  make  it  par- 
ticularly liable  to  be  confounded  with  a  variety  of  aifec- 
tions,  such  as  typhoid  fever,  tuberculosis,  chronic  rheu- 
matism, malaria,  and  malarial  cachexia.  Suspicion  as  to 
the  nature  of  typical  cases  should  be  aroused  by  the 
presence  of  an  undulating  temperature  curve  and  the 
characteristic  frequent  relapses.  Additional  aids  to  the 
differential  diagnosis  may  be  named  as  follows: 

From  malarial  fever  we  can  separate  Malta  fever  by 
several  factors  which  make  difl'erentiation  possible.  In 
the  first  place  the  absence  of  the  plasmodium  of  malaria  in 
the  blood,  and  the  presence  of  the  Micrococcus  melitensis 
in  the  spleen  on  puncture  is  of  course  a  definite  means  of 
separation.  Again,  the  fever  does  not  yield  to  quinine 
as  does  that  of  malaria,  and  the  pyrexia  is  too  persistent 
for  the  intermittent  type  of  that  disease,  although  at 
times  the  waves  of  fever  may  be  abrupt  enough  to  re- 
semble it.  Again,  the  marked  arthritic  symptoms  and 
the  neuralgic  pains  are  not  met  with  in  malarial  infection. 

The  possibility  of  tuberculosis  must  be  also  considered. 
Careful  physical  examination  of  the  thorax  and  abdomen 
will  usually  reveal  signs  of  tuberculosis  if  it  be  present, 
and  if  need  be  the  tuberculin  test  can  be  applied.  Typhoid 
fever  presents  a  temperature  range  after  the  first  few 
days  which  does  not  resemble  that  of  Malta  fever,  and 
the  absence  of  rose  spots  in  Malta  fever  is  also  an  impor- 
tant differential  point.  The  presence  of  the  Widal  test 
will  also  aid  in  the  differentiation. 

Duration  and  Prognosis. — ^The  average  duration  is  from 
seventy  to  ninety  days,  although  some  cases  last  as  long 
as  six  months.  Prognosis  as  regards  life  is  favorable,  the 
mortality  being  about  2  per  cent.  From  the  evidence  thus 
far  accumulated  it  seems  that  the  serum  test  may  afford 

prognostic  as  well  as  diagnostic  information,  for  it  has    J^JZTZt^  tit 
been  observed  that  those  cases  in  which  the  agglutinatmg    fever.    (Hughes.) 


t^^ 


218 


DISEASES  DUE  TO  A  SPECIFIC  IXFECTIOX 


power  of  the  blood  serum  is  lii<;li  diirini;  the  early  stages  of  the  fever  run  a  favorable 
course,  while  those  in  which  the  agf^lutinius  remain  low  rluring  the  entire  course 
of  the  fever  are  subject  to  many  relapses  and  a  ijrotnuted  convalescence.  A 
continuous  rise  with  improving  clinical  symptoms  iiidiiiitis  approacliing  convales- 
cence  fHassctt-Smith). 

Complications. — The  principal  complications  are  hyperpyrexia,  cardiac  failure, 
and  pulmonary  congestion.  Pleural  and  pericardial  effusions  sometimes  occur, 
and  persistent  vomiting  has  been  observed  by  Hughes,  who  regards  it  as  a  very 
dangerous  complication. 

Fig.  47 


Temperature  chart  in  the  intermittent  form  of  Malta  fev 


(Hughes.) 


Treatment. — Malta  fever  has  to  be  treated  solely  on  the  expectant  method,  for 
tiicre  are  no  specific  remedies.  The  diet  should  be  nutritious  and  supporting. 
Dalton,  of  the  English  navy,  deprecates  the  practice  of  keeping  ^Nlalta  fever  patients 
on  liquid  food.  All  his  patients  who  do  not  have  an  evening  temperature  higher 
than  103°  are  put  on  solid  food,  such  as  eggs,  bread,  and  rice,  and  in  addition 
receive  two  or  three  pints  of  milk  a  day.  If  this  diet  is  well  borne,  it  is  supplemented 
in  the  course  of  a  few  days  by  fish  or  meat.  In  severe  cases  with  high  temperature, 
foul  tongue,  and  diarrhea,  nothing  but  liquid  diet  is  given.  Dalton  also  believes 
that  patients  whose  temperature  keeps  below  102°  are  benefited  by  being  allowed 
to  sit  up  part  of  the  time,  it  being  necessary,  of  course,  to  have  them  avoid  exertion 
and  not  remain  up  too  long.  The  bowels  should  be  carefully  regulated.  Cold 
spongings  with  friction  should  be  used  to  reduce  fever  and  the  kidneys  be  kept 
active  by  mild  diuretics.  When  the  patient  is  strong  enough  to  travel,  he  is  greatly 
benefited  by  change  of  climate.  During  the  early  stages  of  con\-alescence  he 
should  receive  inunctions  of  oils  and  cocoa-butter,  get  plenty  of  fresh  air  and  sun- 
shine, and  receive  aids  to  digestion,  witli  iron  to  overcome  his  anemia,  wiiicli  is 
alwavs  marked. 


PHLEBOTOMOUS  FEVER. 

Phlebotomous  Fever,  sometimes  called  "Pym's  Fever"  or  "three  day  fever" 
is  met  with  in  countries  bordering  on  the  ^Mediterranean,  in  the  Sudan  and  in  the 
Far  East.  It  has  been  particularly  frequent  in  the  English  troops  in  ]\Ialta,  and 
in  Dalmatia  and  Herzigovina  in  warmer  months  of  the  year.  One  attJick  confers 
innnunity,  although  the  disease  rarely  lasts  over  3  or  4  days.  The  infection  is 
produceii  by  the  bite  of  a  sand  fly,  the  Phlebotomous  papatasil  which  feeds  on  blood. 
This  fly  becomes  infective  seven  to  ten  days  after  biting  an  individual  suffering 
from  the  malady.  The  period  of  incubation  is  four  to  seven  days.  The  virus 
passes  through  a  Pasteur-Chamberland  filter.  Mosquito  nets  do  not  protect 
as  their  mesh  will  not  obstruct  so  small  a  fly.  The  symptoms  consist  in  headache, 
malaise,  backache,  flushing  of  the  face,  a  foul  tongue,  infected  conjunctiva  and 
marked    con.stipation.     Recovery    practically    always    occurs,    the    temperature 


ANTHRAX  219 

reaching  normal  by  the  third  day,  although  in  severe  attacks  the  patient  may  feel 
weak  and  miserable  for  several  days  after  the  fe\'er  ceases. 
Treatment. — The  treatment  is  purely  symptomatic. 

ANTHRAX. 

Definition. — Anthrax  is  an  infectious  disease  due  to  the  presence  of  the  BucUhis 
aiifhracis.  It  is  much  more  common  in  Europe  and  in  South  America  than  in  the 
United  States  and  England,  and  affects  animals  far  more  frequently  than  man. 
While  it  is  possible  for  one  man  to  convey  it  to  another  by  contact,  the  infection 
in  the  great  majority  of  instances  takes  place  directly  from  one  of  the  lower  animals. 
Among  animals  it  is  met  with  most  frequently  among  herbivora,  next  among  omni- 
vora,  and  least  frequently  among  carnivora.  Anthrax  is  sometimes  called  malignant 
pustule,  splenic  fever,  charbon,  and  carbuncle.  The  first  synonym  is  unfortunate, 
for  in  many  cases  no  pustule  is  found ;  the  second  synonym  is  incorrect,  as  in  man 
the  spleen  is  not  particularly  affected,  and  the  last  is  equally  erroneous,  as  it  is 
an  entirely  different  state  from  ordinary  carbuncle  due  to  the  staphylococcus. 

History. — ^Anthrax  as  it  occurs  in  man  has  been  recognized  for  o\'er  2000  years, 
and  as  long  ago  as  the  time  of  the  Romans  it  was  treated  by  the  cautery.  During 
the  seventeenth  and  eighteenth  centuries  it  was  very  prevalent.  Barthelemy 
proved  in  1823  that  animals  could  be  inoculated  with  it.  In  1850  Heusinger 
published  an  accurate  exhaustive  account  of  the  disease.  The  bacillus  was  observed 
in  the  blood  by  Pollender  in  1849  and  its  relation  to  the  disease  was  more  fully 
worked  out  by  Davaine  in  1863.  Since  then  this  discoAcry  has  been  confirmed 
by  manj'  observers,  the  chief  of  whom  are  Pasteur  and  Koch. 

Etiology. — As  already  stated,  anthrax  is  due  to  the  entrance  into  the  body  of 
the  anthrax  bacillus.  It  usually  occurs  as  a  result  of  handling  some  part  of  an 
animal  which  has  suffered  from  this  malady.  Of  Legge's  211  cases  72  were  in 
workers  in  wool  and  65  were  handlers  of  hides.  The  infection  takes  place  through 
some  break  in  the  skin,  as  a  rule,  and  in  the  great  majority  of  cases  the  site  of 
inoculation  is  the  hand  or  forearm,  but  it  may  appear  on  the  face  and  chest.  In 
Legge's  series  infection  occurred  in  the  neck  in  84  cases,  in  the  face  and  head  in  77, 
forearm  16,  and  in  but  1  case  was  the  finger  thought  to  be  the  point  of  infection. 
Sometimes  more  than  one  point  of  infection  is  present;  but  it  occasionally  happens 
that  no  external  lesion  is  to  be  found,  although  general  systemic  infection  is  mani- 
fest. In  such  instances  the  bacillus  gains  access  to  the  body  by  being  inhaled 
in  dust,  or  by  being  swallowed  in  milk  or  other  food.  Rarely  infection  of  an  external 
wound  takes  place  by  the  transference  of  the  bacillus  by  flies  from  an  infected 
animal  to  the  break  in  the  skin  of  man  or  animal. 

Prevention. — The  disease  can  be  prevented  in  man  by  forbidding  workmen  to 
handle  raw  hides  or  infected  animals  if  they  have  any  superficial  wounds,  by  the 
use  of  respirators  designed  to  prevent  the  inhalation  of  dust  laden  with  the  bacillus 
of  the  disease,  and  by  the  disinfection  of  w'ool,  hair,  rags,  and  other  articles  of 
commerce  w-hjch  may  convey  the  infection. 

All  animals  suffering  from  anthrax  should  be  killed  and  then  destroyed  by  burning. 
Mere  burial  is  insufficient,  for  it  is  claimed  that  earth-worms  are  capable  of  carrying 
the  bacilli  to  the  surface  and  so  causing  the  reinfection  of  healthy  animals.  When 
incineration  is  impossible  burial  in  quicklime  may  be  resorted  to.  It  is  needless 
to  add  that  the  utmost  care  must  be  exercised  by  physicians  and  nurses  in  dressing 
cases  of  this  disease  when  it  occurs  in  man. 

Frequency. — In  the  United  States  anthrax  is  not  a  very  common  disease,  even 
among  sheep  and  cattle,  and  is  rarely  met  with  in  man.  Inquiry  among  employers 
of  men  who  handle  raw  hides  in  Philadelphia  develops  the  fact  that  it  is  very  seldom 
met  with,  and  when  it  occurs  is  nearly  always  the  result  of  handling  imported  hides. 


220  DISEASES  DUE  TO  A  SPECIFIC  IXFECTIOX 

Pathology  and  Morbid  Anatomy. — The  changes  in  the  skin  i)ro{hice(l  hy  primary 
external  aiitlirax  will  he  dcserihed  hiter  under  the  liead  of  Symptoms.  Wiien 
systemic  infection  occurs  as  the  result  of  cither  external  or  internal  jirimary  inocula- 
tions, very  marked  lesions  of  the  viscera  become  apjjarent.  The  bronchial  f;lands 
are  generally  swollen,  and  their  increase  in  size  may  be  quite  remarkable.  The 
pericardium  may  be  dotted  by  petechial  spots,  and  its  cavity  may  contain  a  consid- 
erable quantity  of  gelatinous  material.  The  muscles,  including  the  heart,  are 
dark  colored,  soft,  and  flabby.  The  blood  is  fluid  and  dark  in  hue — sometimes 
almost  black.  Clots  may  be  found  in  the  pericardial  space.  Clear,  straw-colored 
fluid  may  be  present  in  the  pleural  cavity,  anrl  if  the  lungs  are  afl'ected  they  are 
found  engorged  with  dark-colored  blood,  the  right  lung  being  more  afl'ected  than 
the  left  as  a  rule;  the  posterior  portion  is  most  congested  and  edematous,  particnlarlv' 
at  the  bases.     Sometimes  pulmonary  infarctions  are  present. 

In  the  abdominal  cavity  numerous  extravasations  of  the  blood  may  be  found  in 
the  mesentery.  Petechial  hemorrhages  may  be  present  in  the  stomach  and  intes- 
tines. The  spleen  is  usually  enlarged  and  contains  a  large  amount  of  grumous 
blood.  Microscopic  examination  of  the  tissues  of  the  body,  when  general  infection 
is  present,  discloses  the  bacillus  usually  in  large  numbers.  They  are  particularly 
numerous  in  the  small  blood\essels  and  lymph  glands  which  are  near  the  site  of 
the  primary  lesion. 

Symptoms. — Anthrax  occurs  in  two  forms,  the  external  and  internal.  The 
external  manifests  itself  by  the  development  at  the  point  of  infection,  about  three 
to  six  days  after  contact  with  the  source  of  the  disease,  of  a  small,  itching  yaintle, 
which  is  soon  surrounded  by  an  inflamed  area.  Usually  this  lesion  is  so  insignificant 
that  no  attention  is  paid  to  it  save  the  scratching  or  rubbing  of  it.  There  may  be  a 
history  of  an  abrasion,  scratch,  or  pimple  through  which  infection  has  occurred. 
The  papule  speedily  becomes  red  and  angry-looking,  and  at  its  simimit  a  reside 
develops  which  is  filled  with  bloody  .serum.  Around  this  centre  of  infection,  on 
the  reddened  and  edematous  zone  or  base,  additional  papules  and  vesicles  appear 
and  the  inflammatory  process  spreads  rapidly  in  all  directions.  The  vesicles  may 
become  dry  and  crusty,  and  as  they  do  so  the  tissues  underneath  undergo  softening, 
the  central  part  becoming  black  and  necrotic.  Curiously  enough,  this  rapid 
process  rarely  causes  much  pain,  but  the  neighboring  li/inphati';  vessels  become 
reddened  and  the  nodes  enlarged.  By  the  end  of  forty-eight  hours  after  the  papule 
first  appears  the  anthrax  bacilli  may  be  found  in  the  blood,  and  in  such  a  case  the 
symptoms  of  systemic  disturbance  rapidly  become  very  marked. 

The  local  lesion  rapidly  spreads  up  the  arm  if  the  hand  be  the  part  first  attacked, 
and  the  part  becomes  intensely  sirollen  and  livid,  the  skin  being  dotted  by  blebs, 
but  it  is  a  noteworthy  fact  that  the  rapid  spread  of  the  surrounding  inflammation 
is  due  largely  to  secondary  infection  by  other  organisms.  In  cases  of  pure  anthrax 
infection  the  central  papule  is  often  surrounded  by  an  area  of  induration,  but  no 
red  areola  even  after  the  slough  has  formed.  There  is  general  wretchedness  and 
rapidly  increasing  debility,  followed  by  rigors,  high  fever,  sireafs.  and  diarrhea, 
but  after  the  early  stages  the  fever  falls  and  the  temperature  may  be  normal. 
Deliriimi  rapidly  ensues,  and  dyspnea  and  cyanosis,  with  jjrofound  evidences  of 
septic  infection,  close  the  scene  in  death.  In  some  cases,  however,  the  mind 
remains  perfectly  clear. 

When  recovery  takes  place  the  local  area  is  walled  off  by  ])rotective  efl'orts  on 
the  part  of  the  body,  so  that  severe  constitutional  symptoms  do  not  appear.  The 
diseased  tissues  at  the  focus  of  infection  undergo  necrosis,  are  thrown  off,  and 
healing  is  finally  accomplished. 

A  second  form  of  external  anthrax  infection  is  that  which,  liccause  of  its  course, 
is  called  malignant  anthrax  edema.  This  usually  develops  on  the  face  or  head  and 
differs  from  the  type  just  described  in  that  no  papule  or  similar  local  lesion  is 


ANTHRAX  221 

present,  but  in  its  stead  an  intense  edema  of  the  tissues  is  produced.  So  active 
may  be  the  local  process  that  the  parts  may  speedily  slough  or  become  gangrenous. 
Death  usually  comes  rapidly  to  such  cases. 

The  internal  form  of  anthrax  manifests  itself  in  the  lungs  or  alimentary  tract. 
In  the  first  instance  the  anthrax  bacilli  enter  the  respiratory  passages  by  inhalation 
in  the  dust  arising  from  the  handling  of  dried  hides  or  wool.  Hence  it  is  called 
"wool-sorters'  disease."  The  sjTnptoms  in  these  cases  vary  to  an  extraordinary 
degree  in  their  severity.  In  some  instances  the  patient  feels  wretched  and  miser- 
able, and  soon  has  a  chill  which  is  followed  by  fever  and  very  marked  thoracic  distress. 
There  may  be  pain  in  the  side  and  labored,  difficult  breathing.  Cough  may  or 
may  not  be  present.  The  face  becomes  li^dd,  marked  cyanosis  de\'elops,  and  the 
patient  dies  in  a  few  hours  or  days  in  asthenia  and  collapse.  Pneumonia  is  rare, 
but  areas  of  impaired  resonance  on  percussion  and  bronchial  breathing  may  be 
found  as  the  result  of  enlargement  of,  and  pressure  by,  the  bronchial  and  mediastinal 
glands.  In  other  cases  the  symptoms  are  so  mild  and  indefinite  as  to  possess  no 
diagnostic  \-alue.  A  workman  may  feel  only  weak  and  feeble,  his  hands  may  be 
cold,  and  his  breathing  oppressed,  yet  he  may  die  within  twenty-four  hours  in 
collapse.  Bell  records  several  cases  in  -n-hich  death  came  within  twenty-four 
hours  of  what  seemed  to  be  perfect  health. 

When  the  intestinal  tract  is  infected,  there  are  present  diarrhea,  vomiting,  great 
weakness,  and  failure  of  the  circulation,  followed  by  collapse  and  death  in  from  two 
to  five  days. 

Diagnosis. — In  the  external  form  of  the  disease  the  occupation  of  the  patient 
and  the  presence  of  an  itching  papule  should  at  once  arouse  the  suspicion  of  anthrax 
infection,  which  will  be  strengthened  by  the  rapid  formation  of  the  vesicle  already 
described.  The  diagnosis  can  be  confirmed  by  a  microscope  examination  of  the 
fluid  for  the  bacillus,  or  by  inoculating  a  mouse  with  one  drop  of  the  fluid  from  a 
vesicle.  This  will  cause  the  death  of  the  mouse  in  about  forty-eight  hours,  and 
in  its  organs  the  bacillus  will  be  found  in  immense  numbers,  and  from  these  cultures 
may  be  made. 

This  condition  is  separated  from  carbuncle  by  the  lack  of  pus  and  by  the  absence 
of  its  sloughing  core.  From  erysipelas  of  the  phlegmonous  type,  or  from  dift'use 
cellulitis,  it  is  separated  in  the  later  stages  by  the  absence  of  pain  and  fever.  From 
malignant  edema  it  is  distinguished  by  the  absence  of  crepitation  due  to  gas  in 
the  tissues.  Agglutination  tests  based  on  the  same  principle  as  the  Widal  test 
in  typhoid  fever  have  not  been  generally  adopted. 

Prognosis. — The  prognosis  of  the  external  form  depends  upon  the  degree  of 
general  systemic  infection,  and  therefore  the  size  of  the  local  lesion  has  not  any 
great  importance  in  determining  the  outlook.  It  not  rarely  hapi^ens  that  a  small 
papule  may  be  followed  by  the  death  of  the  patient  in  a  few  days,  whereas  a  larger 
lesion  may  be  recovered  from.  Thus,  Bell  states  that  a  patient  M'ith  so  severe  a 
lesion  on  the  face  as  to  have  large  bullae  and  a  free  discharge  of  straw-colored 
fluid,  with  swelling  of  the  entire  head  and  the  submaxillary  glands,  may  recover. 
In  other  words,  everything  depends  upon  the  degree  of  systemic  infection.  A 
rapid-running  pulse  is  always  an  evil  omen. 

Death  may  come  as  early  as  the  first  day  of  illness,  but  the  majority  of  deaths 
occur  on  the  fourth  to  seventh  day.  So  far  as  mortality  is  concerned  statistics 
vary  very  greatly,  probably  because  of  variations  in  the  virulence  of  the  infection. 
Thus,  Woolmer  states  that  out  of  50  cases  he  lost  only  2,  and  IMuskett  treated  50 
cases  with  one  death;  whereas  in  England,  even  when  the  workmen  ha^^e  been 
taught  to  present  themselves  for  treatment  at  once,  the  mortality  has  been  21 
per  cent.,  and  in  some  collections  of  statistics  it  has  reached  50  per  cent.  In 
Eppinger's  epidemic  among  rag-pickers  78  out  of  88  cases  were  fatal. 

In  the  internal  form  the  prognosis  is  bad  and  death  often  comes,  as  already 


222  DISEASES  DUE  TO  A  SPECIFIC  IXFECTIOM 

stated,  as  early  as  twenty-four  hours  after  the  primary  syni])t()ins.  Cases  in 
which  recovery  has  taken  place  are,  however,  on  record. 

Treatment. — ^The  treatment  of  the  external  form  consists  in  the  destruction  hy 
actual  cautery  of  the  primary  focus  of  the  disease  at  the  earliest  possil)Ie  moment. 
If  this  is  not  done  it  should  be  excised.  Not  only  should  the  infected  tissues  be 
removed,  but  the  surrounding  tissues  for  at  least  an  inch  as  well.  As  soon  as  this 
is  done  the  part  is  to  be  swabbed  with  pure  carbolic  acid  and  then  flrcssed,  so  that 
drainage  into  the  dressings  may  occur.  The  ])atient's  \itality  sliould  be  main- 
tained by  good  food  and  stimulants,  and  anthrax  antitoxin  should  be  given. 

Within  the  last  few  years  an  anti-anthrax  serum  has  been  employed  with  success. 
Legge  states  the  following  facts  as  to  its  use:  (1)  In  very  large  doses  it  is  innocuous; 
(2)  it  can  be  well  borne  even  when  introduced  into  the  veins;  (3)  no  ease  taken  in 
an  early  stage,  or  of  moderate  severity,  is  fatal  if  treated  with  serum;  (4)  with  the 
serum  some  cases  are  sa\'ed  when  the  condition  is  most  critical  and  prognosis 
almost  hopeless;  (5)  when  injected  into  the  veins  the  serum  cjuickly  arrests  the 
extension  of  the  edematous  process  so  as  to  reduce  notably  the  danger  from  suffo- 
cation which  exists  in  many  of  the  cases  where  the  pustule  is  situated  on  the  face  or 
neck;  (G)  the  serum,  if  used  early  enough,  reduces  to  a  minimimi  tlie  destruction 
of  tissue;  (7)  in  some  situations  of  the  pustule,  as  the  eyelid,  serum  must  be  used 
in  preference  to  any  other  treatment;  (8)  persons  attacked,  when  treated  with 
the  serum,  appear  to  become  con\alescent  in  the  course  of  a  few  hours;  to  these 
I  may  add  (9)  that  in  internal  anthrax  if  it  is  administered  intravenously  it  is 
the  only  treatment  which  can  hold  out  any  hope. 

In  almost  all  cases  injection  of  the  serum  is  followed  by  a  rise  in  temperature 
often  to  over  10,5°,  and  with  this  there  is  an  improvement  in  the  general  condition 
of  the  patient.  The  prognosis  where  there  is  this  rise  Sclavo  regards  as  favorable. 
In  the  same  way  the  necrotic  process  itself  is  to  be  regarded  as  a  sign  that  the 
organism  is  making  effort  to  resist  the  antlirax  infection. 

HYDROPHOBIA. 

Definition. — Hydrophobia  is  an  acute  infectious  disease  of  animals  comn\uni- 
cablc  to  man,  the  specific  cause  of  which  has  not  as  yet  been  isolated,  but  which  is 
without  doubt  a  micro-organism.  It  is  characterized  by  great  restlessness  and  delir- 
ium, by  an  apparent  dread  of  water  in  some  instances,  and  by  delirium  and  para- 
lysis in  its  later  stages.    It  is  often  called  "rabies"  or  "lys.m." 

History. — Hydrophobia  was  well  described  as  long  ago  as  nearly  500  B.C.  by 
Democritus,  but  not  uiftil  about  200  years  B.C.  was  it  described  in  man.  Since 
then  it  has  been  discussed  by  many  ancient  and  modern  writers,  of  whom  Griiner, 
in  1S13,  found  that  the  saliva  was  the  vehicle  of  infection. 

Trousseau  wrote  its  best  description  in  modern  times  in  1850.  In  1882  Pasteur 
first  clearly  discussed  the  cause  of  the  disease  and  dcxised  a  plan  of  rational 
treatment. 

Distribution. — No  less  an  authority  than  Vircliow  belic\ed  that  h>(lr(ipliobia 
was  not  to  be  met  with  in  Greenland,  Denmark,  Africa,  and  jiarts  of  Asia  and 
South  America,  and  with  others  claimed  that  it  is  ])eculiar  to  temperate  zones, 
but  in  ISfiO  an  epidemic  occurred  in  Greenland  among  animals  when  the  tempera- 
ture was  25°  lielow  zero.  Boulangcr  is  probably  correct  in  stating  that  no  part 
of  the  world  is  free  from  it.  The  idea  that  it  is  more  prevalent  in  summer  than  in 
winter  is  erroneous.  Suzor  has  reported  twice  as  many  cases  in  animals  in  March, 
April,  and  May  as  in  the  summer  months.  Two-fifths  of  all  cases  in  human  beings 
are  imder  fifteen  years  of  age.  The  disease  aft'ects  dogs,  skunks,  foxes,  and  wolves 
more  commonly  than  other  animals,  but  all  animals  are  apparently  susceptible  to 
it.    Cows  may  de\elop  it  from  dog-bites  or  from  bites  of  other  infected  cows,  and 


HYDROPHOBIA  223 

in  1888  I  saw  a  number  of  deer  from  the  royal  herd  in  Richmond  Parle,  near 
London,  which  suffered  from  this  disease  and  which  were  studied  at  the  Brown 
Institution. 

Etiology. — As  already  stated,  the  cause  of  this  disease  has  not  been  determined 
with  certainty,  although  recently  Negri  claims  to  have  established  that  it  is  due 
to  a  protozoal  organism.  These  are  known  as  Negri  bodies.  They  are  round  or 
oval  in  shape,  10  to  25  microns  in  diameter,  and  are  almost  always  intracellular. 
They  are  found  especially  in  the  pyramidal  cells  of  Amnion's  horn  but  also  occur 
in  the  cerebellum  and  the  large  cells  of  the  cerebrum.  Watson  pictures  sexual  and 
asexual  phases  of  these  bodies  and  places  them,  as  protozoal  parasites,  in  the  sub- 
order of  cryptocysts  of  the  sporozoa.  Some  observers  believe  these  bodies  are 
reaction  products  of  cells  and  contain  the  real  cause  of  the  disease  either  in  the 
shape  of  the  chromatin  portion  or  as  structures  yet  undemonstrated.  Filtration 
studies  lend  some  weight  to  the  view  that  the  virus  may  be  idtramicroscopic. 
It  is  known  that  its  cause  has  a  special  affinity  for  the  nervous  system,  and  is 
found  in  the  saliva,  but  not  in  the  urine  or  tlie  blood.  The  disease  can  be  passed 
from  animal  to  animal,  from  an  animal  to  man,  and  from  man  to  an  animal,  and 
it  can  be  passed  on  from  one  to  another  without  rapidly  losing  its  virulence.  The 
transfer  is  always  made  through  some  solution  of  continuity,  usually  a  bite,  but  it 
has  occurred  through  a  pimple.  The  milk  of  animals  suffering  from  rabies  is 
capable  when  inoculated  into  the  tissues  of  healthy  ones  of  inducing  the  disease 
but  not  when  taken  as  a  food. 

In  the  dog  it  has  been  proved  that  the  saliva  may  be  virulent  as  long  as  three 
days  before  anj'  symptoms  of  the  disease  appear. 

The  incubation  period  varies  greatly,  from  a  week  to  several  months.  In  man 
it  is  from  fifteen  to  sixty  days,  but  cases  are  on  record  in  which  it  has  developed 
after  a  j'ear  has  elapsed,  probably  because  the  virus  has  been  temporarily  encap- 
sulated. A  bite  received  as  long  as  two  days  before  the  development  of  symptoms 
in  an  animal  is  rarely,  if  ever,  infectious.  The  period  of  incubation  is  much  shorter 
when  the  bite  is  on  the  face  than  when  it  is  on  the  hand. 

Prevention. — The  only  efficient  measures  of  prevention  are  the  uni\"ersal  muz- 
zling of  dogs,  particularly  when  a  mad  dog  is  known  to  have  been  in  the  neighbor- 
hood, and  the  killing  of  all  animals  found  suffering  from  the  disease.  In  London 
the  muzzling  of  dogs  decreased  the  disease  from  176  cases  in  dogs  in  1889  to  3  in 
1892,  but  on  relaxation  in  enforcing  the  law  the  number  of  cases  in  dogs  and  man 
rose  again  to  about  the  original  number.  "If  all  rabid  dogs  could  be  prevented 
from  biting  other  animals,  rabies  would  in  the  course  of  a  year  be  a  mere  historical 
curiosity  of  medicine,  an  illegitimate  field  of  research  for  the  investigator  in  pure 
pathology."    (Stimson.)     (For  preventive  inoculation  see  Treatment.) 

Frequency. — Hydrophobia  is  not  a  common  malady  in  animals,  and  is  rare, 
comparatively  speaking,  in  man.  Sporadic  cases  are  met  with  in  animals  in  every 
large  city  during  the  year.  (See  Bulletin  449  of  the  U.  S.  Departinent  of  Agricul- 
ture, 1911,  by  Mohler.)  Woodhead  states  that  only  about  16  per  cent,  of  those 
bitten  by  rabid  animals  become  victims  of  the  disease. 

Pathology  and  Morbid  Anatomy. — It  has  been  generally  stated  that  there  is 
nothing  pathognomonic  in  the  morbid  anatomy  of  rabies,  but  this  is  only  true 
of  macroscopical  appearances.  Examined  microscopically  the  medulla  and  spinal 
cord  show  small  hemorrhages  and  large  numbers  of  small  round  cells  in  the  peri- 
vascular lymph  spaces  and  around  the  motor  ganglia  cells,  and  progressive  degen- 
erative changes  in  the  spinal  nerve  cells  appear,  consisting  in  chromatolysis  and 
overgrowth  of  the  nucleolus.  These  changes  are,  however,  by  no  means  pathogno- 
monic, as  they  may  be  found  in  other  diseases. 

Van  Gehuchten  and  Nelis  have,  however,  discovered  changes  in  the  peripheral, 
cerebral,  and  sympathetic  ganglia,  in  the  intervertebral  ganglia,  and  in  the  plexi- 


224  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

form  ganglia  of  the  pneumogastric  nerve,  which  they  consider  to  l)e  diagnostic  of 
rabies.  These  changes  consist  in  the  destruction  of  the  nerve  cells  hy  newly  formed 
cells  from  the  capsule.  The  rabic  tubercle  of  Babes  is  an  accumulation  of  embryonal 
cells  around  the  nerve  cells.  The  cells  of  the  ])ulbar  nuclei  undergo  degeneration 
and  manifest  various  stages  of  chromatolysis.  As  a  diagnostic  sign  botli  of  these 
June  been  largely  discarded  in  favor  of  the  Negri  body. 

Symptoms  in  Animals. — The  symptoms  of  rabies  in  animals  vary  greatly.  In 
the  dog  we  find  that  he  is  at  first  stupid  and  heavy  and  often  cross  and  restless. 
When  he  stands  up  he  may  sway  slightly  and  stagger  when  he  runs.  At  this  time 
he  is  easily  frightened  and  his  reflexes  are  acutely  increased.  He  usuall\'  refuses 
food  and  drink,  but  will  often  gulp  down  all  sorts  of  substances  not  food,  such  as 
rags,  manure,  and  pieces  of  wood.  Even  at  this  time  he  may  be  obedient,  and 
may  not  bite  his  master,  although  he  will  snap  at  a  stranger.  The  bark  is  muffled 
and  peculiar,  and  may  be  a  series  of  yelps  or  howls,  the  lower  jaw  never  completely 
closing  as  in  health.  Thirst  may  be  manifest,  but  though  the  animal  may  lap  the 
water,  spasm  of  the  tliroat  prevents  swallowing.  The  idea  that  a  mad  dog  has  a 
peculiar  dread  of  water  is  erroneous.  Any  repulsion  he  may  have  to  it  is  due  to  the 
spasm  of  the  gullet. 

He  next  becomes  delirious  and  maniacal,  galloping  or  swiftly  trotting,  with  a 
slouching  demeanor,  as  if  shrinking  from  some  enemy.  The  jaws  are  usuallj'  open, 
and  the  saliva  may  flow  freely  from  the  mouth.  Some  amblyopia  may  develop 
so  that  he  is  prone  to  run  into  objects  which  should  be  easily  avoided.  This  may, 
however,  be  due  to  stupidity  or  muscular  inco-ordination.  Sometimes  he  seems  to 
see  imaginary  objects  and  snaps  at  them.  Rapid  emaciation  is  a  noteworthy 
symptom.  Finally,  the  animal  becomes  more  feeble  and  paralyzed.  The  jjaralysis 
is  gradual  in  onset.  The  hind  legs  are  at  first  moved  with  difficulty  and  finally  the 
animal  sinks  on  his  haunches,  there  being  a  simultaneous  loss  of  power  in  the  fore- 
legs, upon  which,  however,  he  can  occasionally  raise  himself.  During  this  period 
convulsions  may  ensue.  Death  occurs  on  the  fifth  or  sixth  day  as  a  rule,  but  life 
may  be  prolonged  until  the  eighth  day,  but  ne\-er  longer  than  the  tenth  day. 

In  some  cases,  probably  in  those  which  are  very  severe,  the  paralysis  may  develop 
almost  at  once. 

Animals  sometimes  manifest  symptoms  of  what  is  known  as  "dumb  rabies," 
which  is  to  be  distinguished  from  the  maniacal  form.  In  this  condition  the  lower 
jaw  is  dropped  and  the  animal  is  unable  to  close  the  mouth.  The  tongue  hangs 
out  and  the  saliva  dribbles.  As  the  jaw  is  paralyzed  the  dog  is  unal)le  to  bite, 
and  does  not  attempt  to  do  so.  This  form  usually  causes  death  in  about  two  to 
four  days.  It  is  important  that  these  manifestations  of  dumb  rabies  be  remembered. 
Dr.  Gill,  a  veterinary  surgeon  of  New  York,  asserts  that  this  is  a  very  common 
form  of  the  disease,  which  frequently  misleads  persons  into  thinking  that  the  dog 
has  a  bone  in  its  throat.  They  are  still  further  deceived  by  the  fact  that  the  animal 
has  no  hydrophobia  and  not  infrequently  actually  plunges  his  head  into  water, 
or  will  e\cn  swim  a  river.  He  adds  as  additional  advice:  "Beware  of  a  dog  when 
it  becomes  dull  and  hides  away,  appears  restless,  is  always  on  the  move  and  prowl- 
ing, whose  countenance  is  sombre  and  sullen,  and  which  walks  with  his  head  down 
like  a  bear.  Beware  of  one  which  barks  at  nothing  when  all  is  still.  Beware  of 
the  dog  that  barks  incessantly  and  tears  up  things.  Look  out  for  the  dog  which 
has  become  too  fond  of  you  and  is  continually  licking  your  hand  and  face;  and 
beware,  above  all,  of  the  dog  which  has  difficulty  in  swallowing,  which  appears  to 
have  a  bone  in  its  throat,  and  of  one  which  has  wandered  away  from  home  and 
returns  coAered  with  dirt,  exhausted  and  miserable." 

These  symptoms  in  the  dog  have  been  described  in  detail  because  a  correct  diag- 
nosis of  the  malady  in  the  dog  is  of  Altai  importance  in  determining  whether  a 
patient  is  to  be  a  victim  of  rabies  and  if  he  should  be  given  Pasteur's  treatment. 


llYDkdI'llOlUA  22;> 

Cats  with  rabies  usually  hide  under  pieces  of  furniture  and  spring  suddenly 
into  the  face  of  a  passerby,  scratching;  and  clawing  any  exposed  jjart. 

Symptoms  in  Man. — It  is  usually  shorter  in  young  children  than  in  adults.  At 
the  end  of  the  period  of  incubation  the  part  infected  begins  to  itch  and  tingle 
and  then  to  burn.  The  skin  in  its  neighborhood  may  develop  vesicles,  and  the  old 
wound  may  open. 

The  primary  systemic  symptoms  in  man  are  apprehension,  restlessness,  and 
finally  marked  anxiety.  This  is  followed  by  thirst,  but  when  the  water  is  brought 
near  the  patient  he  seems  to  have  great  fear  of  it — hydropholjia.  This  fear  is 
chiefly  due  to  the  pharyngeal  spasm,  which  is  produced  at  the  sight  of  water,  which, 
if  the  patient  tries  to  swallow,  becomes  exaggerated.  This  spasm  is  the  most 
pathognomonic  symptom  of  rabies  in  man. 

This  stage  lasts  about  five  days  and  is  followed  by  the  stage  of  excitement,  with 
labored  respirations  and  spasm  of  the  laryngeal  and  pharyngeal  muscles.  The 
reflexes  are  greatly  exaggerated  and  delirium  or  mania  may  come  on.  Occasion- 
ally the  jaws  may  be  snapped  together,  although  snapping  is  said  to  be  characteristic 
of  false  rabies.  Very  commonly  the  curious  symptom  of  spitting  develops,  the 
patient  ejecting  small  quantities  of  spittle  upon  surrounding  objects. 

If  the  patient  survives  the  convulsive  stage  paralytic  sjTnptoms,  exhaustion, 
and  death  follow. 

Diagnosis. — It  is  only  in  the  early  stage  of  the  disease  in  either  the  animal  or 
man  that  any  difficulty  can  exist  as  to  its  diagnosis.  As  the  saliva  of  a  dog  for 
several  days  before  it  seems  very  ill  is  virulent,  all  sick  dogs,  ill  of  unknown  causes, 
should  be  regarded  with  suspicion  or  caution.  In  man  the  history  of  having  been 
bitten  will  usually  be  obtainable.  x\n  animal  which  bites  and  is  suspected  of  rabies 
I  should  not  be  killed  at  once  but  carefully  imprisoned  and  watched  to  determine  the 
true  nature  of  the  disease. 

1  Occasionally  a  hysterical  person,  after  reading  or  hearing  a  description  of  rabies, 
develops  symptoms  which  resemble  it.  The  fact  that  the  patient  is  of  this  type, 
and  that  threats,  or  inhalations  of  amyl  nitrite,  speedily  cure  the  ailment  will 
permit  a  differentiation.  This  state  is  called  pseudohydrophobia  or  lyssaphobia. 
It  is  important  to  remember  that  symptoms  of  pseudohydrophobia  or  hysteria 
simulating  the  true  disease  often  develop  as  early  as  twenty-four  or  forty-eight 
hours  after  exposure;  whereas  true  hydrophobia  rarely  develops  in  less  than  four- 
teen days.  Again,  the  hysterical  patient  often  presents  the  symptoms  of  the  second 
convulsive  stage,  without  having  shown  any  primary  symptoms.  He  is  apt  to 
show  a  disposition  to  bite,  which  is  A^ery  rare  in  true  human  hydrophobia,  and  if 
he  barks,  growls,  or  snaps  it  is  an  imitation  and  not  the  true  disease.  Finally, 
should  the  patient  survive  for  a  period  of  active  symptoms  longer  than  ten  days 
the  case  is  probably  hysteria. 

True  hydrophobia  is  to  be  differentiated  from  tetanus  by  the  presence  of  marked 
lock-jaw  in  the  latter  disease,  and  by  the  fact  that  in  tetanus  there  is  no  dribbling 
of  saliva  and  no  expression  of  terror.  The  convulsions  in  true  hydrophobia  are 
rarely  as  tonic  as  in  tetanus.  The  paralytic  form  of  rabies  may  resemble  Landry's 
paralysis. 

Prognosis. — No  case  of  recovery  has  ever  been  reported  in  which  there  was 
undeniable  evidence  that  the  diagnosis  was  correct. 

Treatment. — The  treatment  of  hydrophobia  is  entirely  in  the  line  of  preventi^'e 
medicine,  for,  once  the  disease  is  developed,  curative  measures  are  not  possible. 
As  soon  as  the  bite  is  received  the  wound,  if  a  punctured  one,  should  be  washed 
and  then  sucked  and  the  spittle  expectorated.  If  the  part  injured  be  an  extremity 
a  tourniquet  should  be  used  until  this  is  done.  The  punctured  wound  should  be 
concerted  into  an  incised  wound,  and  the  opening  should  not  be  closed,  but  gi^'en 
free  drainage  and  kept  open,  well  protected  from  other  infection,  for  several  weeks.- 
15 


226  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

Where  possible,  without  great  nnitiUition,  tlie  part  should  be  excised  as  is  now 
recommended  for  the  prevention  of  tetanus.  The  value  of  caustics  depends  on 
the  one  employed.  Fuming  nitric  acid  is  one  of  the  best  and  may  be  wisely  used 
even  if  several  days  have  elapsed  since  the  bite.  Formaldehyde  solution  is  also 
useful.  If  the  wound  is  incised,  well  washed  with  normal  saline  or  with  bichloride 
of  mercury,  real  tissue  destroyers  may  be  set  aside. 

The  specific  and  rational  method  of  treatment  is  that  proposed  and  instituted 
by  Pasteur  by  means  of  attenuated  virus.  This  investigator  found  that  if  the  virus 
of  hydrophobia  is  propagated,  through  the  inoculation  of  a  series  of  ral)bits,  it 
increases  in  virulence,  and  the  spinal  cords  of  the  rabbits  of  the  last  series  of  inocu- 
lations contain  the  poison  in  a  very  active  state.  If  these  spinal  cords  are  preserved 
under  certain  conditions  this  degree  of  virulence  progressively  diminishes.  If  an 
emulsion  be  made  from  the  attenuated  cords  and  a  dog  inoculated  with  it  in  small 
amount  the  animal  survives,  and  if  successively  inoculated  with  virus  of  increasing 
virulence  gradually  becomes  immune  as  larger  doses  are  given,  until  he  is  able  to 
stand  inoculation  with  the  most  virulent  matter  obtained  from  the  cords  of  rab- 
bits. This  same  process  is  now  employed  for  the  treatment  of  a  man  who  has  been 
bitten,  the  endeavor  being  made  to  produce  an  artificial  immunity  before  the  stage 
of  incubation  following  the  bite  is  completed. 

Out  of  17,395  cases  treated  at  the  Pasteur  Institute  in  Paris  in  this  manner 
between  1SS6  and  1895  there  were  139  deaths  from  rabies.  If  the  average  mor- 
tality after  inoculation  is  in  the  neighborhood  of  20  per  cent.,  as  already  stated, 
it  is  evident  that  instead  of  there  being  139  deaths  there  would  have  been  approxi- 
mately 3476  deaths,  which  shows  the  great  value  of  the  plan.  As  the  treatment 
is  absolutely  harmless  if  properly  employed,  the  value  of  Pasteur's  method  can- 
not be  doubted.    It  is,  of  course,  useless  after  the  malady  is  well  developed. 

Two  methods  of  producing  immunity  to  hydrophobia  are  now  employed.  One 
is  known  as  the  "simple"  and  the  other  as  the  "intensive."  In  both  methods 
spinal  cords  of  infected  animals  are  employed  in  gradually  increasing  strength 
until  finally  what  is  known  as  a  three-day  cord — that  is,  one  which  has  been  kept 
three  days — is  administered  subcutaneously.  In  the  "simple"  method  nineteen 
injections  are  given  in  fourteen  days. 

In  those  cases  which  have  severe  lacerated  wounds  of  the  face,  in  which  not  only 
infection  has  taken  place,  but  the  tissues  have  been  devitalized  by  traumatism,  the 
"intensive"  method  is  used.  This  consists  in  the  administration  of  twenty-eight 
injections  in  twenty-one  days.  During  the  first  three  days  as  many  injections  are 
given  in  the  "intensive"  method  as  are  given  in  five  days  by  the  simple  method. 

Gumming  describes  a  method  of  treatment  devised  in  the  Pasteur  Institute 
of  the  the  University  of  Michigan.  A  vaccine  is  prepared  by  dialyzing  a  sus- 
pension of  rabic  brain  against  running  distilled  water.  Two  c.c.  of  this  is  given 
daily  for  fifteen  to  twenty-five  days,  depending  on  the  U-pe  and  se\crity  of  the 
lesion.  A  local  reaction  on  the  seventh  or  eighth  day  and  lasting  for  twenty-four 
hours  is  not  uncommon.  This  vaccine  protects  animals  against  8  INI.  L.  D.  (mini- 
mum lethal  dose)  while  the  Pasteur  material  protects  against  only  2.  It  has 
been  given  to  more  than  SOO  persons,  62  per  cent,  of  whom  had  been  bitten  by 
animals  proven  to  have  been  rabid,  without  the  development  of  a  case  of  rabies. 
This  so-called  vaccine  appears  on  the  market  in  packages  containing  seven  doses 
in  syringes  ready  for  use.  Twenty-one  doses  are  needed  in  e\'ery  case,  given  over 
the  space  of  twenty-one  days.  The  injection  is  given  as  is  antidiphtheritic 
serum. 

This  antirabic  vaccine  should  always  be  used  in  preference  to  the  attenuated 
virus  originally  devised  by  Pasteur. 

After  the  disease  is  established  care  must  be  taken  that  the  patient  does  not 
wound  his  attendants.    His  suft'erings  should  be  relieved  by  morphine  or  chloral 


TETANUS  227 

in  sufficient  doses  to  spare  him  from  much  misery.     Nutrient  enemata  may  be 
used  to  help  support  nutrition  if  food  cannot  be  swallowed. 

Efforts  have  been  made  from  time  to  time  to  provide  an  antirabic  serum,  but  so 
far  without  success. 

TETANUS. 

Definition. — Tetanus  is  an  acute  infectious  disease  due  to  the  entrance  and 
development  in  the  body  of  a  specific  organism,  the  bacillus  of  tetanus.  It  is 
characterized  by  the  development  of  rigidity  of  the  muscles  so  that  the  limbs  are 
fixed  and  the  jaw  locked. 

History. — Tetanus  has  been  known  for  many  centuries  as  a  disease  that  occa- 
sionally follows  small  wounds,  but  it  was  not  until  1884  that  Carle  and  Rattone 
discovered  that  when  an  animal  showed  symptoms  of  tetanus  it  was  possible  to 
produce  similar  symptoms  in  healthy  animals  by  injecting  virus  obtained  from 
the  first.  In  1885  Nicolaier  obtained  from  the  pus  of  infected  animals,  bacteria 
which,  when  inoculated  into  healthy  animals,  caused  tetanus,  but  he  was  unable 
to  isolate  the  organism  absolutely,  although  he  described  it  as  a  small,  slender 
bacillus.  In  1886  Eosenbach  confirmed  Nicolaier's  discovery,  but  he  also  did  not 
get  a  pure  culture  of  the  bacillus  of  the  disease.  In  1889  Kitasato,  Tizzoni,  and 
Cattani  succeeded  in  its  complete  isolation.  Faber  also  proved  that  he  could 
obtain  from  a  culture  of  this  bacillus  a  toxin  which,  when  injected  into  animals, 
caused  symptoms  identical  with  those  met  with  in  human  beings  suffering  from 
this  malady. 

Distribution. — Tetanus  is  met  with  everywhere  in  tropical  and  temperate  zones. 
Its  bacillus  is  particularly  prevalent  in  garden  soil  and  about  stables  and  dungheaps. 
In  the  United  States  it  is  most  pre\-alent  in  Louisiana,  New  York,  Pennsylvania, 
Texas,  and  Ohio  in  the  order  named.  Wells  has  shown  that  the  cur\'e  of  deaths 
in  this  disease  starts  in  May,  reaches  its  highest  point  in  July,  and  then  declines 
to  October. 

Etiology  and  Frequency. — The  specific  organism,  the  Bacilhis  tetani,  is  4/i  to 
bfi  in  length  and  about  0.4;U  wide;  during  sporulation  one  end  enlarges  giving  the 
organism  a  drumstick  appearance.  This  bacillus  is  an  anaerobic,  slightly  motile, 
flagellated  rod,  possessing  unusually  resistant  spores  and  the  faculty  of  producing  a 
highly  poisonous  toxin.  It  is  frequently  demonstrated  in  discharges  from  wounds  in 
cases  of  tetanus,  and  has  been  found  on  the  object  producing  the  w'ound  and  in 
freshly  made  wounds. 

The  chief  causative  factor  in  tetanus  is  the  presence  of  a  wound  through  which 
the  specific  germ  may  enter  the  body.  This  wound  may  be  so  insignificant  as  to 
be  overlooked.  In  other  cases  the  infection  takes  place  through  a  break  in  the 
mucous  membrane  of  the  mouth.  I  have  seen  it  follow  an  operation  for  piles, 
the  bacilli  being  in  the  stools  from  infected  food.  Accidents  of  this  type  prob- 
ably account  for  the  cases  of  so-called  idiopathic  tetanus.  Small,  punctured 
wounds  are  much  more  apt  to  result  in  the  development  of  the  disease  than 
large  ones  with  free  drainage,  for  the  accumulated  necrotic  tissues  of  punctured 
wounds  afford  approximately  ideal  conditions  for  the  development  of  the  anaerobic 
bacillus.  Within  the  last  few  years  several  outbreaks  of  tetanus  have  followed  the 
use  of  contaminated  vaccine. 

Tetanus  is  not  a  very  common  disease,  but  nearly  every  large  hospital  service 
has  presented  to  it  occasionally  an  isolated  instance.  It  has  been  epidemic  in 
many  hospitals  and  camps;  it  has  also  been  epidemic  among  newborn  infants, 
infection  taking  place  through  the  umbilicus  and  causing  a  frightful  mortality,  par- 
ticularly in  the  West  Indies,  where  at  times  more  than  60  per  cent,  of  all  children 
born  died  within  eight  days  after  birth  from  its  ravages.  In  this  country  it  is  seen 
in  hostlers,  gardeners,  agricultural  laborers,  men  employed  about  stables,  and  in 


228  DISEASES  DUE  TO  A  SPECIFIC  IXFECTIOX 

children  wlio  run  about  with  l)iire  feet.  By  far  the  most  common  incidence  of  the 
disease  occurs  in  children  who  sufl'er  from  wounds  produced  by  toy  pistols  and 
fire-crackers.  As  many  as  4(i()  cases  of  this  disease  were  due  to  these  causes  in 
the  celebration  of  the  Fourth  of  July  in  1903  in  the  I'nitcd  States;  hut  it  is  interest- 
ing to  note  that  owing  to  the  warning  issued  by  medical  men  against  the  use  of 
these  explosives  the  number  of  deaths  due  to  this  cause  has  been  reduced  to 
almost  nil. 

Incubation. — The  incubation  period  is  one  to  twenty  days,  l)ut  the  maximum 
number  of  cases  occur  after  seven  days. 

Prevention. — Tetanus  is  to  be  prevented  by  the  excision  or  conversion  of  all 
jjunctured  wounds  into  incised  wounds,  washed  out  with  3  per  cent,  tincture  of 
iodine  followed  by  hydrogen  peroxide,  packed  with  gauze  laden  with  a  dusting 
powder  made  of  powdered  antitoxin  serum  and  provided  with  free  drainage;  by 
the  use  of  tetanus  antitoxin  as  soon  as  the  wound  is  recei\-ed,  and,  if  the  disease 
develops  in  a  hospital  or  camp,  by  the  careful  isolation  of  those  who  are  ill  with  it. 

The  measures  taken  to  destroy  the  bacillus  and  its  spores  outside  the  body, 
as  in  dressings  and  clothing,  must  be  very  radical,  because  the  spores  are  extra- 
ordinarily resistant  to  those  measures  usually  employed  to  destroy  pathogenic 
germs.  Thus,  the  spores  can  survi\e  two  hours'  exjiosure  to  corrosive  sublimate 
1  :  lOOO,  and  even  survive  exposure  to  boiling  water  if  the  exposure  is  brief.  So, 
too,  fifteen  hours'  treatment  with  1  :  20  of  carbolic  acid  is  necessary  to  destroy 
their  vitality.  Drying  does  not  kill  the  bacillus.  Miguel  has  produced  the  disease 
from  infected  soil  kept  for  eighteen  years. 

Pathology  and  Morbid  Anatomy. — A  most  important  fact  to  Ije  remembered  in 
regard  to  tetanus  is  that  the  .specific  organism  primarily  does  not  spread  through 
the  body,  but  develops  at  the  site  of  infection,  and  from  this  focus  the  toxin  which 
produces  the  symptoms  of  the  malady  is  disseminated.  It  has  been  proved  by 
Meyer  and  Ransom  that  the  poison  passes  to  the  central  nervous  system  through 
the  axis-cylinders  of  the  motor  nerve  trunks  and  lymph  channels.  Another  fact 
of  importance  is  that  the  toxin  combines  with  the  cells  of  the  nervous  system  with 
remarkable  celerity,  and  having  done  so  forms  so  firm  a  combination  that  it  can- 
not be  dislodged,  and  in  consequence  the  subsequent  use  of  antitoxin  often  fails. 

The  tetanic  convulsions  are  not  due  to  any  influence  of  the  poison  on  the  nerves 
or  muscles,  but  upon  the  spinal  cord  and  brain. 

In  cases  of  death  from  tetanus  there  are  no  characteristic  changes  in  the  tissues 
of  the  nervous  system. 

Symptoms. — ^The  symptoms  of  tetanus  are  so  characteristic  that  they  can  hanlly 
be  mistaken  for  any  other  disease  save  hysteria  and  strychnine  poisoning.  The 
dominant  symptom  is  the  state  of  rigidity  of  the  vohtntori/  muscles,  which,  when  the 
disease  is  well  developed,  are  practically  constantly  contracted,  although  at  inter- 
vals they  relax  and  contract  spasmodically,  causing  the  well-developed  convulsions 
of  the  disease.  It  is  a  curious  fact  that  the  earliest  symi)toms  often  emanate  from 
the  muscles  nearest  the  focus  of  infection,  but  very  commonly  they  originate  in  the 
muscles  of  the  jaw  and  neck,  producing  the  symptom  called  "lock-jaw,"  that  is, 
a  state  in  which,  by  reason  of  the  spasm  in  the  masseter  muscles,  the  lower  maxilla 
is  firmly  pressed  against  the  upper  jaw. 

The  contraction  of  the  facial  muscles  in  the  spasm  gives  the  face  a  peculiar 
expression  of  painful  mirth,  or  risiis  sardoniciis,  and  it  is  a  noteworthy  fact  that 
this  expression  may  be  the  first  warning  of  an  oncoming  attack  of  the  disease,  for 
as  the  patient  attempts  to  show  his  tongue  to  the  physician  who  is  inquiring  as 
to  his  general  health,  the  iiliysicinn  is  startled  to  sec  tiic  facial  muscles  produce 
this  strange  expression. 

The  muscles  of  the  back  and  abdominal  wall  are  rigid  to  the  touch,  and  pain 
and  oppression  -due  to  spasm  of  the  diaphragm  may  be  present  when  the  disease  is 


TETANUS  229 

well  developed.  The  museles  of  the  hand  are  the  least  affected  of  ail  the  volun- 
tary muscles,  as  a  rule. 

If  the  more  powerful  muscles  contract  forcibly  the  jjatient's  body  is  arched, 
resting  on  his  heels  and  the  occiput;  this  is  called  opisthotonos.  If  the  muscles 
of  the  anterior  part  of  the  body  are  the  more  powerfully  contracted  he  may  be 
arched  forward — emprosthotonos. 

Pain  in  the  affected  muscle  is  not  severe  as  a  rule,  but  is  rather  the  aching  due 
to  prolonged  strain  and  weariness.  Sometimes,  however,  it  is  se^■ere.  Tliere  may 
be  alarming  spasm  of  the  glottis  or  fixation  of  the  respiratory  muscles  endangering 
life,  and,  indeed,  in  severe  cases,  this  is  the  cause  of  death,  particularly  when,  by 
reason  of  exliaustion,  the  patient  is  unable  to  withstand  asphyxia  for  any  length  of 
time. 

The  7nind  usually  remains  clear  till  the  time  of  death.  The  temperature  is 
moderate  if  the  convulsions  are  moderate,  and  high  if  they  are  severe,  ranging 
from  100°  to  106°.  The  pidse  varies  in  speed,  becoming  rapid  during  a  seizure. 
Finally  it  becomes  feeble  from  exhaustion. 

Diagnosis. — Tetanus  rarely  is  as  sudden  in  onset  as  is  strychnine  poisoning, 
and  it  very  rarely  causes  death  so  rapidly.  It  affects  the  muscles  of  the  face  primar- 
ily, which  strychnine  very  rarely  does.  There  is  usually  a  history  of  punctured 
wound  in  one  case  or  of  the  ingestion  of  poison  in  the  other.  In  strychnine  poison- 
ing the  convulsions  are  followed  by  periods  of  complete  relaxation,  whereas  in 
tatanus  constant  spasm  is  present  with  exacerbations. 

In  hysteria  the  ecstatic  fades  of  the  patient,  the  presence  of  clonic  movements, 
the  fact  that  the  patient  is  a  woman  of  a  neurotic  type,  and  that  laughing  and  cry- 
ing are  often  present,  aid  greatly  in  the  diagnosis.  Further,  areas  of  anesthesia 
are  often  present  in  hysteria  and  inhalations  of  nitrite  of  amyl  may  cause  relaxa- 
tion, followed  by  sobs  and  tears  as  the  spasm  is  relieved  by  the  drug. 

Tetany  rarely  presents  such  se^-ere  contractions,  but  it  may  do  so.  The  spasms 
are  often  localized,  and  if  they  occur  in  children  signs  of  rickets  or  gastric  dilatation 
may  be  present.  Tetany  practically  never  causes  death,  and  it  affects  chiefly  the 
hands  and  feet,  which  tetanus  does  not. 

Prognosis. — The  prognosis  in  tetanus  depends  very  greatly  upon  the  severity 
of  the  paroxysms  and  upon  the  virulence  of  the  infection.  In  ^•irulent  infections 
death  comes  as  early  as  the  second  day  and  usually  by  the  sixth.  Hippocrates 
said,  "The  patient  dies  in  four  days,  or  if  he  passes  these  days  he  lives."  It  is 
essential  that  two  forms  of  the  disease  be  recalled  in  studying  this  question.  There 
is  an  acute  form  with  a  very  high  mortality  of  80  per  cent.,  and  a  chronic  form 
in  which  recovery  takes  place  in  a  large  percentage,  about  50  per  cent.  So,  too, 
the  shorter  the  period  of  incubation  the  worse  the  prognosis.  Hill  has  shown  that 
not  until  the  tenth  day  does  the  patient  have  an  equal  chance  for  life  or  death. 
After  the  eleventh  the  prognosis  constantly  impro\-es.  The  mortality  is  very 
high  in  children  in  all  cases.  An  opinion  as  to  recovery  must  be  gi^-en  with  caution, 
for  death  often  comes  when  recovery  seems  assured  and  recovery  takes  place  when 
the  condition  seems  hopeless. 

Treatment. — Before  everj^thing  else  in  the  treatment  of  tetanus  must  be  con- 
sidered the  use  of  tetanus  antitoxin  in  the  form  of  antitetanic  serum  or  antitetanic 
globulin,  the  latter  preparation  making  a  less  bulky  dose,  even  after  it  has  been 
dissolved  in  water  or  normal  salt  solution.  Its  value,  how-ever,  is  chiefly  limited 
to  those  cases  in  which  it  can  be  administered  as  soon  as  the  inoculating  wound 
occurs,  or  w-ithin  a  short  time  after  this.  Its  failure  to  be  of  value  when  employed 
after  the  symptoms  are  well  developed  is  not  due  to  any  lack  of  power  on  the 
part  of  the  tetanus  antitoxin,  but  to  the  fact  that  the  tetanus  toxin  so  rapidly 
and  firmly  combines  with  the  nervous  protoplasm  of  the  brain  and  spinal  cord 
that  it  is  impossible  for  it  to  be  disassociated  from  this  protoplasm,  ancl  therefore 


230  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

the  antitoxin  cannot  combine  with  it  and  prevent  it  from  (himasing  the  central 
nervous  system. 

When  children  are  wounded  by  means  of  toy  pistols  tetanus  antitoxin  should  be 
injected  at  once,  since  the  proportion  of  cases  in  which  tetanus  develops  from  this 
injury  is  very  large,  and  by  the  prompt  administration  of  the  remedy  the  disease 
may  be  prevented  from  producing  its  characteristic  symptoms.  Thus  in  1903,  out 
of  56  cases  of  so-called  Fourth-of-July  tetanus  treated  without  antitoxin  16  died, 
whereas  in  1904,  out  of  36  cases  treated  with  antitoxin  none  died.  In  1210  cases  of 
tatanus  treated  by  antitoxin,  Packard  and  Wilson  found  that  the  mortality  was 
42.2  per  cent.,  and  Moschowitz  in  461  cases  treated  in  this  way  found  a  mortality 
of  40.3  per  cent.  As  the  death  rate  of  acute  tetanus  is  about  bO  per  cent,  and  of 
chronic  tetanus  about  50  per  cent.,  it  is  evident  that  antitoxin  saves  many  lives. 
Even  after  tetanic  symptoms  have  developed  tetanus  antitoxin  should  still  be 
used,  and  should  be  given  intravenously  in  the  dose  of  20,000  units  daily  or  by 
spinal  puncture  in  the  dose  of  6,000  daily. 

A  suggestion  has  been  made  that  in  severe  cases  the  patient  be  trephined  and 
the  antitoxin  injected  by  the  hypodermic  needle  between  the  membranes  of  the 
brain  or  into  a  cerebral  ventricle.  It  does  not  seem  that  this  measure  offers  suffi- 
cient promise  of  usefulness  to  justify  so  serious  a  method  of  treatment,  as  intra- 
spinal injection  is  ecjually  useful.  The  needle  should  be  introduced  according  to 
the  directions  given  in  the  article  on  Cerebrospinal  Meningitis,  and  proof  that 
it  has  entered  the  membranes  of  the  cord  assured  by  the  discovery  that  a  few 
drops  of  cerebrospinal  fluid  drip  from  its  external  orifice.  The  syringe  containing 
the  tetanus  antitoxin  is  then  attached  to  the  needle  and  tlie  injection  is  made. 
According  to  Luckett  it  is  best  to  withdraw  a  considerable  quantity  of  cerebro- 
spinal fluid  before  injecting  the  antitoxin.  Antitoxin  should  also  be  injected  into 
the  nerve  trunk  supplying  the  part  of  the  body  through  which  the  infection  is 
threatened,  because  the  infection  spreads  along  the  nerve. 

The  wound,  by  means  of  which  tetanus  infection  has  possibly  taken  place, 
should,  if  small,  be  excised,  or  if  it  is  large  it  must  be  thoroughly  cleansed  first 
with  normal  salt  solution.  No  antiseptic  is  to  be  employed  as  it  is  useless  and 
interferes  with  the  vitality  of  the  tissues  with  which  it  comes  in  contact.  The 
vitality  of  these  tissues  is  of  greater  value  in  protecting  the  individual  against  in- 
fection than  are  the  ordinary  antiseptic  drugs.  If  the  wound  is  a  pimctured  wound, 
it  should  be  converted  into  an  incised  wound  in  order  that  the  tetanus  bacillus 
may  be  thoroughly  washed  out  of  it  and  that  free  drainage  may  be  pro\'ided. 
This  is  exceedingly  important.  Nothing  aids  in  the  production  of  tetanus  so 
certainlj'  as  the  closure  of  such  a  wound  in  its  early  stages.  Adhesive  strips  or 
collodion  are  death-dealing;  keep  the  wound  open.  Wounds  should  be  allowed  to 
heal  by  granulation,  as  this  is  the  surest  way  to  prevent  the  development  of  the 
disease. 

The  patient  must  be  fed  with  nutritious  and  easily  digested  foods  in  order  that 
his  nutrition  may  be  maintained.  In  the  rapid  type  of  tetanus  death  usually  comes 
so  soon  that  great  emaciation  does  not  occur.  But  in  the  more  ciironic  form  the 
question  of  nutrition  must  be  constantly  kept  in  mind. 

If  the  jaws  are  so  locked  that  food  cannot  be  introduced  into  the  mouth,  one 
or  more  teeth  should  be  remo\"ed  in  order  that  a  stomach-tube  may  be  passed, 
or  a  rubber  tube  may  be  passed  by  way  of  the  nostril,  as  in  feeding  insane  patients 
who  refuse  to  take  nourishment.  Ilumplirey  has  gone  so  far  as  to  recommend 
in  these  cases  that  a  gastrotomy  be  performed,  the  tube  introduced,  and  the 
patient  nourished  through  the  operati\e  wound.  This  seems,  howe\'er,  an  unneces- 
sarily heroic  method  when  the  tube  can  be  used. 

The  severity  of  the  tetanic  seizures  can  be  to  some  extent  modified  by  the  ad- 
ministration of  full  doses  of  chloral  and  the  bromides,  which  act  as  sedati\es  to 


GLANDERS  231 

the  motor  and  sensory  portions  of  the  spinal  cord.  These  remedies  are,  however, 
in  no  way  curative,  but  simply  symptomatic  in  that  they  diminish  to  some  extent 
the  force  of  the  convulsions  without  in  any  way  influencing  the  deleterious  influ- 
ence of  the  poison  upon  the  system. 

Meltzer  has  shown  that  the  injection  of  1  c.c.  to  each  25  pounds  of  body  weight 
of  magnesium  sulphate  solution  in  the  strength  of  25  per  cent,  materially  reduces 
the  convulsions,  but  it  is  not  a  cure.  It  possesses  the  danger  of  respiratory  failure 
and  may  be  difficult  of  performance  because  of  spasms.  Chloretone  seems  to 
be  of  undoubted  value;  30  to  60  grains  may  be  used  by  rectal  injection  as  a  means 
of  controlling  convulsions,  producing  sleep  and  preventing  exhaustion. 

Care  should  be  taken  that  the  activity  of  the  kidneys  is  maintained  by  the 
administration  of  mild  diuretics  and  by  providing  the  patient  with  plenty  of  water. 
The  state  of  the  bladder  should  also  be  watched,  as  retention  of  urine  is  not  un- 
common.   To  prevent  this,  repeated  catheterization  should  be  resorted  to. 

Under  the  name  of  "Kopf -tetanus,"  or  head  tetanus,  a  modified  form  of  the 
disease  sometimes  occurs.  It  is  said  to  be  particularly  apt  to  take  place  after 
injuries  to  the  face.  In  these  instances  the  spasm  is  chiefly  confined  to  the  muscles 
of  the  neck  and  face,  but  often  extends  to  the  abdominal  muscles,  and  there  is 
frequently  spasm  or  paralysis  of  the  glottis,  which  not  rarely  becomes  a  most 
serious  symptom.  In  some  instances  the  disease  gradually  spreads  until  it  becomes 
like  an  ordinary  case  of  tetanus.  It  is  to  be  treated  by  the  employment  of  anti- 
toxin and  other  antitetanic  measures. 

GLANDERS. 

Definition. — Glanders  is  a  disease  which  is  usually  met  with  in  the  horse,  but 
it  may  also  aft'ect  man.  It  is  due  to  the  presence  of  the  BaeUhis  mallei.  When 
it  appears  as  nodular  masses  in  the  nostrils  of  the  horse  it  is  called  "glanders." 
but  when  these  nodules  are  in  the  skin  it  is  called  "farcy."  Analogous  tj^pes 
occur  in  man. 

Etiology. — The  Bacillus  mallei  is  usually  conveyed  to  man  while  caring  for  a 
horse  suffering  from  glanders,  and  enters  his  body  through  some  break  in  the  skin. 
It  may  also  find  its  way  into  the  system  by  way  of  the  nasal  mucous  membrane. 
Rarely  one  person  is  infected  by  another  by  contact  or  through  a  wound.  The 
bacillus  is  a  slender  organism,  somewhat  thicker  in  proportion  to  its  length  than 
the  bacillus  tuberculosis,  with  rounded  ends.  It  is  easily  stained  wdth  aniline  dyes, 
but  is  equally  readily  decolorized  by  feeble  acids  or  alcohol.  It  can  be  readily 
cultivated  outside  the  body. 

Pathology  and  Morbid  Anatomy. — The  Bacillus  mallei  produces  a  circumscribed 
infiltration  of  the  tissues  with  accumulations  of  leukocytes  and  connective-tissue 
cells,  which  resemble  macroscopically  small  miliary  tubercles,  but,  as  Baum- 
garten  has  shown,  these  nodules  histologically  occupy  a  position  midway  between 
tubercles  and  miliary  abscesses.  The  surrounding  tissues  are  infiltrated  with 
blood  or  show  many,  or  iew,  petechial  extravasations.  After  a  short  time  they 
undergo  necrotic  changes,  and  as  they  break  down  abscesses  are  formed,  which 
by  necrosis  of  the  overlying  tissues  are  changed  into  ulcers,  which  may  be  super- 
ficial or  deep.  Like  tuberculosis,  the  infection  tends  to  spread  along  the  lymphatics 
and  eventually  the  bacilli  may  reach  the  blood  and  be  distributed  in  the  viscera, 
causing  nodules  in  various  organs.  Such  nodules  occur  in  the  testicles,  lungs, 
spleen,  liver,  and  kidneys,  and  sometimes  the  bones  are  affected  causing  an  osteo- 
myelitis. 

When  the  nodules  break  down  secondary  infections  perpetuate  the  suppuration, 
the  specific  bacilli  become  much  diminished,  and  it  may  be  impossible  to  discover 


232  niSEAS?:s  DIE  TO  A   SI'F.CIFIC  I XFECTIOX 

them  by  staininj;,  because  at  tliis  period  tbey  lose  tbcir  proixTty  of  beinj,'  readily 
stained. 

Symptoms. — Acute  glanders  develops,  in  about  four  days  after  inoculation, 
with  (/eiicral  wretchedness,  some  fever,  and  the  appearance  at  the  site  of  infection 
of  a  cirnmiscribed  red  swelling.  This  is  followed  in  a  few  days  by  breaking  down 
of  the  granulomatous  mass,  in  ulceration  of  the  nasal  mucous  membrane,  and  the 
discharge  of  mucopus  from  the  anterior  nares.  Secondary  infection  of  the  lymph 
glands  in  the  neck  may  occur,  and  if  the  process  is  severe  the  nose  may  become 
necrotic.  Cough  and  fiysphagia  may  be  present.  Upon  the  face  and  about  the 
joints  there  de\elops  an  array  of  pajjiiles  which  as  they  become  pustules  may  very 
closely  resemble  the  eruption  of  smallpox.     A  septic  pneumonia  often  comes  on. 


Character  of  the  cutaneous  eruption  in  human  glanders.  The  variation  in  size  and  general  lack  of 
umbiHeation  are  noteworthy  points  in  diiTerentiating  it  from  that  of  smallpox.  On  account  of  shrinkage 
the  skin  and  pustules  appear  more  wrinkled  than  they  did  before  removal  from  the  body.  (Photograph, 
natural  size,  Ijy  Roman  Mercado,  assistant  photographer  of  the  Bureau  of  Animal  Industry,  U.  S.) 

Death  comes  to  such  cases  almost  invariably  by  the  end  of  a  week  or  ten  days. 

In  rare  instances  the  process  becomes  subacute  or  chronic,  and  the  nasal  dis- 
charge, imless  accompanied  by  the  severe  symptoms  described,  may  make  a  diag- 
nosis difficult,  if  not  impossible,  by  the  ordinary  methods  of  observation. 

When  the  inoculation  is  by  the  skin,  producing  farcy,  the  same  acute  localized 
swelling  takes  place  and  the  neighboring  lymphatics  become  inflamed  and  swollen. 
Not  only  does  this  occur  as  it  does  in  most  acute  local  infections  which  are  severe, 
but  small  nodules  are  found  scattered  along  the  neighboring  lympiiatics  forming 
the  so-called  "farcy  buds."  These  undergo  necrosis,  and  sloughs  form.  A  septic 
arthritis  may  develop.  The  nasal  passages  escape,  as  a  rule,  in  farcy.  Death 
takes  place  in  the  majority  of  these  cases  in  from  ten  to  twelve  days. 

Chronic  farcy  lasts,  like  chronic  glanders,  for  a  longer  period  of  time  than  the 
acute  disease,  sometimes  for  years.  It  presents  the  picture  of  multiple  abscesses 
and  sloughs,  associated  with  more  or  less  general  septicemia,  death  taking  place 
from  tliis  cause,     ^'ery  rarely  recovery  occurs. 

Diagnosis. — Glanders — that  is,  infection  of  the  nasal  mucous  membrane  by  the 
Bacillus  mallei — can  scarcely  be  mistaken  for  any  other  disease.  Farcy  must  be 
separated  from  multiple  abscesses  and  carbuncles.  This  is  done  by  the  history 
of  exposure,  the  distribution  of  the  "farcy  buds,"  and,  finally,  by  the  injection 
of  mallein,  which  produces  a  reaction  as  does  tuberculin  in  the  tuberculous. 


ACTINOMYCOSIS  233 

Treatment. — The  swellings  should  be  promptly  opened  and  free  drainage  providcfl. 
If  possiljje  the  local  focus  should  be  well  removed  by  excision  or  by  the  cautery. 
A  nutritious  diet  should  be  given  and  stimulants  used  if  needed.  IMaliein  has  been 
used  as  a  curative  agent,  but  nearly  all  acute  cases  die,  do  what  we  will. 


ACTINOMYCOSIS. 

Definition. — This  is  a  chronic  infectious  disorder  produced  by  the  Sirrpiaihrix 
actinomyces,  sometimes  called  the  "ray  fungus."  It  is  far  more  common  in  cattle 
than  in  man,  and  in  cattle  it  usually  affects  the  lower  jaw,  producing  a  tumor  or 
growth  which  gives  the  disease  the  popular  name  "lumpy  jaw."  In  other  cases 
the  tongue  is  involved,  producing  the  so-called  "wooden  tongue." 

Etiology. — The  actinomycotic  infection  may  be  con\eyed  from  cattle  to  man  by 
the  hands  of  the  individual,  or  by  straws  used  for  picking  the  teeth,  whereby 
infection  of  the  jaw  occurs.  Direct  transmission  from  man  to  man,  or  beast  to 
beast,  or  beast  to  man  does  not  appear  to  be  of  very  frequent  occurrence ;  apparently 
both  are  infected  independently  by  some  common  route  or  source,  the  exact  char- 
acter of  which  often  cannot  be  determined.  Grain  which  has  been  soiled  by  the 
slobber  of  an  infected  animal  maj'  infect  other  cattle.  Cereals  are  thought  by 
some  to  be  the  most  frequent  carriers  of  the  disease  to  man  and  beast. 
.  The  organism  appears,  in  the  discharges  from  the  areas  of  infection,  as  a  minute, 
rounded  mass  so  tiny  as  to  be  microscopic  in  some  instances,  but  in  others  as  aggre- 
gated masses,  called  granules,  which  are  as  large  as  a  pin's  head.  These  masses 
are  yellowish-white,  resembling  particles  of  sulphur  or  iodoform,  grayish  or  drab 
in  hue,  and  even  with  slight  magnification  often  appear  in  groups  or  clumps  of 
radiating  filaments,  which  have  caused  the  organism  to  be  called  the  "ray  fungus." 
Each  terminal  filament  in  some  stage  of  its  evolution  develops  a  bulbous  end. 

Pathology  and  Morbid  Anatomy. — In  the  lower  animals  the  disease  produces  a 
slow,  suppu^ati^•e,  and  proliferati-\-e  process,  which  results  in  the  de\-elopment 
of  large  fungous  growths,  which  may  in  part  become  calcareous.  From  these 
growths,  which  are  usually  situated  primarily  in  the  jaw,  secondary  extensions 
occur,  so  that  the  fungus  is  found  in  the  tissues  of  the  tongue  and  pharynx,  and 
even  in  the  lungs,  the  intestines,  and  in  the  nearly  related  glands  and  skin.  When 
the  disease  affects  man  it  does  not  so  commonly  involve  the  jaw,  but  results  in  the 
development  of  abscesses  which  often  change  into  ulcers  or  form  fistulte.  These 
may  lead  to  the  deeper  tissues  although  the  disease  is  usually  superficial. 

Histologically  the  new  tissue  may  closely  resemble  sarcoma,  for  which  it  is  often 
mistaken,  but  its  richness  in  pus  cells  and  resemblance  to  granulation  tissue,  com- 
bined with  the  presence  of  the  fungus,  should  prevent  this  error. 

The  lower  jaw  is  more  frequently  attacked  than  the  upper;  cutaneous  or  sub- 
cutaneous forms  occur  and  invasion  of  the  alimentary  and  respiratory  organs, 
both  primarily  and  as  a  secondarj'  process,  is  not  uncommon.  A  chronic  bronchitis 
acfinomycotica  and  cerebral  actinomycosis  are  among  the  rarer  manifestations  of 
the  disease. 

Symptoms. — The  symptoms  of  actinomycosis  in  man  depend  to  a  great  extent 
upon  the  part  of  the  body  which  is  affected.  When  the  infection  takes  place 
through  a  carious  tooth  or  by  ulcer  of  the  gum  the  jaw  is  invaded,  and  the  tissues 
covering  it  become  swollen.  To  such  an  extent  may  this  swelling  increase  that 
the  neck  and  face  may  be  involved.  In  these  tissues  suppuration  ensues  and  pus 
is  discharged  from  chronic  and  somewhat  puckered  sinuses,  which  heal  in  one 
place  only  to  break  out  elsewhere.  Rarely  the  disease  may  spread  to  the  fauces 
and  to  the  tongue. 

By  the  swallowing  of  the  fungus  it  may  infect  the  intestines  and  even  the  li\-er. 


234  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

and  in  all  these  organs  it  often  causes  the  formation  of  abscesses.  It  has  been 
found  in  the  stools  in  these  cases. 

Actinomycosis  affects  the  lungs  even  more  frequently  than  the  alimentary  tract, 
and  produces  symptoms  of  subacute  bronchitis  or  bronchiectasis  or  even  those 
of  pulmonary  abscess.  The  patient  suffers  from  cough  and  from  fever,  and  expecto- 
rates purulent  material  in  which  the  micro-organism  is  often  found.  Tlie  pulmo- 
nary lesions  are  not  very  acute  in  their  course,  but  rather  clironic,  life  usually  being 
prolonged  in  these  cases  for  a  year  or  even  longer  tlian  this.  Rare  cases  of  brain 
abscess  have  been  recorded  as  the  result  of  the  organism  reaching  this  organ. 
Ho%Yard  has  been  able  to  find  only  four  primary  cases  beside  his  own,  and  thirteen 
secondary  cases.  Such  cases  must  not  be  confused  with  those  equally  rare  instances 
of  streptothrix  infection  which  IMusser  has  reported. 

Diagnosis. — The  disease,  when  the  jaw  is  affected,  must  be  separated  from  ordi- 
nary necrosis  and  from  sarcoma.  In  the  first  the  swelling  is  not  so  widespread 
and  the  sinuses  not  so  numerous.  In  the  second  condition  there  is  no  suppuration, 
the  growth  is  usually  more  rapid,  and  the  surface  is  not  so  fluctuating.  An  examina- 
tion of  the  pus  in  those  cases  in  which  it  escapes  will  decide  the  diagnosis  by  revealing 
the  ray  fungus.  It  is  to  be  remembered  that  secondary  pyogenic  infection  and 
extensive  necrosis  may  render  the  detection  of  the  specific  fungus  difficult  if  not 
impossible,  and  undoubted  cases  are  on  record  in  which  for  relatively  long  periods 
the  characteristic  organism  was  absent.  Search  for  the  germ  is  most  likely  to  be 
rewarded  during  recrudescence  in  old  lesions  and  in  newly  formed  nodules  or 
extensions,  when  they  are  freshly  opened. 

Treatment. — This  is  largely  surgical  when  the  growth  is  so  placed  as  to  permit 
of  its  being  attacked  by  this  means.  The  mass  and  the  surrounding  tissues  should 
be  excised  and  all  dead  bone  and  infected  tissue  removed,  after  which  drainage 
should  be  maintained  and  the  sinuses  irrigated  \\'ith  weak  solutions  of  iodine  or  of 
iodoform  in  oil.  When  the  pleura  is  involved  iodoform  injections  are  particularly 
useful.  Iodide  of  potassium  is  also  an  effective  drug  when  given  internally  in 
doses  of  from  20  to  60  grains  a  day,  it  being  thought  that  in  its  liberation  of  iodine 
it  acts  as  a  specific  against  the  ray  fungus. 

Periods  of  marked  improvement  and  even  apparent  cure  should  not  cause  relaxa- 
tion in  treatment,  nor  do  they  justify  a  too  hopeful  prognosis,  as  a  recrudescence 
of  lesions  long  obsolescent  is  of  frequent  occurrence. 

MYCETOMA  (MADURA  FOOT,  FUNGUS  FOOT  OF  INDIA). 

This  is  a  mycotic  disease,  usually  invading  one  or  both  feet  and  rarely  appearing 
in  other  parts  of  the  body.  It  is  most  commonly  observed  in  India.  Sporadic 
cases  occur  in  other  parts  of  Asia,  in  Europe,  and  in  South  America.  A  number 
of  cases  have  been  reported  in  the  United  States.  Two  varieties  of  the  disease 
are  recognized;  the  melanoid,  or  mycetoma  with  black  granules,  and  the  ochroid, 
with  white  or  yellow  granules.  They  are  due  to  distinct  varieties  of  streptothrix 
{Streptothrix  madurw  and  Streptothrix  mycetoinw).  Tlie  disease  is  closely  related 
to  actinomycosis;  indeed,  some  of  the  cases  reported  in  the  United  States  as  myce- 
toma are  undoubted  cases  of  actinomycotic  feet. 

The  disease  commonly  attacks  one  foot;  beginning  as  a  firm,  hard  nodule  on  the 
sole,  which  gradually  softens  and  discharges  an  oily,  fetid  pus  containing  the  black 
or  yellow  granules.  The  sinus  thus  formed  persists.  Other  nodules  appear  and 
go  through  the  same  course.  The  foot  gradual!}-  enlarges  and  the  sole  is  greatly 
thickened.  The  disease  attacks  the  deeper  tissues  until  eventually  all  structures, 
including  the  bones,  are  converted  into  a  greasy,  yellowish  mass.  The  appearance 
of  the  fungus  foot,  with  the  thickened  sole,  the  toes  strongly  extended  upwarrl,  and 
the  plantar  and  dorsal  surfaces  covered  with  the  button-like  orifices  of  the  siiuises. 


FRAMBESIA  235 

is  characteristic.  Occasionally,  the  disease  shows  some  tendency  to  the  formation 
of  secondary  deposits,  spreading  along  the  lymphatic  vessels.  The  diagnosis 
between  mycetoma  and  actinomycosis  rests  on  the  microscopic  character  of  the 
organisms. 

Treatment. — The  treatment  consists  of  conser\-ati\'e  resection  in  early  cases  and 
amputation  in  older  cases. 

FRAMBESIA  (FRAMBESIA  TROPICA,  YAWS). 

Definition. — Frambesia,  or  yaws,  is  a  chronic  contagious  and  infectious  disease, 
characterized  by  the  appearance  of  a  diffuse  granulomatous  eruption  on  the  skin. 

History. — The  history  of  yaws  begins  with  the  historians  of  the  Spanish  conquest 
of  America.  It  is  a  disease  very  closely  confined  to  tropical  countries  and  very 
widely  distributed  in  Africa,  in  the  coast  countries  of  tropical  Asia,  and  in  many 
of  the  Pacific  Islands.  It  also  occurs  in  Central  and  tropical  South  America  and 
the  Antilles.  The  disease  was  exceedingly  common  in  Cuba  and  the  southern 
United  States  during  the  first  half  of  the  nineteenth  century,  ha^■ing  been  brought 
there  during  the  slave-trading  days.  At  one  time  it  caused  such  a  degree  of  dis- 
ability among  the  negroes  that  the  planters  were  forced  to  adopt  stringent  rules 
for  its  limitation.  Most  of  the  large  plantations  maintained  isolation  barracks, 
or  "yaw  houses,"  for  these  cases.  The  disease  still  lingers  in  Cuba  and  the  rest 
of  the  Antilles.     It  has  all  but  disappeared  from  the  United  States. 

Etiology. — Many  bacterial  forms  have  been  isolated  from  yaw  lesions,  although 
as  yet  the  specific  cause  has  not  been  determined,  but  Castillain  of  Colombo  has 
isolated  a  spirochete  or  treponema  which  he  thinks  is  the  specific  cause  and  called 
it  the  Treponema  pertenms.  The  disease  can  be,  and  frequently  is,  conveyed  by 
direct  inoculation,  intentional  or  accidental.  Such  inoculation  may  take  place 
in  wounds,  abrasions,  and  other  injuries  of  the  skin.  In  some  yaw  countries, 
notably  in  Fiji,  it  is  a  common  practice  for  mothers  to  inoculate  their  children, 
under  the  same  idea  which  prevails  among  our  lower  classes,  who  frequently  expose 
their  children  to  pertussis  and  eruptive  diseases,  on  the  theory  that  the  illness 
must  be  gone  through  with  some  time,  and  the  earlier  the  better.  Heredity 
has  no  bearing  on  the  etiology  of  yaws.  Neither  does  a  pregnant  or  nursing  woman 
with  yaws  necessarily  infect  her  child.  Outside  of  direct  inoculation  the  disease 
is  conveyed  by  food,  particularly  by  cooking  utensils.  In  persons  particularly 
susceptible,  infection  may  take  place  by  sleeping  in  a  yaw  house.  AH  ages  are 
attacked,  but  the  majority  of  cases  are  seen  in  children.  The  black,  yellow,  and 
white  races  are  susceptible  in  the  order  named.  As  a  rule,  one  attack  confers 
complete  immunity.     Frambesia  is  also  seen  in  domestic  fowls. 

Symptoms. — The  incubation  period  of  yaws  is  very  variable.  Generally  speaking, 
in  inoculation  cases,  it  varies  between  fifteen  and  twenty  days.  In  cases  ordinarily 
acquired,  the  incubation  is  longer,  ranging  from  fourteen  to  sixty  days.  In  a 
small  proportion  of  cases  prodromal  symptoms,  languor,  malaise,  headache,  and 
rheumatic  pains  are  observed.  This  condition  is  followed  by  what  is  known  as 
the  primary  eruption  or  the  primary  sore,  concerning  which  there  is  some  dispute 
among  tropical  practitioners.  In  experimental  inoculation  cases  the  primary 
sore  is  constant  and  occurs  at  the  point  of  inoculation.  It  begins  as  a  sviall  papule, 
which,  in  the  course  of  a  week,  is  converted  into  a  shalloiv  ulcer.  In  another  week 
the  ulcer  heals,  leaving  a  slight,  thickened  scar.  In  ordinary  infection  by  yaws  it 
is  sometimes  present  and  sometimes  absent. 

The  generalized  eruption,  the  so-called  secondary  eruption,  begins  with  the 
primary  sore  in  exceptional  cases,  but,  as  a  rule,  is  delayed  for  several  weeks. 
Occasionally,  in  the  period  between  the  eruption  of  the  primary  and  secondary 
lesions,  a  dry,  scaly  affection  of  the  skin  is  seen. 


236  DISEASES  DVE  TO  A  SPECIFIC  IXFECTIOX 

The  secondary  eruption  begins  as  small  jjap-iiles,  wiiich  itch  intensely.  They 
are  scattered  all  over  the  body,  but  arc  most  commonly  seen,  in  order,  on  the  face, 
neck,  limbs,  f;;cnitals,  and  trunk.  The  hairy  seal])  is  not  connnonl.v  invaded; 
the  axilla  very  rarely.  The  lesions  are  particularly  numerous  at  the  mucocutaneous 
borders,  the  moutli,  nose,  anus,  and  vulva.  The  eru])tion  is  rouf^hly  synunctrical. 
The  papules,  at  first  the  size  of  a  pinhcad  and  slightl\'  prominent  under  the  skin, 
gradually  increase  in  size  till  they  arc  as  large  as  a  pea  or  a  hazel-nut.  Small, 
yellow  xpofs  of  pu.ftulalion  a])])ear  on  the  summit  of  tlie  lesions;  the  skin  cracks;  a 
sticky,  yellow,  seropurulent  fluid  exudes,  which  hardens  and  forms  rui)ia-like 
crusts  or  caps  over  the  summit  of  the  growths.  The  ca])  is  tough  and  adherent. 
When  it  is  pulled  off  it  reveals  a  shiny,  red  papilloma  underneath.  This  warty 
growth,  the  true  yaw,  resembles  a  berry  in  appearance,  hence  the  name  yaw,  i.  e.,  a 
strawberry;  frambesia  from  framboise,  a  raspberry.  Indeed,  most  of  the  local 
native  names  for  the  disease  are  words  which  mean  berry  in  their  dialect. 

The  growths  resemble  syphilitic  condylomata  in  their  appearance.  They  spring 
from  the  papillary  layer  of  the  skin,  and  the  warty-like  lobulations  represent  the 
greatly  hypertrophied  papillre.  The  uncovered  yaw  freely  exudes  the  sticky, 
yellow  pus,  already  mentioned,  and  in  a  little  while  the  cap  is  reproduced.  As  a 
rule,  the  lesions  are  painless,  excepting  where  they  occur  under  thick,  dense  skin, 
as  in  the  palms  and  the  soles,  where  tension  may  cause  great  pain.  Itching  is, 
however,  very  persistent  and  annoying.  After  persisting  weeks  and  months, 
sometimes  passing  through  recrudescences  and  successive  crops,  the  lesions  grad- 
ually grow  smaller,  the  papillomata  disappear,  and  a  dry  eschar  is  left,  which  fails 
oil',  leaving  a  patch  of  thickened  skin,  bleached  in  the  negro  and  pigmented  in  the 
light-skinned  races. 

In  old,  long-standing,  and  neglected  cases,  severe  hone  and  joint  pains  develop, 
and  occasionally  extensive  periostitis  and  caries  occur.  These  are  the  so-called 
tertiary  lesions  of  frambesia.  They  are  not  constant;  indeed,  they  never  appear 
in  properly  treated  cases. 

Diagnosis. — There  are  only  two  diseases  with  A\hich  typical  yaws  can  be  confused, 
syphilis  and  verruga.  Hutchinson  believes  yaws  and  syphilis,  if  not  the  same 
disease,  are  descendants  of  the  same  parent  stock;  that  originally  they  were  identical 
and  have  become  differentiated  by  thriving  for  long  periods  on  different  soils. 
Yaws  undoubtedly  suggests  syphilis  very  strongly,  but  there  can  be  no  question 
of  the  duality  of  the  diseases.  Syphilis  and  yaws  have  frequently  been  observed 
in  the  same  individual;  syphilitics  have  been  successfully  inoculated  with  yaws, 
and  vice  versa.  Finally,  the  histological  differences  are  marked.  Xo  giant  cells 
are  seen  in  yaws  and  no  thickened  blood\'essels. 

Scheube  believes  yaws  and  verruga  to  be  identical,  but  (llogner  has  recently 
drawn  a  clear  distinction  between  the  histology  of  the  two  diseases,  and  has  clearly 
shown  that  they  are  not  identical. 

Prognosis. — The  prognosis  is  uniformly  good. 

In  patients  reduced  by  disease  and  in  infants  the  j^rognosis  of  yaws  is  not  .so 
favorable. 

Treatment. — Iodide  of  potash  is  the  remedy  for  frambesia  as  is  also  saharsan. 
i\Iercury  not  only  does  not  do  these  patients  good,  but  actually  seems  to  do  them 
harm.  Stomatitis  occurs  with  the  greatest  facility  and  is  very  severe.  When  the 
general  condition  is  low,  arsenic,  iron,  and  the  bitter  tonics  are  indicated.  Most 
tropical  practitioners  advise  local  treatment  of  the  lesions.  This  includes  antiseptic 
and  .stimulating  applications  and  removal  of  old  lesions  with  the  curette.  The 
prophylaxis  of  yaws  consists  in  cleanliness  and  isolation  of  the  infected,  (ireat 
care  must  be  taken  of  abrasions  and  cuts,  and  infected  dwellings  should  be  avoided. 


TUBERCULOSIS  237 

TUBERCULOSIS. 

Definition. — Tuberculosis  is  an  infectious  disease  caused  by  the  presence  in  the 
body  of  the  Bacillus  tvhcrcvlosis.  It  is  characterized  by  a  local  inflammatory 
process  followed  by  the  development  of  areas  of  necrosis.  While  the  lesions  pro- 
duced by  the  disease  are  varied,  the  typical  manifestation  is  the  formation  of  small 
nodules  which  appear  as  gray,  or  white,  or  sometimes  yellowish  bodies  called 
tubercles.  It  is  because  of  these  tubercles  that  the  name  "tuberculosis"  is  applied 
to  the  malady. 

Etiology. — The  chief  etiological  factors  in  this  disease  are  the  specific  bacillus 
and  the  presence  of  a  favorable  state  in  the  tissues  of  the  individual  for  the  growth 
of  the  germ.  As  the  disease  is  constantly  present  all  over  the  world,  except  in  a 
few  scattered  areas,  the  specific  germ  is  always  at  hand,  and  as  a  large  number 
of  causes  produce  a  condition  of  the  tissues  which  is  favorable  to  their  development 
the  disease  is  only  too  prevalent. 

The  bacillus  of  tuberculosis  appears  as  a  straight,  slightly  curved  or  bent  rod 
with  rounded  ends,  devoid  of  motility,  and  reproducing  itself  by  fission;  the  often- 
expressed  belief  that  it  is  a  spore-bearing  organism  is  not  unequivocally  established. 
It  stains  with  the  ordinary  aniline  dyes  and  by  Gram's  method.     (See  Pathology.) 

The  Bacillus  tuberculosis  enters  the  body  by  several  pathways,  of  which  the 
most  common  one  is  undoubtedly  the  respiratory  passages  (Fig.  49).  It  also  gains 
access  by  way  of  the  alimentary  canal  with  the  food,  particularly  in  children, 
and  occasionally  by  accidental  inoculation.  Recent  studies  have  shown  that 
the  tonsils  and  lymphoid  tissues  of  the  pharynx  are  portals  through  which  the 
tubercle  bacillus  frecjuently  enters.  The  position  of  the  tonsils  exposes  them  to 
both  air-borne  and  food-borne  infection,  and  their  crypts  and  lymphatic  communica- 
tions aft'ord  favorable  opportunities  for  the  entrance  and  dissemination  of  the 
micro-organism,  ^'ery  rarely  true  hereditary  transmission  takes  place  by  the 
passage  of  the  bacillus  through  the  placenta  or  possibly  by  the  infection  of  the 
o^'um  by  this  organism.  Such  instances  are,  however,  so  rare  that  they  are  medical 
curiosities. 

When  the  infection  takes  place  by  inhalation  it  usually  occurs  by  the  bacilli 
being  dissipated  through  the  air  in  the  form  of  dust,  or  by  their  expulsion  in  small 
masses  of  sputum  which,  falling  on  pillows,  bedding,  or  clothing,  are  easily  taken 
into  the  respiratory  passages  when  the  sputum  dries.  Fliigge  has  shown  that  when 
a  patient  coughs  with  his  mouth  open  the  ejected  air  may  contain  droplets  holding 
the  bacillus,  thereby  rendering  the  immediate  neighborhood  of  the  suft'erer  especially 
dangerous.  There  can  be  no  doubt  of  these  facts,  for  they  are  proved  by  the  very 
great  frequency  of  the  disease  in  the  lungs,  particularly  when  opportunity  exists 
for  infection  by  dust,  and  by  the  fact  that  susceptible  animals  can  be  infected  by 
this  disease  if  forced  to  breathe  dust  which  has  been  contaminated  by  dried  tuber- 
culous sputum. 

Kingsford  found  in  analysis  of  339  cases  that  216,  or  63.7  per  cent.,  occurred 
by  inhalation,  65,  or  19.1  per  cent.,  by  ingestion,  and  17  per  cent,  were  of  doubtful 
origin. 

Von  Pirquet  gives  the  relative  frequency  of  paths  of  infection  in  infancy  as 
represented  in  Fig.  49. 

Tuberculous  infection  by  way  of  the  alimentary  tract  occurs  very  commonly 
as  the  result  of  drinking  milk  from  tuberculous  cows,  or  milk  that  has  been  con- 
taminated by  the  sputum  from  tuberculous  human  beings.  The  infection  of  milk 
by  coughing  or  sneezing  by  persons  suffering  from  this  disease  occurs  quite  fre- 
cjuently.  The  milk  of  a  tuberculous  cow  will  con\ey  the  infection  even  if  local 
tuberculous  lesions  are  not  present  in  the  udder,  and  the  bacillus  may  be  found 
in  butter  made  from  such  milk.    The  fact  that  tuberculosis  is  so  frequently  found 


238 


DISEASES  DUE  TO  A  SPECIFIC  INFECTION 


in  the  mesenteric  glands  of  young  children  is  significant  in  this  connection.  Infec- 
tion by  the  meat  of  a  tuberculous  animal  can  only  occur  if  the  meat  actually  con- 
tains the  bacilli  and  is  eaten  uncooked.  This  form  of  infection  is  probably  very 
rare  except  when  sausages  made  from  what  are  known  as  bologna  cows'  are  eaten 
in  a  raw  or  half-cooked  state. 

Medical  publications  have  teemed  during  the  last  few  years  with  rather  heated 
debates  as  to  the  communicability  of  bovine  tuberculosis  to  man.  In  the  minds 
of  some  bacteriologists,  in  Germany  in  particular,  this  question  is  still  fnih  jitdice, 
but  the  majority  of  those  best  qualified  to  judge  now  agree  that  no  doul)t  can  exist 
of  its  transference,  particularly  from  the  udders  of  tuberculous  cows  to  the  mesen- 
teric glands  of  children  who  drink  the  milk  from  these  animals. 


I 
1 


INFECTIONS  P 


a 


BRONCHOGENOUS 
INFECTIONS 
95  PER  CENT 


DEATHS  BY 

BRONCHOGENOUS 

INFECTIONS 


Incidence  and  mortality  from  tuberculosis  in  infants.  Diagram  showing  approximate  proportions 
of  different  channels  of  infection  among  the  infants  of  Vienna.  (Von  Pirquet,  modified  from  Edin- 
burgh Medical  Journal.) 

Raw,  Theobald  Smith,  and  others  have  maintained  that  man  is  subject  to  two 
forms  of  tuberculosis,  one  derived  from  members  of  his  own  zoological  group  and 
another  due  to  infection  by  the  bovine  bacillus.  The  wide  distribution  of  tubercu- 
losis in  the  animal  kingdom,  the  morphological,  cultural,  and  pathogenic  differ- 
ences in  the  bacillus  found  under  dilferent  conditions,  and  the  generally  tulmitted 
possibility  of  ranging  these  organisms  in  a  scale,  or  at  least  in  closely  allied  groups, 
explain,  at  least  in  part,  the  different  phenomena  as  seen  in  man. 

The  mere  presence,  however,  of  the  tubercle  bacillus  is  not  the  only  requisite 
for  the  development  of  tuberculosis,  for  as  already  stated  the  tissues  must  lie  in  a 
favorable  state  for  its  growth.  This  favorable  state  is  produced  by  any  cause  which 
imi)airs  vital  resistance  and  prevents  the  body  from  destroying  invading  micro- 
organisms soon  after  they  enter  it.  Of  these  causes,  aside  from  diseases  which 
impair  the  general  health,  we  find  the  most  potent  are  bad  air,  particularly  that 
due  to  poor  ventilation  when  large  numbers  of  persons  are  crowded  together;  lack 
of  exercise,  so  that  all  parts  of  the  lungs  are  not  thoroughly  expanded;   and,  lastly, 


A  bologna  cow  is  an  animal  so  feeble  and  wasted  that  it  cannot  be  used  for  milking,  breeding,  or  for 
!  providing  of  ordinary  butcher's  meat.    It  is  killed  and  used  to  make  sausage. 


TUBERCULOSIS  239 

those  conditions  of  air  and  soil  which  are  associated  with  excessive  humidity, 
particularly  if  there  be  much  dust  in  the  atmosphere,  as  in  large  cities. 

In  addition  to  these  causes,  which  increase  the  susceptibility  of  all  persons,  we 
also  find  that  certain  individuals  inherit  conditions  which  undoubtedly  i)redispose 
them  to  this  disease.  They  belong  to  two  classes:  those  who  by  inheritance 
possess  faulty  thoracic  development,  or  bad  chest  configuration,  so  that  the  apices 
of  the  lungs  never  expand  properly,  and  those  who  seem  to  inherit  a  condition  of 
the  tissues  which  is  unable  to  cope  with  the  infection  when  it  takes  place.  Both 
these  causes  are  often  present  in  one  case.  Such  persons  are  usually  lightly  built 
and  have  small  bones  and  delicate  features,  with  a  thin  skin  and  superficial  veins 
about  the  temples.  It  is  a  mistake,  however,  to  think  that  this  configuration  is 
always  present,  for  another  type  exists  in  which  the  bony  structures  are  large  and 
the  muscles  powerful,  the  so-called  "lanky"  type,  in  which  tuberculosis  is  very 
apt  to  run  a  rapid  course.  Every  clinician  of  experience  has  been  astonished  to 
find  active  tuberculosis  of  the  lungs  in  heavy  and  powerfully  built  men,  and  has 
seen  more  than  one  generation  of  the  same  family,  though  strongly  built,  succumb 
to  this  malady,  although  promising  in  early  life  to  escape  all  danger  from  it.  In 
these  instances  the  vital  resistance  to  infection  is  poor,  although  the  physique  may 
seem  excellent. 

The  influence  of  age  upon  the  development  of  the  disease  is  distinct,  but  it  is 
not  sufficiently  powerful  to  confer  immunity  upon  any  period  of  life.  In  the  first 
ten  years  of  life  tuberculosis  is  quite  common,  afTecting  the  lymphatic  system 
most  frequently,  the  bones  being  also  commonly  involved,  and  more  rarely  the 
membranes  covering  the  brain.  After  puberty  the  pulmonary  tissues  are  the  parts 
which  are  affected  in  the  majority  of  cases,  and  this  predisposition  of  the  lungs  to 
the  disease  persists  throughout  the  rest  of  life,  although  after  the  thirty-fifth  year 
the  frequency  of  pulmonary  tuberculosis  rapidly  decreases,  so  that  in  persons  over 
fifty  years  of  age  it  is  really  very  uncommon  as  a  new  ailment,  unless  they  have 
been  specially  exposed  to  infection  by  the  malady.  The  only  cases  I  have  seen  of 
primary  pulmonary  tuberculosis  which  began  in  persons  of  over  fifty  years  of  age 
were  miners  and  grinders. 

The  sexes  are  about  equally  affected  by  tuberculosis. 

Of  the  races,  negroes  and  North  American  Indians  are  very  susceptible,  and 
half-breed  negroes  and  half-breed  Indians  are  peculiarity  prone  to  the  malady. 
I  have  had  opportunities  of  studying  the  frequency  of  tuberculosis  among  both  of 
these  classes  and  have  been  impressed  by  this  well-recognized  fact.  Perhaps  this 
susceptibility  is  due  to  the  fact  that  the  white  father  is  usually  a  degenerate,  or 
one  whose  vitality  is  impaired  by  alcohol  and  abuse. 

Of  the  occupations  which  favor  the  development  of  tuberculosis  may  be  named 
knife-grinding,  mining,  weaving,  and  other  pursuits  which  cause  large  quantities 
of  dust  to  enter  the  lungs.    (See  Pneumonoconiosis.) 

All  the  infectious  diseases  which  diminish  the  vitality  of  the  patient  predispose 
him  to  infection  by  this  bacillus.  Thus,  pneumonia,  particularly  that  of  the  catar- 
rhal type,  not  rarely  causes  pulmonary  tuberculosis  to  develop,  and  influenza 
renders  the  patient  especially  prone  to  its  development.  In  many  cases  the  catar- 
rhal process  provides  the  centre  in  which  a  new,  or  an  old  and  slumbering,  infec- 
tion can  become  active.  Among  the  acute  infections,  measles  and  whooping-cough 
are  active  predisposing  factors,  causing  catarrhal  pneumonia  or  exhaustion  and 
diminished  vitaHty.  Diabetes  mellitus  very  commonly  ends  in  a  rapidly  developing 
tuberculosis. 

A  very  important  point  is  the  relation  of  injury  to  the  development  of  tubercu- 
lous lesions.  There  can  be  no  doubt  that  trauma  to  the  chest  wall  may  be  followed 
by  an  outbreak  of  pleural  or  pulmonary  tuberculosis,  that  injuries  to  the  joints, 
even  if  seemingly  trivial,  may  cause  tuberculous  arthritis,  and  blows  on  the  abdo- 


240  DLSI'JASKS  DUE  TO  A  SPECIFIC  ISFECTIOX 

men  may  incite  tuberculous  peritonitis  or  tuberculosis  of  the  retroperitoneal  or 
mesenteric  glands.  (See  also  article  on  Pneumonia  for  traumatic  lesions  of  the 
thorax  followed   by  pulmonary  disease.) 

Prevention. — In  the  prevention  of  tuberculosis  the  most  important  factor  is  the 
destruction  of  the  bacillus  as  soon  as  it  leaves  the  body  of  the  patient.  This  is 
by  no  means  as  easy  to  accomplish  as  would  appear  at  first  sight,  since  it  is  often 
expelled  in  enormous  numbers  by  sneezing  and  coughing.  The  moustache  or  beard 
of  the  consumptive  is  a  veritable  nest  of  infection,  and  his  bed-clothing  may  be 
equally  \irulent  unless  he  holds  something  in  front  of  his  face  when  he  coughs. 

All  sputum  should  be  received  into  rags,  which  should  be  burned  in  a  hot  fire 
before  they  become  dry,  or  into  a  paper  spit-cup  which  can  be  Inirned.  If  a  china 
cup  is  used,  it  should  always  contain  bichloride  of  mercury  solution. 

The  health  departments  of  nearly  all  large  cities  are  active  in  stamping  out 
tuberculosis,  or  consumption.  Under  ordinances,  physicians  are  required  to  report 
every  case  of  this  disease  that  comes  under  their  care.  In  the  poorer  districts  this 
is  followed  by  inspection,  and,  if  necessary,  disinfection  of  tiie  quarters  occupied 
by  the  sick  man,  and  this  again  has  been  supplemented  by  the  distribution  of  cir- 
culars in  which  directions  are  given  whereby  the  patient  can  take  precautions  against 
the  infection  of  his  family,  and  the  family  can  protect  themselves. 

The  second  great  preventive  of  tuberculosis  is  sunlight,  for  sunlight  destroys 
the  bacillus.  If  this  were  not  the  case  our  streets  would  infect  more  thousands 
than  they  do.  Sunlight  not  only  destroys  the  bacillus,  but  increases  the  vital 
resistance  of  the  patient  and  of  the  uninfected  as  well.  The  absence  of  sunlight 
and  the  presence  of  bad  air  are  the  most  potent  auxiliaries  to  the  disease.  This  is 
shown  by  the  prevalence  of  the  malady  in  tenement  houses,  in  prisons,  and  in 
asylums  which  are  badly  arranged  or  managed.  These  facts  have  not  only  been 
proved  on  a  gigantic  scale  by  unintentional  te"sts  with  human  beings,  but  experi- 
mentally as  well,  particularly  by  Trudeau,  who  inoculated  two  sets  of  rabbits 
with  the  bacillus  tuberculosis.  He  kept  one  set  in  a  dark  cellar  and  the.se  animals 
suffered  an  unusually  high  mortality.  The  other  set  he  turned  out-of-doors,  and 
these  animals  survived  or  were  affected  only  by  a  modified  form  of  the  disease. 

In  those  who  have  an  hereditary  predisposition  to  the  disease  or  who  have  a 
faulty  thoracic  development,  out-door  life  is  in  many  cases  an  absolute  necessity 
to  prevent  the  disease. 

As  bovine  tuberculosis  can  be  conveyed  to  man,  careful  inspection  and  testing 
of  cows  supplying  milk  should  be  frequently  made  and  especially  when  the  milk 
is  to  be  used  as  an  infant  foot!. 

Frequency. — The  prevalence  of  tuberculosis  in  its  various  forms  is  very  great. 
About  one  death  in  every  seven  is  due  to  this  cause,  and  when  we  add  to  this  fact 
the  additional  statement  that  a  very  large  proportion  of  those  who  die  of  other 
diseases  show  more  or  less  well-developed  tuberculous  lesions,  it  becomes  evident 
that  tuberculosis  contributes  to  the  death  of  a  still  larger  proportion  of  persons. 

Thus  Schlenker  in  100  autopsies  made  on  adults  and  children  il,\ing  of  various 
diseases  found  that  65  per  cent,  had  tuberculosis.  Biggs  found  it  in  (10  per  cent, 
of  his  postmortems,  and  out  of  4000  consecutive  autopsies  in  Breslau  about  biOO 
showed  tuberculosis.  These  statistics,  which  gi\e  some  concej^tion  of  the  ordinary 
pre\alence  of  the  disease,  are  outclassed  in  an  extreme  degree  by  the  reports  of 
Xaegeli  in  Zurich,  who  found  in  the  Pathological  Institute  of  that  canton  that  500 
consecuti\e  autopsies  revealed  tuberculosis  in  some  form  in  97  per  cent.  This 
percentage  held  true  of  adults  as  well  as  of  children.  Naegeli  also  found  that  tuber- 
culosis is  very  rare  in  the  first  twelve  months  of  life,  uncommon  \\\>  to  the  age  of 
five  years,  but  so  frequent  from  five  to  fourteen  years  that  it  was  foimd  in  one-third 
of  all  bodies  examined.  In  studying  these  statistics  of  Xaegeli  it  must  be  remem- 
bered that  in  many  of  the  autopsies  tuberculosis  was  not  the  cause  of  death,  and 


TUli/'JRCUWSIS 


241 


in  some  cases  was  present  in  siieh  a  very  slight  degree  that  only  careful  search 
revealed  its  presence.  Burrell  believes  that  about  70  to  80  per  cent,  of  all  persons 
who  reach  the  age  of  forty  years  have  or  have  had  some  form  of  the  disease. 

The  far  greater  frequency  of  tuberculosis  in  cities  as  compared  to  country  dis- 
tricts and  villages  is  shown  by  the  statistics  of  Paris,  in  which  the  number  of  cases 
per  thousand  is  4.9;  whereas  in  0(52  villages  in  France  it  is  only  1.81. 

Notwithstanding  these  facts  it  is  interesting  to  note  that  in  many  parts  of  the 
world  tuberculosis  has  undergone  a  most  remarkable  decrease  in  its  frequency, 
although  the  mortality  rate  of  1  in  7  still  holds  true  for  man\-  cities.  In  New 
York  the  mortality  has  decreased  from  4.()  to  2.6  per  thousand  in  ten  years,  and 
a  similar  fall  of  about  40  per  cent,  has  occurred  in  Philadelphia  in  that  time.  Abbott 
has  shown  that  in  1853  the  mortality  of  pulmonary  tuberculosis  in  ilassachusetts 
was  42  per  10,000  inhabitants,  whereas  in  1895  it  was  21.8  per  10,000  inhabitants. 
The  decrease  in  the  entire  United  States  has  been  from  254.4  per  100,000  in  1890 
to  190.5  per  100,000  in  1900,  and  in  1910,  160.3  per  100,000.  Hiller  has  shown  that 
at  the  present  rate  of  decrease  the  disease  will  be  extinct  in  Prussia  in  1927  and 
in  England  about  1947.  In  Prussia  the  mortality  fell  from  31  per  10,000  in 
1886  to  19  per  10,000  in  1901,  and  in  England  it  has  fallen  50  per  cent,  in  the  last 
forty  years.     In  New  York  City  the  decrease  in  sixteen  years  equals  40  per  cent. 


m 


Annual  death  rate  from  pulmonary  tuberculosis  per  10,000  inhabitants  in  Germany  from 
1875  to  1903.     (Locke.) 


A  very  great  difference  in  frequency  is  found  in  different  races.  Thus,  in  the 
United  States  the  death  rate  in  those  of  English  descent  is  15  per  10,000,  whereas 
for  the  Irish  it  is  43,  and  59  for  the  colored  race. 

Occupation  also  makes  great  differences;  thus,  the  death  rate  among  trades- 
people is  17  per  10,000,  among  barbers  33  per  10,000,  book-keepers  40,  and  stone- 
cutters .54  per  10,000. 

.  The  average  age  at  death  from  pulmonary  tuberculosis  is  thirty-five  years,  but 
the  actual  incidence  of  the  disease  is  from  fifteen  to  thirty-five  years. 

The  relative  frequency  of  the  different  forms  of  tuberculosis  is  difficult  to  deter- 
16 


242  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

mine.     Statistics  of  deaths  from  tuberculosis  in  Ireland  from  the  years  1S91  to 
1901  show  the  following  figures  as  to  the  relative  frequency: 

Pulmonary  tuberculosis 21.35  por  10,000 

Tuberculosis  of  the  mesenteric  glands 2.2     "  " 

Tuberculous  meningitis 2.25    "  " 

Other  forms  of  tuberculosis 2.3     "  " 

Some  difference  exists,  howe\'er,  between  the  freciuency  of  primary  and  secondary 
lesions.  Thus,  Heller,  of  Kiel,  found  but  1.45  per  cent,  of  primary  intestinal 
tuberculosis,  Init  '.'u.S,  per  cent,  in  which  the  principal  lesion  was  abdominal. 

Pathology  and  Morbid  Anatomy. — As  already  stated,  when  discussing  the  etiology 
of  tuberculosis,  the  bacillus  enters  the  body  usually  through  the  respiratory  mucous 
membrane,  or  through  that  of  the  alimentary  canal.  It  is  possible,  iiowe\er,  for 
infection  to  take  place  through  the  skin,  but  this  is  usually  followed  liy  a  localized 
lesion  and  rarely  by  visceral  disea.se.  The  results  which  accrue  from  the  entrance 
of  the  bacillus  vary  greatly  with  the  virulence  of  the  micro-organism,  the  vital 
resistance  of  the  individual  and  the  organ  or  part  in  which  the  primary  localiza- 
tion of  the  bacillus  takes  place.  The  effect  of  the  bacillus  upon  the  local  tissues 
is  to  cause  an  accumulation  of  cells  in  the  immediate  neighborhood,  followed  in 
favorable  cases  by  repair  or,  under  less  promising  conditions,  by  necrosis.  This 
aggregation  of  cells,  composed  of  lymphoid,  endothelioid,  and,  it  may  be,  giant  cells, 
and  containing  the  bacillus,  is  the  histological  or  rather  anatomical  characteristic 
of  the  disease,  and  is  called  a  tubercle. 

In  the  great  majority  of  instances  the  pathological  process  which  is  induced  is 
inflammatory  in  type,  and,  as  already  stated,  the  lungs  and  their  adjacent  lymph 
nodes  are  the  parts  which  are  usually  affected  in  adults,  whereas  in  young  children 
the  gastro-intestinal  tract  and  its  adjacent  glands  are  commonly  involved,  either 
alone  or  with  the  structures  just  mentioned.  When  the  collection  of  the  cells  is 
small  the  growth  is  said  to  be  a  miliary  tubercle,  because  it  is  approximately  the 
size  of  a  millet-seed;  but  when  a  tubercle  becomes  large  enough  to  be  called 
a  nodule  its  growth  to  these  proportions  is  accomplished  by  the  coalescence  of 
a  number  of  miliary  tubercles.  This  growth  usually  is  limited,  in  the  miliary 
tubercle  or  nodule,  by  the  fact  that  an  exudate  takes  place,  as  part  of  the  inflamma- 
tory process  which  the  bacilli  produce,  which  prevents  the  spread  of  the  bacilli  to 
adjacent  areas,  and  so  limits  the  held  occupied  by  the  micro-organisms. 

As  the  disease  progresses  this  exudate  becomes  organized  and  is  finally  devel- 
oped into  a  dense  fibroid  or  cicatricial  tissue,  which  acts  as  a  protective  barrier 
against  the  spread  from  that  particular  area  of  invasion.  This  barrier  in  a  great 
number  of  cases  remains  effective  and  in  a  sense  imprisons  or  restricts  the  pro- 
duction of  poisons  and  lessens  their  dissemination.  Within  this  limited  zone  of 
action  the  bacterial  products  cause  necrosis  and  in  the  dead  tissue  the  germ  is  sup- 
pressed or  actually  destroyed.  After  the  local  necrotic  process  is  complete  the 
necrotic  contents  are  more  or  less  full\-  absorbed  and  only  a  cicatrix  remains  to 
mark  the  site  of  the  original  lesion,  or  if  this  does  not  take  place  the  caseous  and 
degenerated  mass  undergoes  calcification.  In  either  instance  a  natural  process 
tends  to  bring  about  a  cure. 

If  for  any  cause  this  protective  barrier  is  removed  by  absorption  while  the 
imprisoned  bacilli  are  still  alive,  or  if  the  wall  which  is  formed  is  incomplete,  the 
bacilli  escape  and  speedily  infect  adjoining  or  distant  areas,  being  conveyed  by 
the  lymph  or  blood  streams.  Such  is  the  explanation  of  those  cases  in  which  a 
patient  who  has  sufl^ered  from  some  acute  infection,  like  pneumonia,  typhoid 
fever,  or  influenza,  speedily  develops  tuberculosis  during  convalescence,  although 
the  acute  illness  may,  by  confining  him  to  a  healthful  and  well-vcntilated  room, 
have  protected  him  from  any  recent  infection. 


TUBERCULOSIS  243 

In  still  other  cases  the  protective  barrier  of  surrounding  exudate  is  not  formed 
and  the  amalgamation  of  tubercles  produces  a  nodule  which  undergoes  necrosis 
and  softening  and  its  bacterial  contents  become  diffused  into  the  surrounding 
tissues,  thus  spreading  the  infection.  In  still  a  third  type  of  cases  the  lesions  con- 
sist in  a  diffuse  exudative  process,  with  little  or  no  tubercle  formation,  and  as  a 
consequence  we  find  that  it  is  possible  for  the  entrance  of  the  tubercle  bacillus  to 
be  followed  by  a  tuberculous  pneumonia  or  pulmonarj'  consolidation,  tuberculous 
serositis,  or  lymphadenitis,  the  lesion  not  containing  the  characteristic  tubercle. 
In  other  words,  in  certain  instances  the  tuberculous  inflammation  is  so  intense 
and  the  poison  formed  by  the  bacilli  is  so  abundant  or  virulent,  or  the  resistance  of 
the  soil  so  inadequate,  that  no  attempt  at  protection  is  made,  but  instead  there 
occurs  a  profuse  exudative  process  which  is  extremely  liable  to  undergo  necrosis,  and 
this  results  in  rapid  breaking  down  not  only  of  the  exudate  itself,  but  of  the  involved 
tissues  as  well. 

Under  certain  admittedly  unusual  conditions  the  tubercle  bacillus  becomes 
distinctly  pyogenic  and,  rapidly  developing  in  the  lung,  produces  not  only  the 
degenerative  and  necrotic  changes  peculiar  to  tubercle  formation,  but  fills  the  air 
vesicles  with  pus,  serum,  and  dead  epithelial  cells  and  leukocytes,  a  state  in  which 
the  part  involved  speedily  goes  on  to  widespread  destruction.  It  is  also  to  be 
recalled  that  in  nearly  all  cases  of  tuberculous  disease  infection  by  other  pyogenic 
organisms,  such  as  the  staphylococcus  and  streptococcus,  aids  in  producing  local 
inflammation  and  pus,  and  leads  to  the  formation  of  toxins  which  cause  local  and 
general  impairment  of  vitality. 

In  some  cases,  on  the  other  hand,  the  bacilli,  in  the  presence  of  the  resistance 
offered,  do  not  seem  capable  of  originating  an  acute  inflammatory  process,  nor  do 
they  cause  the  formation  of  tubercles  with  caseation,  but  produce  a  condition  in 
which  an  excessive  formation  of  connective  tissue  occurs,  which  prevents  the 
rapid  spread  of  the  disease  and  constitutes  a  form  of  infection  called  chronic  hyper- 
plastic tuberculosis  in  the  intestine  or  in  the  lung  which  is  closely  allied  to  fibroid 
phthisis,  so  called;  but  this  fibroid  process  is  by  no  means  entirely  dependent 
upon  the  presence  of  the  bacillus  tuberculosis,  since  other  causes  may  produce  it. 

It  is  fully  established  that  the  noxious  action  of  the  tubercle  bacillus  in  the  human 
organism  is  due  to  its  poisons,  a  number  of  which  have  been  described.  The  early 
coagulation  necrosis  and  subsequent  caseation  are  clearly  the  result  of  bacillary 
toxins.  The  tendency  to  fibrosis  seen  in  many  cases  has  been  thought  to  be  due  to 
a  sclerogenous  toxin  and  the  frequent  cheesy  disintegration,  so  commonly  present, 
to  a  caseogenous  poison;  it  is  probable,  howe^-er,  that  the  same  noxious  agent  in 
some  individuals  induces  caseation  and  in  those  more  resistant  to  its  action  a 
fibroid  or  fibrocalcareous  change.  Progressing  caseation  maj-  be  looked  upon  as 
an  evidence  of  low  resistance,  while  fibrosis,  with  or  without  calcification,  indicates 
strong  reparative  and  antagonistic  powers  on  the  part  of  the  aiJected  tissues. 

With  these  preliminary  remarks  we  may  proceed  to  a  discussion  of  the  various 
manifestations,  pathological  and  clinical,  which  are  to  be  met  with  in  persons 
affected  by  this  disease. 

Acute  Miliary  Tuberculosis. — By  acute  miliary  tuberculosis  is  meant  a  con- 
dition in  which  a  single  organ,  or  a  number  of  organs,  or  perhaps  the  whole  body, 
is  infected  by  the  Bacillus  tuberculosis,  causing  the  formation  of  innumerable 
tubercles  of  the  type  already  described.  It  arises  not  by  the  inhalation  of  dust 
laden  by  bacilli,  but  by  the  escape  of  bacilli  in  large  numbers  from  some  infected 
focus,  as,  for  example,  a  caseous  IjTQphatic  gland.  The  escape  takes  place  into  a 
bloodvessel,  and  in  a  few  hours  at  most  the  bloodvessels  of  the  neigliboring  parts, 
or  perhaps  of  the  entire  body,  are  swarming  with  bacilli,  so  that  in  a  very  brief 
space  of  time  the  lungs,  the  liver,  and  other  parts  are  found  studded,  or,  as  it  has 
been  well  expressed,  "stuffed,"  with  miliary  tubercles.     The  caseous  gland  or 


244  DISEASES  DUE  TO  A  SPECIFIC  IKFECTWS 

primary  clieesy  nodule  wliich  j^ives  origin  to  this  acute  secondary  infection  is 
usually  so  situated  that  it  is  adherent  by  inflammatory  products  to  a  vein,  com- 
monly the  pulmonary  vein  or  one  of  its  branches,  or  to  the  thoracic  duct,  or  the 
superior  cava.  By  a  process  of  extending  necrosis  the  soft  contents  of  the  gland, 
laden  with  tubercle  bacilli,  break  into  the  vessel  or  duct.  Sometimes  an  active 
tuberculosis  of  the  wall  of  the  bloodvessel  is  present,  so  that  tubercles  may  be 
fouufl  in  the  intima.  Councilman  has  observed  a  tuberculous. aortitis  apparently 
resulting  from  infection  through  the  vasovasorum. 

Weigert  has  divided  the  results  of  this  vascular  invasion  by  the  bacilli  into 
three  classes:  (1)  that  in  which  all  the  organs  of  the  body  become  filled  with 
tubercles  of  the  miliary  type;  (2)  that  in  which  the  disease,  though  widely  dis- 
seminated, nevertheless  appears  in  multiple  but  widely  separated  foci;  and  (3)  that 
in  which  the  tubercles  are  not  so  numerous,  tlieir  growth  is  more  chronic,  and 
their  size  causes  them  to  be  classed  as  nodules.  This  is  manifestly  an  artificial 
division  which  is  not  closely  adhered  to  under  natural  conditions,  for  the  process 
may  represent  all  these  types  in  one  case,  while  in  other  instances  it  may  be  im- 
possible to  tell  to  which  class  the  case  belongs  because  the  lesions  shade  into  one 
another. 

Symptoms. — The  symptoms  of  widely  diffused  miliary  tuberculosis  are  to  be 
carefully  studied  because  they  simulate  those  of  enteric  fe^■er  and  other  typhoid 
states  so  closely  that  not  rarely  an  erroneous  diagnosis  is  made.  The  chief  mani- 
festations may  be  said  to  be  those  of  profound  toxemia  without  any  localized 
lesion  to  explain  the  illness,  which  begins  with  the  gnwral  wretchedness  common 
to  the  early  stages  of  all  acute  infections  and  which  is  followed  hy  fever,  rising  each 
evening  to  102°  or  103°.  The  j^ti^se  is  iinduh/  rapid,  and  there  are  often  profuse 
siceats.  In  such  cases  there  are  three  symptoms  which,  while  not  patiiognomonic 
by  any  means,  are  nevertheless  of  some  value  in  separating  this  condition  from 
typhoid  fever.  The  fever  is  often  irregular,  sometimes  breaking  with  a  profu.se 
sweat.  In  other  cases  it  is  higher  in  the  morning  than  at  night.  The  jiulse  is  often 
exceedingly  rapid  in  the  early  stages,  a  phenomenon  which,  as  a  ride,  is  not  ob- 
served in  typhoid  fever.  The  temperature  does  not  resist  cold  sponging  in  the  first 
week  as  does  that  of  typhoid  fever,'  but,  on  the  contrary,  falls  with  great  rapidity 
to  below  normal.  Later  there  is  the  absence  of  rose  spots  to  lead  one  to  a  current 
opinion,  and  careful  examination  of  the  lungs  may  reveal  some  area  of  infiltration 
or  softening,  or  of  dulness  on  percussion  which  should  arouse  suspicion. 

Additional  differential  factors  are  as  follows:  There  is  alisence  of  the  Widal 
reaction.  This  reaction,  however,  often  does  not  appear  in  typhoid  fever  until 
after  the  tenth  day.  Tubercle  bacilli  may,  by  .spinal  puncture,  be  found  in  the 
cerebrospinal  fluid,  and  in  some  instances  the  ophthalmoscope  will  reveal  tubercles 
in  the  choroid.  Rarely  the  bacillus  can  be  demonstrated  in  the  blood  or  urine. 
Enlargement  of  the  spleen,  the  diazo  reaction  in  the  urine,  the  presence  of  active 
diarrhea  or  severe  constipation,  and  the  fever  are  not  dift'erential  points  in  favor 
of  ty])hoid,  for  they  all  appear  in  miliary  tuberculosis.  Unlike  typhoid  fever, 
herpes  labialis  may  be  present  in  acute  miliary  tuberculosis. 

In  other  instances  the  disease  has  a  much  more  ahriijjf  ansei.  Tlic  patient  is 
seized  with  a  chill  followed  by  hicjh  fever,  or  raj)id  jiulse,  profauiid  pnistrafiaii,  and 
coploHs  sweatf.  Emaciation  proceeds  with  remarkable  rapidity.  The  aspect  of 
the  patient  is  profoundly  toxic  or  septic  and  his  expression  anxious.  The  tongue 
is  dry  and  the  cheeks  flushed. 

^Yhen  miliarii  tuberculosis  involves  the  lunc/s  the  pulmonary  symptoms  are 
chiefly  those  of  diffuse  acute  bronchitis,  although  careful  examination  may  reveal 
at  one  apex,  or  at  both,  some  impairment  of  resonance  due  perhaps  to  an  ancient 
infection.  The  general  symptoms  are  distinctly  asthenic,  as  already  described, 
and  added  to  them  there  are  fine  rales  o\"er  the  greater  part  of  the  chest  and  a  degree 


TUBERCULOSIS  245 

of  dyspnea  far  out  of  proportion  to  the  lesions  which  can  be  discovered.  The 
respirations  may  be  unduly  rapid.  The  cyanosis  is  very  pronounced,  the  ccmgb 
constant,  and  the  patient  may  seem  surprisingly  ill  considering  that  no  cause  can 
be  discovered.  The  sputum  may  be  rusty  or  blood-strcakecl,  or  a  true  hemoptysis 
may  develop.  Auscultation  may  reveal  ])leural  friction  due  to  tuberculosis  of  the 
pleura,  and  as  the  case  progresses  widely  distributed  rales  may  be  heard  in  the 
back  and  front  of  the  chest.  In  these  cases  great  mental  anxiety  is  often  a  marked 
symptom  unless  the  disease  attacks  a  child,  when  the  patient  usually  lies  limp  and 
apathetic  and  perhaps  stuporous. 

These  patients  usually  die  in  from  one  to  three  months,  but  cases  are  occa- 
sionally met  with  in  which  death  ensues  as  early  as  the  fourteenth  day.  In  still 
other  instances  the  case  becomes  less  fulminating  in  character,  the  symptoms  mod- 
erate, and  the  patient  passes  into  ordinary  subacute  pulmonary  tuijerculosis. 
Acute  tuberculous  bronchopneumonia  is  more  frequently  seen  in  children  than  in 
adults. 

Diagnosis. — The  diagnosis  is  not  difficult  in  the  pulmonary  form  if  there  is  a 
history  of  an  old  tuberculous  lesion  elsewhere,  or  if  the  marked  c\anosis  as  com- 
pared to  the  apparent  limited  area  of  disease  is  considered.  Here  again  the 
presence  of  tuberculous  foci  may,  if  found,  show  that  an  acute  condition  is  imposed 
upon  an  older  one.  The  physician  must  not  be  led  into  the  belief  that  the  lungs 
are  normal  because  he  is  able  to  elicit  a  clear  and  resonant  percussion  note  on  the 
chest  wall,  for  a  compensatory  emphysema  often  is  present  in  these  cases. 

When  the  miliary  process  chiefly  or  entirely  in^oh-es  the  meninges  the  symptoms 
are  of  course  cephalic  in  large  degree,  and  we  have  that  grave  state  known  as 
acute  tuberculous  meningitis  present.  (See  Tuberculous  [Meningitis  and  Tuber- 
culosis of  Serous  ^Membranes.) 

Spinal  puncture  to  determine  the  cause  of  the  disease  is  a  most  valuable  aid. 
If  tuberculosis  is  present  the  cerebrospinal  fluid  will  be  turbid  and  occasionally, 
if  it  is  placed  in  a  centrifuge,  the  bacilli  can  be  found,  or  some  of  the  fluid  may  be 
injected  into  a  guinea-pig,  which  will  develop  tuberculosis,  if  tliis  be  the  cause  of 
the  illness. 

From  typhoid  fever  of  the  meningeal  type  tuberculous  meningitis  is  separated 
by  the  presence  of  spots  and  by  the  Widal  test.  Again,  the  diagnosis  of  tuberculous 
meningitis  may  be  confirmed  if  a  focus  of  primary  tuberculosis  can  be  found  in  the 
other  organs,  as  in  the  lungs,  the  bones,  or  the  mesenteric  glands. 

Prognosis. — ^The  prognosis  is  always  fatal,  although  cases  said  to  have  recovered 
have  been  reported. 

Treatment. — The  treatment  consists  in  the  use  of  nutritious  food  and  stimulants 
and  in  the  relief  of  restlessness  by  chloral  or  the  bromides. 

Glandular  Tuberculosis. — Glandular  tuberculosis,  or  tuberculosis  of  the 
lymphatic  glands,  is  the  condition  which  was  formerly  called  "scrofula,"  before 
Koch  demonstrated  the  existence  of  the  tubercle  bacillus.  It  is  now  known 
that  no  such  disease  exists  as  scrofula,  or  scrofulosis,  in  the  sense  of  a  separate 
entity. 

Tuberculosis  of  the  Ijonph  glands  is  often  a  very  mild  form  of  the  infection  and 
the  mortality  from  its  presence  is  very  low.  Indeed,  it  may  be  said  that  if  the 
infection  does  not  escape  to  other  parts  of  the  body  life  will  not  be  seriously 
jeopardized. 

In  studying  this  state  it  must  be  recalled  that  one  of  the  important  functions 
of  the  lymph  nodes  is  to  arrest  and  perhaps  destroy  such  micro-organisms  as  may 
endeavor  to  enter  the  general  system.  As  soon  as  pathogenic  germs  enter  a  healthy 
gland  one  of  several  processes  takes  place.  In  a  strong  individual  with  great 
vital  resistance  the  gland  becomes  enlarged  and  active  in  an  evident  endeavor  to 
destroy  the  invaders.     In  this  it  may  succeed,  or  the  few  bacilli  which  escape 


246 


DISEASES  DUE  TO  A  SPECIFIC  INFECTION 


are  caught  and  destroyed  by  adjacent  glands.  If  the  infection  is  virulent 
and  the  vital  resistance  is  below  par,  the  battle  is  more  prolonged,  the  inflamma- 
tion in  and  about  the  gland  is  more  acti\e,  and  the  general  system  may  be  saved 
by  the  additional  safeguard  of  a  wall  of  protective  tissue  thrown  around  the  in- 
fected gland  to  protect  tiie  rest  of  the  body.  In  still  other  cases  the  glands  go 
on  to  caseation  and  the  necrotic  contents  escape  externally  or  even  internall}-. 
It  is  a  noteworthy  fact,  however,  that  this  so-called  pus  is  usually  sterile  or  con- 
tains bacilli  in  such  small  niuubers  as  to  be  demonstraljlc  only  by  inoculation  ex- 
periments. Again,  if  the  infection  wins  the  battle  and  the  gland  undergoes  casea- 
tion, it  is  still  possible  for  the  area  to  he  surrounded  by  a  filirovis  barrier  which  walls 
up  the  caseous  mass  and  its  bacilli  and  protects  the  body  even  though  the  gland 
is  destroyed. 

When  the  protective  processes  fail  the  bacilli  pass  the  lymph  nodes,  or  a  caseous 
gland  in  juxtaposition  to  a  bloodvessel  breaks,  and  general  tuberculosis  ensues  as 
already  described. 

Tuberculous  infection  of  the  lymph  nodes  takes  place  in  four  chief  areas:  the 
cervical  glands,  the  mediastinal  glands,  and  the  mesenteric  and  retroperitoneal 
glands.  In  the  first  class  the  infection  takes  place  through  the  tonsils,  in  the  naso- 
pharynx, or  because  of  the  presence  of  bad  teeth  or  a  break  in  the  gums.  Koenigs- 
feld,  as  a  result  of  elaborate  experiments  with  human  and  bovine  bacilli,  concludes 
that  the  tubercle  bacillus  can  pass  through  the  unwounded  skin.  He  believes  that 
clinical  evidence  supports  the  view  that  this  is  the  method  of  infection  in  not  a 
few  human  beings,  including  cases  of  "  scrofulosis"  in  children.  The  mediastinal 
glands  sufi'er  by  the  entrance  of  the  bacillus  through  the  mucous  membrane  of 

the   larynx,   bronchial   tubes,    or  smaller 
Fig.  51  bronchioles,  while  the  abdominal  lymphat- 

ics receive  their  infection  from  the  intes- 
tines. 

The  diagnosis  of  cervical  adenitis  is  not 
difficult,  although  occasionally,  when  the 
disease  is  bilateral  and  the  swelling  is 
great,  the  possibility  of  Hodgkin's  disease 
may  have  to  be  considered. 

The  involvement  of  the  mediastinal 
(jlands  by  tuberculous  infection  results  in 
a  spread  of  the  disease  to  the  retroperi- 
toneal lymphatics  or  in  the  growth  of  the 
tissues  aft'ccted  to  such  a  degree  that 
lymphatic  tumors  may  be  formed  which 
cause  serious  symptoms  by  pressure.  Thus, 
the  recurrent  laryngeal  nerve  may  be 
pressed  upon  and  laryngeal  spasm  result, 
or  the  superior  vena  cava  or  pulmonary 
vein  suffers  from  compression,  and  in  a 
similar  manner  bronchial  obstruction  may 
ensue.  More  important,  howe^•cr,  than 
the  pressure  symptoms  are  possible  perforation  by  ulceration  of  the  bronchi  or 
trachea,  or  even  of  the  bloodvessels,  with  rapid  diffusion  of  the  infection  all 
through  the  body  (Fig.  51).  So  too,  it  is  possible  for  bacilli  to  enter  the  lung, 
to  pass  to  the  lymphatics,  to  cause  disease  in  these  glands,  and  finally  cause 
pulmonary  tuberculosis,  pleural  tuberculosis,  or  pericardial  tuberculosis  by  softening 
and  rupture  into  these  parts  through  the  adhesions  which  are  formed. 

In  diseases  of  the  retrobronchial  glands  auscultation  over  the  upper  end  of  the 
sternum,  when  the  head  is  well  thrown  back,  may  reveal  a  tracheal  hum,  and 


Contents  of  a  caseous  gland  escaping  into  the 
right  bronchus.     (T.  Fisher's  case.) 


TUBERCULOSIS  247 

careful  percussion  may  elicit  some  dulness.  The  .T-rays  often  giN'e  valuable 
assistance  in  diagnosis. 

When  the  mesenteric  and  retroperitoneal  glands  are  in\-olved,  producing  what 
is  called  "tabes  mesenterica,"  the  child  is  anemic,  poorly  nourished,  has  consti- 
pation alternating  with  diarrhea,  and  presents  an  enlarged  abdomen  ("pot-belly"). 
The  size  of  the  belly  as  compared  to  the  rather  wasted  arms,  legs,  and  thorax  is 
noteworthy,  and  careful  palpation  may  occasionally  reveal  enlarged  glands  deeply 
situated  in  the  abdominal  cavity.  This  condition  is  to  be  separated  from  tuber- 
culosis of  the  peritoneum  and  from  consumption  of  the  bowels,  for  both  of  these 
structures  are  usually  free  from  the  disease  in  these  cases,  although  they  may  be 
infected  by  softening  of  the  glands  themselves.  These  lesions  probably  exist  in 
a  far  larger  proportion  of  cases  than  is  generally  thought,  and  end  by  a  process  of 
fibrosis  and  calcification,  for  the  involvement  of  these  glands  is  met  with  in  many 
cases  at  autopsy  when  death  is  due  to  another  cause,  and  when  no  suspicion  of 
tuberculous  infection  has  been  present. 

Treatment  of  Glandular  Tuberculosis.— Tuberculosis  of  the  retrobronchial  glands 
and  of  the  retroperitoneal  glands  can  be  treated  only  by  sunshine  and  fresh  air 
with  residence  by  the  sea,  and  by  the  internal  use  of  tonics,  of  syrup  of  the  iodide 
of  iron  and  cod-liver  oil  to  combat  anemia. 

Persistent  enlargement  of  the  cervical  glands  demands  their  surgical  removal, 
not  their  incision,  but  their  excision,  because,  as  has  already  been  stated,  a  tuber- 
culous focus  is  always  a  threatening  focus.  On  the  other  hand,  it  cannot  be  denied 
that  large  numbers  of  very  healthy  adults  bear  scars  showing  that  they  have  had 
cervical  adenitis  in  early  life.  In  these  cases  the  battle  between  vital  resistance  and 
tuberculous  infection  has  been  won  by  the  individual. 

Tuberculosis  of  the  Serous  Membranes. — Tuberculosis  of  the  serous  mem- 
branes may  be  divided  into  the  acute  and  chronic  forms.  The  acute  is  further 
subdivided  into  (a)  an  acute  serofibrinous  form,  macroscopically  identical  or 
indistinguishable  from  serofibrinous  serositis  arising  from  other  causes;  (b)  an 
acute  miliary  tuberculous  serositis  due  to  the  invasion  of  the  serous  membrane 
by  tubercle  bacilli  and  the  formation  of  miliary  tubercles.  The  two  forms  just 
mentioned  may  be  distinct  or  coincident.  The  chronic  tuberculous  serositis  may 
be  (a)  fibrocaseous  or  (b)  fibrohyaline.  The  former  results  from  the  formation  of 
tuberculous  exudates,  in  which  extensive  caseation  gives  rise  to  cheesy  acciunu- 
lations  of  various  sizes  surrounded  by  granulations  or  more  fully  organized  fibrous 
tissue.  Marked  calcareous  change  is  frequently  associated  with  this  form.  The 
fibrohyaline  type  is  characterized  by  marked  thickening,  and  the  formation  of 
adhesions  by  newly  developed  fibrous  tissue  of  a  peculiar  grayish,  translucent  form. 
Both  the  chronic  forms  may  occur  together,  and  the  caseous  masses  may  be 
enclosed  by  hyaline  fibrous  tissue  of  the  type  just  mentioned. 

Minot  states  that  Robert  Whytt,  of  Edinburgh,  in  1768,  first  accurately 
described  this  condition,  although  he  had  no  clear  conception  of  its  cause. 
Guersant,  in  1827,  reported  that  the  pathological  appearances  of  the  membranes 
were  of  so  peculiar  a  type  that  he  suggested  the  name  "granular  meningitis." 
In  1830  Papavoine  described  the  disease  as  a  true  tuberculous  lesion,  and  the 
condition  of  moderate  hydrocephalus  which  existed  with  the  meningitis  was  recog- 
nized as  having  its  origin  in  the  tuberculous  infection.  It  was  reserved  for  W. 
W.  Gerhard,  of  Philadelphia,  in  1833,  to  show  not  only  that  this  type  of  meningitis 
was  tuberculous,  but  that  it  was  practically  in  every  instance  secondary  to  some 
tuberculous  lesion  elsewhere. 

Acute  Meningeal  Tuberculosis. — Meningeal  tuberculosis  is  an  inflammation  of 
the  pia  mater  produced  by  an  infection  of  this  membrane  with  the  Bacillus  tiiber- 
culosis  and  accompanied  by  an  effusion  of  lymph,  it  may  be  the  formation  of  pus, 
and  the  development  of  tubercles.    These  tubercles  are  usually  very  minute,  but 


248 


DISEASES  DUE  TO  A  SPECIFIC  IXFECTIOX 


occasionally  are  large  from  the  amalgamation  of  se\eral  tubercles  into  one.  They 
are  most  profuse  at  the  liase  of  the  brain,  hence  the  name  basilar  meningitis,  and 
extend  upward  on  its  sides  following  chiefly  the  vascular  pathways.  In  some 
instances,  however,  the  pia  mater  on  the  convexity  of  the  brain  contains  more 
tubercles  than  exist  at  the  base.  Nearly  always  at  the  base  there  is  a  copious 
exudate  of  lymph  which  produces  a  pearly,  gelatinous  appearance.  The  lateral 
ventricles  are  distended  with  fluid. 

Tuberculous  meningitis  is  twice  as  prevalent  in  March,  April,  and  IMay  as  in 
other  months;  probably  because  an  earlier  infection  of  the  respiratory  and  abdomi- 
nal organs,  hitherto  latent,  is  made  active  by  the  severe  weather  and  indoor  life 
of  the  winter  months. 


Fi 

G.  ; 

2 

aO      «.0      cO     ~0     £0     20     -0      »0               -^a                  "I                     1 

4.1 

W 

A 

3.T 

/\ 

an 

j 

\ 

?". 

J 

V 

?,n 

( 

k^ 

^^ 

A 

I.T 

1 

\ 

V, 

in 

1 

\ 

^ 

/" 

.5 

1 

\ — 

— ^ 

The  age  incidence  in  218  cases  cf  tuberculous  meningilis  in  children.     (Holt.) 

Symptoms. — The  symptoms  of  acute  meningeal  tuberculosis  are  very  char- 
acteristic, whether  it  occurs  in  children  or  adults.  It  is  much  more  frequently 
seen,  however,  in  children  between  two  and  se\'en  years.  These  symptoms  are 
best  divided  into  three  stages  for  study.  At  first  the  parent  notices  that  the  child 
is  unusually  peevish  and  irriiahle,  or  in  other  cases  peeuliarly  languid  and  indisposed 
to  play.  There  is  little  restful  sleep  and  the  child  often  has  night  terrors.  The 
appetite  is  capricious  and  the  bowels  irregidar.  After  these  symptoms  ha\e  lasted 
for  some  days,  during  which  time  the  tubercles  have  probably  been  deposited 
in  the  pia  mater,  the  well-developed  symptoms  of  the  disease  appear.  Headache 
may  be  constant  and  is  characterized  by  sharp  exacerbations  of  pain  which  cause 
the  child  to  give  a  peculiar  high-pitched  scream  which  is  quite  characteristic.  Sud- 
den attacks  of  vomiting  of  an  explosive  character  may  occur.  At  times  a  fleeting 
delirium  may  be  present. 

It  is  almost  impossible  in  many  of  these  cases  to  exclude  early  tyiihoid  fever, 
for  a  similar  train  of  symptoms  may  be  presented  in  its  early  stages. 

The  temperature  is  usually  elevated,  rising  as  high  as  102°  or  103°.  The  pulse 
is  sloic  and  the  respirations  are  irregular  and  nighing.  Rapid  emaciation  takes 
place,  and  if  the  child  be  very  young,  so  that  the  fontanelle  is  open,  there  may  be 
distinct  hydrocephalic  enlargement.  The  patient  now  lies  stuporous  or  somnolent, 
with  the  eyes  half-closed.  Indeed,  the  appearance  may  be  that  of  deep  sleep 
with  sighing  breathing. 

In  some  cases  in  which  the  onset  of  the  aft'cction  is  rather  acute,  the  patient 
sufl'ers  from  a  series  of  convulsions.  I  have  seen  such  a  case  with  Dr.  Brouwer,  of 
Tom's  River,  New  Jersey,  while  preparing  this  article,  in  which  the  child  had  as 
many  as  sixty  convulsions  in  twentv-four  hours. 


TUBERCULOSIS  249 

As  the  exudate  increases  symptoms  of  intracranial  pressure  and  signs  of  inter- 
ference with  the  cranial  nerves  appear,  so  that  squint,  twitching  of  the  facial 
muscles,  and  chewing  movements  of  the  lips  and  jaws  de\'elop. 

Kernig's  sign  (see  Cerebrospinal  Fever)  is  present  in  most  cases  as  is  also  that 
of  Babinski.  Brudzinski's  sign  consists  in  contraction  of  the  muscles  of  one  leg 
when  the  leg  of  the  other  side  is  passively  bent.  This  is  called,  also,  the  contra- 
lateral reflex.  Another  symptom  consists  in  the  fact  that  when  the  neck  is  passively 
flexed  on  the  chest,  the  child  being  in  the  dorsal  decubitus,  flexion  of  the  knees  and 
of  the  thighs  on  the  pelvis  takes  place.    This  is  called  Brudzinski's  neck  sign. 

Even  as  late  as  this  the  patient  may  be  aroused  and  may  seem  so  much  better 
for  a  time  that  the  friends  are  much  encouraged,  but  a  relapse  inevitably  occurs. 
The  child  is  now  too  stuporous  to  be  roused,  the  eyes  are  filled  with  sticky  secre- 
tion, and  the  parents  find  solace  in  the  belief  that  even  if  hopelessly  ill  the  patient 
does  not  suffer.  The  solace  is,  however,  occasionally  rudely  dispelled  by  a  shrill, 
piercing  cry  which,  interrupting  the  profound  stillness,  is  more  than  usually  start- 
ling. As  death  approaches  the  pulse  becomes  very  rapid,  probably  from  vagal 
paralysis,  the  pupils  no  longer  react  to  light,  and  the  eyeballs  are  rotated  upward. 

The  duration  of  the  entire  illness  is  about  ten  to  eighteen  days,  as  a  rule,  but 
cases  may  die  as  early  as  the  end  of  fi^•e  days,  in  a  convulsive  seizure,  or  they  may 
last  for  several  weeks. 

Diagnosis. — ^The  diagnosis  of  acute  miliary  tuberculous  meningitis  must  be 
made  with  the  recollection  that  the  following  conditions  simulate  it:  Acute  men- 
ingitis not  due  to  tubercle  is  rare  in  children,  has  a  more  sudden  onset,  as  a  rule, 
and  ends  in  a  week  in  most  cases.  The  delirium  accompanying  it  is  more  marked, 
the  febrile  movement  is  sharper,  and  there  is  usually  no  history  of  tuberculosis 
m.  the  family  as  there  is  in  the  tuberculous  case  in  many  instances.  Tuberculous 
meningitis  often  develops  very  rapidly  but  rarely  in  so  short  a  time  as  a  few  hours. 

From  cerebrospinal  meningitis  of  the  epidemic  type  it  is  separated  by  the  sudden 
onset  of  that  disease,  by  the  absence  of  its  eruption,  and  by  the  fact  that  no  cases 
of  cerebrospinal  meningitis  have  occurred  in  the  vicinity.  By  spinal  puncture 
the  meningococcus  may  be  obtained  in  one  case  and  the  tubercle  bacillus  in  the 
other,  although  the  latter  is  not  constantly  discovered.  The  fluid  in  cerebro- 
spinal fever  contains  polymorphonuclear  cells  and  hyaline  leukocytes,  while  in 
tuberculous  meningitis  recent  studies  seem  to  show  that  a  high  lymphoc;ytosis  is 
the  rule.    (See  Cerebrospinal  Fever.) 

Hemenway  found  the  tubercle  bacillus  in  the  cerebrospinal  fluid  in  1.35  out  of 
1.37  cases. 

As  meningeal  tuberculosis  is  so  common  in  children  the  tuberculin  test  of  INIoro 
may  be  resorted  to.  This  consists  in  rubbing  into  the  skin  of  the  abdomen  on  one 
side  an  ointment  of  Koch's  Old  Tubercidin,  5  c.c.  with  5  grams  of  anhydrous 
wool  fat.  A  piece  of  ointment  about  as  large  as  a  pea  is  used  and,  as  a  control,  wool 
fat  is  rubbed  into  the  skin  of  the  opposite  side.  If  the  patient  is  tuberculous  an 
erythema  of  the  skin  develops  in  twenty-four  hours  which,  if  the  reaction  is  severe, 
may  become  papular  and  if  very  severe  the  papules  may  be  greatly  reddened  and 
almost  nodular.  The  great  advantage  of  the  test  is  its  safety.  If  the  patient  is 
very  gravely  ill  of  tuberculosis  no  reaction  may  occur. 

Some  clinicians  divide  tuberculous  meningitis  in  children  into  three  types: 

(1)  The  hemiplegic,  with  localized  or  general  convulsive  seizures  and  finally  coma. 

(2)  The  somnolent,  with  fixity  of  the  eyes  without  winking,  with  occasionally 
wakening  and  finally  deep  coma.  (3)  The  most  common  eclamptic  type  with  high 
temperature  ranges,  paralysis,  hemiplegia,  or  paraplegia  with  much  rigidity  of  the 
neck  and  finally  coma. 

The  prognosis  is  absolutely  hopeless  although  Pitfield  and  others  have  recorded 
single  cases  which  have  recovered. 


250  DISEASES  DUE  TO  A  SPECIFIC  IXFECTION 

Tuberculous  Pleurisy. — Tul)prculous  pleurisy  is,  in  the  vast  majority  of  cases, 
secondary  to  tuberculous  infection  in  other  parts.  Most  commonly  tlie  primary 
focus  is  in  the  lungs  or  in  the  mediastinal  glands.  In  some  instances  the  process 
is  the  result  of  a  general  infection  which  results  in  miliary  tuherculosis,  and  in  tiiese 
instances  it  not  infreciuently  happens  that  the  pleura  is  involved  without  there 
being  any  tuberculous  process  in  the  lungs.  Thus  Hodenpyl,  in  91  autopsies  on 
persons  in  whom  the  lungs  were  free  from  tubercle,  found  miliary  tulierculosis 
of  the  pleura  in  41,  both  the  parietal  and  visceral  layers  being  affected.  lie  also 
believes  that  miliary  tulierculosis  of  the  pleura  is  apt  to  undergo  fibrous  changes. 

The  tuberculous  lesions  are  of  three  types.  In  the  first  type  we  find  scattered 
patches  of  tuberculous  deposit  which  are  the  continuation  of  a  tuberculous  pro- 
cess in  the  lung  beneath  the  visceral  layer  of  the  pleura,  or  similar  patches  are  found 
which  are  independent  of  lung  involvement,  or  again  patches  appear  upon  the  pari- 
etal pleura.  In  the  second  type  the  lesions  are  simply  those  of  a  widespread  miliary 
tuberculosis  of  the  pleura,  and  in  the  third  type,  which  is  representati\-e  of  a  more 
chronic  or  slow  process,  there  is  great  thickening  of  the  pleura,  partly  as  the  result 
of  the  organization  of  formed  exudates  and  also  of  proliferative  changes  in  the 
primitive  serous  layers.  Throughout  this  tissue  and  exudate  miliary  tubercles, 
or  masses  of  miliary  tubercles,  appear.  These  undergo  coagulation  necrosis  in 
some  instances. 

The  presence  of  any  one  of  these  processes  usually  results  in  the  out-pouring 
of  a  certain  amount  of  eff^ision  which  is  often  serous  and  by  no  means  rarely  puru- 
lent. When  it  is  serous  it  is  lacking  in  fibrin  and  it  may  be  tinged  with  l)lood. 
The  physician  should  recall  the  important  clinical  fact,  in  connection  with  these 
tuberculous  pleural  effusions,  that  whether  thej'  be  serous  or  purulent,  an  examina- 
tion of  the  fluid  will  rarely  reveal  the  tubercle  bacillus  unless  in  some  manner  these 
organisms  are  dislodged  from  the  pleural  surface  by  scraping.  In  some  cases  the 
effusion  is  not  due  to  the  bacillus  tuberculosis  alone,  but  to  an  associated  infection. 
Thus,  in  the  purulent  type  the  Pneuviococcus,  Streptococcus,  or  Stafhjlococcvs 
-pyogenes  are  often  found.     (See  Empyema.) 

Reference  has  already  been  made  to  the  fact  that  the  \'isceral  layer  of  the  pleura 
is  often  infected  by  a  tuberculous  process  in  the  lung  as  a  result  of  direct  extension. 
It  may  be  added  that  in  nearly  every  case  an  inflammatory  area — that  is,  a  local- 
ized plcuritis — exists  over  the  seat  of  the  disease  in  the  pulmonary  tissues.  This 
condition  often  gives  rise  to  pain  in  the  chest  and  not  rarely  causes  adhesions  between 
the  layers  of  the  pleura.  The  inflammatory  process,  while  tuberculous  in  origin, 
is  not  necessarily  tuberculous  in  character,  but  it  often  becomes  tuberculous,  as 
already  stated. 

Sometimes  when  the  tuberculous  mass  in  the  lung  softens  and  breaks  down,  the 
visceral  layer  of  the  pleura  is  perforated  and  sudden  dyspnea  and  pain  ensues,  with 
the  production  of  pneumothorax.  (See  Pneumothorax  and  Complications  of 
Pulmonary  Tuberculosis.)  Through  this  opening  infection  with  pyogenic  bacilli 
occurs  or  the  Bacillus  tuherculosis  becomes  pyogenic,  and  as  a  consequence,  pyo- 
pneumothorax develops.    (See  Pyopneumothorax.) 

Tuberculosis  of  the  Pericardium. — Like  tuberculosis  of  the  pleura,  pericardial 
tuberculosis  is  usually  secondary  to  primary  infection  elsewhere.  It  may,  however, 
be  primary.  It  occurs  in  two  forms:  the  miliary,  in  which  the  small  tubercles  are 
scattered  or  profuse,  and  in  a  form  in  which  the  entire  pericardium,  both  in  its 
visceral  and  parietal  layers,  is  thickened  by  an  inflammatory  exudate  which  is 
associated  with  the  development  of  tuberculous  masses  which  undergo  cheesy 
change.  In  this  type  the  pericardial  space  may  be  nearly  obliterated  by  the  adhe- 
sions which  are  formed  between  its  layers.  It  is  a  noteworthy  fact  that  although 
the  pericardium  is  so  near  the  lungs  and  pleura  it  is,  comparatively  speaking,  rarely 
infected.     Out  of  1048  autopsies  Wells  found  tuberculous  pericarditis  only  lU 


TUBERCULOSIS  251 

times  and  in  4500  autopsies  Ba^insky  found  it  15  times.  In  1317  autopsies  on 
phthisical  patients  WilHgk  found  tuberculosis  of  the  pericardium  11  times.  Leudet 
found  it  8  times  in  299  autopsies.  In  1000  autopsies  Osier  found  7  cases  of  tuber- 
culous pericarditis.  Ellis  has  reported  from  the  laboratories  of  the  Jefferson 
Medical  College  a  case  in  which  the  heart,  the  pericardium,  anrl  the  mediastinal 
tissues  formed  one  large,  adherent  mass  of  tuberculous  nodules. 

The  sijmytoms  presented  by  tuberculosis  of  the  pericardium  may  be  so  slight 
that  no  suspicion  of  pericardial  disease  exists  during  life,  or  they  may  resemble 
those  of  mediastinopericarditis,  or  adherent  pericardium.  (See  Adherent  Peri- 
cardium.) 

Tuberculosis  of  the  Peritoneum. — Aside  from  tuberculosis  of  the  lungs,  tubercu- 
losis of  the  peritoneum  is  the  most  frequent  and  most  important  manifestation  of 
tuberculous  infection  met  by  the  physician.  The  statistics  of  Grawitz  and  Brunn 
show  that  in  13,422  autopsies  tuberculosis  of  the  peritoneum  was  found  284  times. 

In  2802  autopsies  on  tuberculous  subjects,  collected  from  various  sources,  the 
peritoneum  was  involved  in  571,  a  percentage  of  20.36.  These  figures  represent 
all  ages.  Steiner  found  the  peritoneum  affected  in  92  out  of  800  cases  of  tuber- 
culosis occurring  in  children,  or  in  11.5  per  cent. 

As  to  the  relative  frequency  of  the  disease  in  adults  and  children  Aldibert's 
statistics,  based  on  326  cases,  are  of  interest.  Of  these  326  cases,  274,  or  84.05 
per  cent.,  occurred  in  adults  and  the  remaining  52,  or  15.95  per  cent.,  occurred 
in  children.  It  is  in  a  very  large  proportion  of  cases  secondary  to  tuberculous  foci 
elsewhere.  The  combined  statistics  of  Munstermann,  Borschke,  and  Pribram, 
comprising  437  cases  of  tuberculous  peritonitis  examined  postmortem,  showed  that 
only  3  were  primary. 

A  tuberculous  family  history  is  present  in  53  per  cent,  of  cases.  The  disease 
is  much  more  common  in  the  female  than  in  the  male;  according  to  Nothnagel, 
90  per  cent,  of  the  cases  are  females.  Konig's  statistics  make  it  78  per  cent.  The 
proportion  of  tuberculous  peritonitis  at  autopsy  is  about  3  per  cent. 

Tuberculous  peritonitis  is  of  especial  interest  not  only  because  of  its  frequency 
and  gra\'ity,  but  because  it  is,  in  one  type  at  least,  more, readily  cured  than  any 
other  well-developed  form  of  internal  tuberculosis.  It  occurs  in  three  chief  vari- 
eties, viz.,  as  miliary  tuberculosis,  as  a  chronic  tuberculosis  with  large  nodules  and 
adhesions,  and  as  a  still  more  chronic  form  with  fibroid  changes.  The  relative 
frequency  of  the  different  forms  of  tuberculous  peritonitis  is  shown  by  the  following 
facts:  In  46  cases  which  came  under  the  observation  of  Munstermann,  25  were 
exudative,  21  were  plastic,  and  8  were  chiefly  caseous.  Of  the  21  plastic  cases  8 
were  fibrous.  Herringham  found  fibrous  adhesions  in  18  out  of  50  cases.  Borschke 
found  the  miliary  form  in  16  out  of  226  cases  which  came  to  autopsy. 

The  miliary  form  is  usually  secondary  to  infection  of  the  mesenteric  and  retro- 
peritoneal glands,  but  occasionally  in  women  the  infection  comes  from  the  Fallo- 
pian tubes,  or  in  males  from  the  bladder  or  other  part  of  the  genito-urinary  appa- 
ratus. The  miliary  tubercles  are  scattered  widely  over  the  peritoneum  on  both 
its  visceral  and  parietal  layers  (Fig.  53),  and  the  surface  of  the  liver  is  often  pro- 
fusely peppered  by  these  formations.  In  these  cases  there  is  a  serous  effusion  into 
the  peritoneum  which  in  some  instances  is  very  profuse,  particularly  if  the  case  is 
rather  subacute  in  the  rapidity  of  its  course.  In  some  instances  the  symptoms 
come  on  acutely  and  give  rise  to  the  diagnosis  of  appendicitis. 

Another  mode  of  its  development  is  well  illustrated  by  a  case  I  saw  some  years 
since  with  my  associate.  Dr.  Thornton.  A  girl  about  twelve  or  thirteen  years, 
while  in  apparently  good  health,  was  bathing  in  a  pond  and  playing  with  a  small 
rowboat,  the  sharp  prow  of  which  struck  her  a  severe  blow  on  the  epigastrium,  which 
made  her  nauseated  and  faint.  She  speedily  began  to  lose  weight  and  strength, 
became  distinctly  emaciated,   and   rapidly   developed   a  marked  ascites.     The 


252 


DISEASES  DUE  TO  A  SPECIFIC  IXFECTIOX 


abdomen  was  opened  and  everj-  peritoneal  surface  was  found  literally  co\-ercd  with 
tubercles.  The  fluid  was  allowed  to  escape,  drainage  was  ])crmitted,  and  perfect 
recovery  followed.  Undoubtedly  the  blow  on  the  belly  ruptured  a  tuberculous 
mesenteric  or  retroperitoneal  gland,  and  so  produced  general  peritoneal  infection. 
In  such  a  case  no  nodules  can  be  found  in  the  belly  on  palpation,  but  the  presence 
of  ascites  in  a  child,  or  in  an  adult,  without  any  signs  of  hepatic  disease  should  lead 
the  physician  to  suspect  tuberculosis  of  this  type,  particularly  if  in  addition  there 
is  present  some  fever  of  an  irregular  type,  whicji  is  commonly  moderate,  but  which 
may  rise  at  times  as  high  as  108°  or  even  104°. 


Miliary  tubercles  ol  the  surface  of  the  small  bowel  and  mesentery.     (Kast  and  Rumpler.) 

How  opening  the  belly  and  permitting  drainage  cures  these  cases  is  not  known, 
but  the  clinical  fact  that  such  a  result  is  often  achieved  is  not  to  be  denied,  and 
this  hokls  true  even  if  this  condition  develops  in  adults.  Walter's  statistics  show 
that  50  per  cent,  of  adults,  who  are  subjected  to  laparotomy  recover,  and  Ilerz- 
feld's  statistics  give  a  recovery  percentage  of  02  per  cent,  for  children.  ]\Iarganecci 
gives  85  per  cent.,  von  Krencki  71.5  per  cent..  Thomas  73  per  cent.  Hall  reports 
94  cures  out  of  110  operations. 

The  second,  caseous,  type  of  peritoneal  tuberculosis  with  nodules  is  characterized 
by  the  presence  of  caseous  masses  of  tubercle  wliicii  tend  to  ulcerate,  which  are 
associated  with  scropurulent,  or  purulent,  effusion  in  moderate  amount,  and  in 
which  the  belly  cavity  is  not  distended  by  fluid  nor  tiic  intestines  by  gas,  as  in  the 
miliary  form  just  described,  but  is  apt  to  present  a  j)eculiar  pasteboard  rigidity. 
The  effusion  in  these  cases  is  often  sacculated  by  reason  of  the  fact  that  there  are 
formed  adhesions  which  wall  off  spaces  in  wliich  the  fluid  collects.  These  spaces 
may  be  between  coils  of  intestine  or  contiguous  mesentery,  between  the  intestine 
and  omentum,  and  between  the  omentum  and  the  parietal  peritoneum. 

In  some  instances  these  sacculations  arc  capable  of  containing  but  a  few  drachms 
of  fluid,  but  in  those  cases  in  which  fairly  large  peritoneal  areas  are  separated  from 


TUBERCULOSIS, 


253 


the  general  peritoneum  by  adhesions  very  large  accumulations  of  fluid  may  be 
present.  If  this  takes  place  in  the  flanks  or  lower  zone  of  the  abdomen,  where  it 
usually  occurs,  the  symptoms  may  very  closely  resemble  ovarian  cyst,  and  many 
cases  have  been  operated  upon  with  the  idea  that  ovarian  disease  was  the  cause 
of  the  fluctuating  mass.  Careful  palpation  under  ether  may  reveal  an  irregular 
nodular  edge  to  the  growth,  or  nodules  elsewhere  may  explain  the  real  state. 
Sometimes  the  masses  are  not  in  great  numbers,  but  occur  singly,  and  if  the 
intestine  be  involved,  tuberculous  ulceration  may  result  and  induce  a  fulminating 
peritonitis.  Often  the  presence  of  tuberculosis  is  not  suspected  until  the  belly  is 
opened. 


A  case  of  peritoneal  tuberculosis  of  the  fibroid  type  in  a  man  aged  twenty-one  years,  with  great  general 
atrophy  and  scaphoid  belly. 

The  chronic  fibroid  type  may  resemble  the  nodular  type  just  spoken  of,  but  in  it 
the  matting  of  the  abdominal  contents  into  a  small  compact  mass  is  quite  extra- 
ordinary, the  intestines  and  omentum  being  glued  together  in  an  adhesive  bundle 
which  cannot  be  separated.  In  these  cases  the  gluing  together  of  coils  of  intestine 
results  in  intestinal  obstruction.  In  this  type  the  belly  is  often  remarkably  sca- 
phoid and  the  degree  of  general  emaciation  extraordinary.  Some  idea  of  its  degree 
may  be  gathered  from  the  illustrations  shown  in  Figs.  54  and  55. 

The  symptoms  of  chronic  fibroid  peritoneal  tuberculosis  are  characteristic.  In 
addition  to  the  general  emaciation  it  will  often  be  found  that  the  sidn  over  the  abdo- 
men looks  and  feels  peculiarly  rough  and  scurf-like,  or  as  if  there  was  marked  "  goose- 
flesh"  over  this  part.    In  addition  it  is  often  stained  a  curious  dirty  yellow  or  is 


254 


DISEASES  DUE  TO  A  SPECIFIC  INFECTION 


light  brownish  in  hue.  The  ahdommal  icall  is  not  only  hard,  but  the  abdominal 
muscles  are  readily  felt  by  the  finger-tips,  while  deep  paljxiHoii  reveals  nodules 
or  gives  the  sense  of  abdominal  vacancy  as  if  the  patient  had  been  eviscerated.  The 
temjjcratvre  range  is  not  markedly  febrile,  and  often  is  subnormal,  ranging  from  9G° 
in  the  morning  to  99°  at  night. 

Fig.  55 


iliuu  ia  a  woman,  due  to  tliorac-it  and  peritoneal  tuberculosis  of  the  fibroid  type. 


It  is  not,  however,  in  these  well-advanced  forms  of  the  disease  that  the  physician 
has  difficulty  in  making  a  diagnosis,  but  in  those  cases  in  which  there  is  general 
impairment  of  health  without  marked  general  emaciation;  and  it  may  be  with- 
out distinct  abdominal  symptoms  save  obstinate  constipation,  with  occasionally 
attacks  of  active  jmrging,  or  in  those  instances  in  which  the  patient  is  still  hale 
and  robust,  but  suffers  from  some  abdominal  distress.  These  cases  often  present 
a  distinct  abdominal  tumor,  or  tumors,  composed  of  tuberculous  nodules,  or  of 
nodules  combined  with  thickened  knuckles  of  intestine  wliich  may  be  so  firmly  held 
by  adhesions  of  exuded  lymph  that  gas  and  feces  produce  a  tumor  that  cannot  be 
readily  dispelled  by  pressure. 

Sometimes  a  tumor  is  met  with  in  the  epigastric  area  extending  across  the 
abdomen  at  this  level,  or  just  above  the  umbilicus,  formed  by  a  peculiar  rolling 
of  the  omentiun  as  a  workman  would  roll  up  his  apron  and  stow  it  under  his  belt. 
A  similar  condition  is  sometimes  found  in  carcinomatosis  of  the  peritoneum,  but 
such  a  roll  is  usually  due  to  tuberculosis. 

When  the  mesenteric  glands  or  retroperitoneal  glands  are  g^a^'ely  infected,  a 
single  nodule  or  several  nodules  may  be  easily  palpated.  When  multiple  they  are 
usually  tuberculous,  but  where  it  is  single  a  careful  exclusion  of  malignant  growth 
must  be  made  liy  finding  a  tui)erculous  focus  elsewhere,  or  by  the  tuberculin  test. 

Treatment  of  Tuberculosis  of  the  Peritoneum. — The  treatment  of  the  subacute 
or  chronic  forms  of  peritoneal  tuberculosis  consists  in  operation.  The  first  thing 
to  be  looked  for  at  operation  in  peritoneal  tuberculosis  in  the  female  is  the  Fallo- 
pian tubes,  for  they  are  the  cause  in  the  majority  of  cases.  If  diseased  they  must 
be  removed,  for  such  tubes  will  persistently  infect  the  pcritoncuni. 

The  operative  treatment  is  most  successful,  as  a  rule,  when  the  state  is  char- 
acterized by  suflRcient  effusion  to  keep  the  intestinal  coils  apart,  and  so  prevent 
adhesions.  The  operation  consists  in  a  single  opening  of  the  peritoneal  cavity 
and  a  free  entrance  into  it  of  atmospheric  air.  Any  attempt  to  remove  the  tuber- 
culous masses  is  useless,  unless  a  single  mass  can  be  excised  without  damaging  the 
tissues  and  without  the  danger  of  setting  free  bacilli  to  cause  infection  elsewhere. 
In  sacculated  cases  the  sac  should  be  incised,  drained,  and  packed  with  iodoform 
gauze.  In  the  chronic  fibroid  type  operation  will  not  be  productive  of  much  good, 
for  it  cannot  result  in  the  loosening  of  the  shrivelled  omentum  or  of  the  cicatricial 
contractions  about  the  intestines,  but  in  these  cases  celiotomy  may  arrest  the 
disease.     When  there  are  sacculations  with  accumulations  of  fluid  or  pus,  the 


TUBERCULOSIS  255 

.operation  is  of  value  in  that  it  evacuates  these  collections  and  may  arrest  the 
process,  but  it  does  not  promise  complete  cure  as  in  the  cases  with  large  ascites. 
(For  statistics  see  page  252.) 

The  medical  treatment  consists  in  active  feeding  with  easily  assimilated  food- 
stuffs and  in  the  use  of  cod-liver  oil.  If  anemia  is  marked  the  syrup  of  the  iodide 
of  iron  may  be  given  in  alternate  weeks  w^ith  the  oil,  and  I  have  certainly  seen  good 
results  follow  the  use  of  nightly  iodoform  inunctions  over  the  abdomen,  a  mixture 
of  olive  oil  and  iodoform  in  the  proportion  of  10  grains  to  the  ounce  being  used. 
Iodoform  suppositories,  10  grains  each,  may  also  be  employed. 

Pulmonary  Tuberculosis. — Pulmonary  tuberculosis,  or  pulmonary  phthisis,  as 
it  is  sometimes  called  because  it  causes  such  emaciation  or  wasting,  is  the  most 
prevalent  disease  to  which  man  is  susceptible.  It  affects,  as  a  rule,  young  adults 
or  adolescents  (see  Frequency  of  Tuberculosis),  but  it  may  occur  at  any  period 
of  life,  being  comparatively  rare  in  the  first  five  years  of  existence  and  in  the  period 
of  well-developed  old  age. 

As  a  result  of  infection  of  the  lung  by  the  Bacillus  tiiherciilo.sk-  we  find  three 
types  of  pulmonary  disease:  the  miliary,  the  chronic  or  caseaiing,  ulcerative  type, 
and  the  so-called  fibroid  type.  Of  these  the  second  form  is  by  far  the  most  common 
and  the  most  important  from  the  clinical  stand-point.  The  infection  takes  place 
as  a  primary  process  through  the  entrance  of  the  bacillus  by  the  respiratory  passages, 
or  secondarily  as  a  result  of  the  transference  of  the  bacillus  from  some  primary 
focus  by  the  bloodvessels  or  lymphatics. 

Much  discussion  has  arisen  as  to  the  mode  by  which  the  first  focus  of  tuberculosis 
in  the  lung  is  produced.  Birch-Hirschfeld  proved  that,  in  many  cases  at  least, 
the  bacilli  gain  their  primary  lodgement  in  a  bronchiole,  where  the  limg  is  least 
able  to  get  rid  of  foreign  matter  by  coughing,  and  that,  from  a  primary  tuberculous 
lesion  at  this  point  the  rest  of  the  lung  becomes  infected.  Aufrecht  also  pro^'ed 
that  the  primary  infection  sometimes  takes  place  through  the  circulation,  to  which 
the  bacilli  gain  access  by  the  tonsils  and  the  alimentary  canal,  the  pulmonary  focus 
being  due  to  a  plugging  of  a  vessel  by  their  presence. 

Whether  the  means  of  infection  be  respiratory  or  vascular,  the  ultimate  lesions 
are  often  the  same;  but  the  early  lesions  differ,  and  the  prognosis  may  be  governed 
to  some  extent  by  the  finding  of  a  primary  focus  elsewhere  which  is  responsible 
for  the  pulmonary  lesions. 

The  early  lesions  of  pulmonary  tuberculosis,  due  to  infection  by  inhalation  (aero- 
genous  infection),  are  found  chiefly  in  the  w^all  of  a  bronchiole  and  in  the  alveoli 
grouped  around  it  and  forming  lobules.  Either  by  extension  from  this  infected 
lobule  or  by  the  fusion  of  a  number  of  similarly  affected  lobules,  large  tuberculous 
masses  are  speedily  formed.  They  are  also  characterized  by  the  extension  of  the 
tuberculous  infection  to  the  tissues  around  the  bronchioles,  giving  rise  to  an  extend- 
ing bronchopneumonia  which  is  nodular  in  its  character  owing  to  the  primary 
lobular  limitations. 

The  early  lesions  of  the  form  of  tuberculosis  of  the  lung  which  is  due  to  infection 
by  way  of  the  bloodvessels  or  lymphatics  are  found  in  the  walls  of  the  alveoli — that 
is  to  say,  in  the  connective  tissue  between  the  alveoli  and  in  the  interlobular  capil- 
laries. The  disease  may  be  well  scattered  through  both  lungs  in  either  instance,  but 
in  the  first  type  the  patches  are  larger,  involving,  it  may  be,  a  lobule  at  a  time, 
whereas  in  the  second  form  they  are  diminutive  and  more  of  the  nature  of  miliary 
tubercles  as  observed  elsewhere.  This  we  would  naturally  expect  from  what  has 
been  said  of  the  cause  of  miliary  tuberculosis.  After  the  disease  has  existed  some 
time  the  areas  of  tuberculous  deposit  in  either  case  may  attain  the  same  size. 

The  discovery  that  there  is  a  primary  seat  of  tuberculosis,  which  has  given  rise 
to  the  pulmonary  lesions,  requires  a  graver  prognosis  because  it  indicates  that  there 
is  more  than  one  focus,  and  because  such  a  primary  lesion  which  has  caused  pul- 


256  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

moiiary  disease  by  infection  through  the  vessels  may  iiave  caused  other  foci  of 
infection  elsewhere  by  the  same  means.  Again,  the  disease  is  more  apt  to  be 
generalized  throughout  the  lung  in  this  case  than  in  the  ins]>irator\'  form  of  infection. 

Tul)ercuk)us  infection  of  the  lung,  therefore,  jiroduces  the  following  changes 
in  the  pulmonary  tissues:  The  gray  and  yellow  tuljcrcles,  wliicii  differ  in  no  way 
from  those  tut)crcles  already  described  as  occurring  elsewhere,  become  amalga- 
mated and  form  caseous  masses,  with,  sooner  or  later,  the  characteristic  softening 
of  the  growth;  if  the  tubercles  do  not  undergo  necrosis  and  fail  to  coalesce,  the 
accompanying  low-grade  irritation  or  iiiflanmiation  may  lead  to  fibroid  changes. 
Along  with  these  changes  in  the  tubercles  themselves  there  is  always  associated  a 
considerable  amount  of  inflammation,  which  often  results  in  the  formation  of  an 
exudate  which  fills  the  air  vesicles  just  as  it  does  in  croupous  or  catarrhal  pneumonia. 
Side  by  side  with  the  development  of  the  tubercles  in  the  lungs,  and  of  the  pneu- 
monic exudate,  there  develops  in  the  interstitial  tissues  themselves  a  process 
which  is  tuberculous  and  which  causes  thickening.  This  is  the  so-called  tuberculous 
infiltration  of  Laennec.  The  lung,  therefore,  becomes  solidified,  partly  as  the 
result  of  the  tuberculous  growth,  and  partly  as  a  result  of  the  inflamnuition  caused 
by  the  bacillus. 

Sooner  or  later  a  large  part  of  the  infiltrated  area  undergoes  caseation.  Around 
this  focus  or  area  of  active  tuberculous  process  inflammatory  changes  occur,  which 
may  cause  the  neighboring  parts  of  the  lung  to  present  lesions  like  those  of  catarrhal 
pneimionia.  On  making  a  section  of  such  an  area  the  lung  presents  a  smooth, 
homogeneous  surface,  as  does  a  piece  of  Castile  soap  or  cheese  (Figs.  56  and  57), 
but  if  the  process  is  not  far  advanced  in  caseation  it  may  show  a  peculiar  gelatinous 
appearance,  the  so-called  gelatinous  pneumonia. 

The  fourth  condition,  which  is  noteworthy,  is  the  lack  of  bloodvessels  in  the 
diseased  portion  of  the  lung,  for  no  new  ones  are  formed  with  the  morltid  growth 
and  the  ones  naturally  present  are  occluded  by  the  <lisease  which  invohes  their 
coats  and  causes  thrombosis;  the  resulting  thrombus  in  turn  undergoes  caseation 
so  that  the  vessels  disappear  in  the  tuberculous  mass.  These  vascular  changes 
possess  great  interest  for  this  reason,  and  also  because  by  this  means  the  tubercle 
bacillus  may  enter  the  blood  and  infect  other  points,  or  by  a  process  of  ulceration 
of  the  vessel  wall  hemorrhages  may  occur. 

All  tuberculous  lesions  in  the  lungs  are,  therefore,  very  similar  in  character; 
all  manifest  a  disposition  to  undergo  similar  reparative  or  degenerative  changes, 
the  alterations  being  differences  in  degree  rather  than  in  kind. 

When  the  restrictive  efforts  of  the  affected  organ  arc  inarlcquate  caseation 
extends  until  a  bronchus  is  reached,  through  which  the  products  of  necrosis  are 
removed  by  drainage  and  expectoration.  Air  takes  the  place  of  the  material 
removed,  and  so  a  cavity  is  formed,  the  walls  of  which  are  lined  by  liroken-dowii 
tubercle-containing  material,  which  continually  softens  (caseation)  and  melts 
down,  thereby  enlarging  the  cavity.  This  cheesy  material  is  loaded  with  bacilli 
in  far  greater  numbers  than  they  exist  in  the  solidified  part  of  the  lung.  The 
cavity  is  also  infected  by  the  pathogenic  bacteria  inhaled  in  the  air,  and  these  aid 
in  the  destructive  local  process  and  increase  the  general  toxemia. 

It  is  interesting  to  note  that  the  smaller  bronchioles  are  usually  dosed  by  tulier- 
culous  infiltration  as  the  disease  progresses  and  onl\'  the  larger  ones  remain  j)atulous. 
These  conununicate  with  the  cavities  by  small  lateral  orifices  as  the  tube  courses 
along  the  wall  of  the  excavation,  or  open  into  the  cavity  like  the  small  papilla  of 
a  duct.  The  walls  of  the  bronchial  tubes  which  provide  drainage  for  the  cavities 
are  often  the  site  of  tuberculous  ulceration. 

Tuberculous  cavities  are  of  two  classes,  moist  or  secreting,  and  dry.  The  first 
is  that  met  with  in  the  acute  types  of  the  disease  and  it  often  increases  in  size  very 
rapidly.     Tlu'  contents  of  this  cavity  are  usually  composed  of  caseous  matter. 


TUBERCULOSIS  257 

broken-down  lung  tissue,  pus  cells,  and  tubercle  bacilli,  and  the  walls  of  the  cavity 
suffer  from  active  ulceration. 

The  dry  cavity,  on  the  other  hand,  is  found  in  the  chronic  cases  which  often 
last  for  years;  efforts  at  repair  smooth  the  wall,  in  which  fil)rous  tissue  develops, 
and  it  not  rarely  happens  that  by  the  fibroid  process  already  described  as  occurring 
in  this  disease  the  size  of  the  cavity  is  greatly  decreased.  These  cavities  contain 
but  little  material  beyond  a  small  amount  of  pus,  and  from  their  walls  hemorrhage 
may  rarely  occur  as  the  result  of  erosion  of  large  vessels.  Secondary  cavities  are 
due  to  the  spread  of  the  infection  by  the  vessels  or  bronchi,  and  follow  the  secondary 
caseation  process  already  described. 


Caseous  consolidation  in  the  upper  lobe  and  bronchiectasis  in  the  lower  lobe.     (Kast  and  Rumplcr.) 

We  have  now  passed  over  the  stage  of  pulmonary  infection,  consolidation, 
caseation,  and  disintegration,  and  come  to  the  study  of  the  processes  often  instituted 
in  reparation.  This  is  not  a  part  of  the  tuberculous  process.  The  small-cell 
infiltration  and  exudation  in  the  inflammatory  zone  surrounding  the  area  of  infection 
sometimes  escape  speedy  involvement  in  the  tuberculous  process,  and  instead 
of  degenerating  rapidly  aid  in  the  production  of  fibrous  tissue.  At  first  it  is 
immature  and  imperfect  in  character,  but  as  time  passes  it  becomes  firm,  dense, 
and  fully-formed  fibrous  tissue.  If  the  tuberculous  focus  is  small  it  may  be  com- 
pletely encapsulated  by  this  fibrous  covering,  with  the  result  that  the  caseous 
mass  becomes  calcareous  or  is  gradually  absorbed  so  that  only  a  puckered  scar 
results. 

When  a  cavity  heals  its  walls  undergo  cicatricial  contraction,  but  it  is  probably 
ne-\'er  obliterated  unless  it  has  been  exceedingly  small  before  the  healing  process 
began. 


258 


DISEASES  DUE  TO  A  SPECIFIC  IXFECTIOX 


In  regard  to  the  distribution  of  the  cavities  Ewart  has  collected  the  following 
interesting  statistics.  In  791  cases  cavity  occurred  at  the  apex  in  282  cases,  in 
the  dorso-axillary  region  in  227,  in  the  mammary  region  in  189,  in  the  sternal  region 
in  61,  and  at  the  base  in  32. 

The  growth  of  fibrous  tissue  is  most  marked  in  those  parts  of  the  lung  wjiicli 
ordinarily  possess  the  greatest  amount  of  connective  tissue,  as  in  the  interlobar 
and  interlobular  portions  of  the  pulmonary  tissues. 


Caseous  consolidation  above.     Red  hepatization  below.     (Kast  and  Rumplcr.) 

If  a  large  cavity  is  present  bands  of  fibrous  tissue  may  persist,  and,  stretching 
across  it,  form  trabecule  (Fig.  58).  At  times  these  trabecule  consist  largely  of 
good-sized  bloodvessels  which  have  not  been  closed  by  the  tuberculous  process. 
If  they  are  perforated  by  ulceration,  so  violent  a  hemorrhage  may  occur  as  to 
cause  death,  even  though  the  process  of  advancing  cicatrization  is  endeavoring 
to  limit  the  progress  of  the  disease.  At  times  the  lesion  in  the  bloodvessel  develops 
into  an  aneurysm,  and  this  may  rupture,  causing  hemoptysis. 

Finally,  we  find  still  another  process  designed  to  arrest  the  disease  and  save  the 
patient,  namely,  thickening  of  the  pleura  which  protects  the  pleural  cavity  from 
pneumothorax  and  which,  as  it  undergoes  fibroid  change,  contracts  and  so  acts 
as  a  sort  of  fibrous  capsule  of  the  entire  diseased  lung. 

Fibroid  tubemdosis  of  the  lungs  is  a  very  chronic  condition,  already  described 
from  the  pathological  stand-point,  and  characterized  by  marked  overgrowth  of 


TUBERCULOSIS 


259 


fibroid  tissue  in  the  affected  organ.  A  somewhat  similar  state  exists  wlien  no 
tubercles  have  been  present.  The  primary  areas  of  tuberculous  invasion  become 
invested  by  fibrous  tissues  so  that  tuberculous  bronchopneumonia  becomes  gradu- 
ally changed  into  one  of  fibrous  overgrowth,  with  shrinkage  of  the  parts  so  that 
the  lung  becomes  much  decreased  in  size  and  even  the  chest  may  be  sunken  and 
deformed.  These  thoracic  changes  are,  however,  more  marked  in  those  cases  in 
which  the  visceral  pleura  is  also  involved  in  the  cicatricial  or  fibroid  process.  The 
disease  loses  many  of  the  symptoms  of  ordinary  pulmonary  tuberculosis,  and  while 


Left  lung,  superior  lobe  and  upper  part  of  lower  lobe,  the  former  containing  a  number  of  communicating 
caverns,  brought  about  by  tuberculous  infiltration,  caseation,  and  evacuation  of  the  contents  through 
the  bronchi:  A,  aneurysmal  dilatation  of  an  artery  spanning  one  margin  of  a  large  ca\'ity ;  B.  communica- 
tion with  another  cavity;  C,  C  thickened  and  adherent  pleura  between  the  two  involved  lobes.  The 
pleura  over  both  lobes  is  thickened,  and  at  the  autopsy  the  cavity  had  been  obliterated  by  universal 
adhesion;  D,  the  pointer  from  the  letter  D  leads  to  a  small  group  of  tubercles  in  which  caseation  is  just 
beginning;  E,  a  fused  group  of  tubercles,  further  advanced  than  at  D, 


the  constricted  cavities  may  contain  bacilli  and  the  bronchial  tubes  provide  copious 
material  for  expectoration,  the  process  of  general  wasting  goes  on  very  slowly  and 
the  strength  does  not  decrease  with. any  speed.  Such  conditions  are  usually  seen 
in  patients  of  middle  life  and  may  last  for  ten  to  twenty  years.  Death  finally 
comes  from  dilatation  of  the  heart  or  from  an  acute  complicating  pneumonia  or  a 
hemorrhage  from  an  ulcerated  bronchial  vessel. 

Symptoms  of  Pulmonary  Tuberculosis. — The  onset  of  this,  the  most  common 
type  of  the  disease,  is  often  such  as  to  mislead  the  physician.  In  some  cases  there 
is  no  cough,  but  only  a  slight  rise  oj  evening  temferature  preceded  by  chilly  sensations. 


260  DISEASES  DUE  TO  A  SPECIFIC  IXFECTION 

If  the  cases  in  wliich  these  symptoms  have  given  rise  to  the  diagnosis  of  "malarial 
jjoisoning"  could  be  gathered  together  they  would  be  a  "multitude  which  none 
can  number."  In  many  instances  this  error  has  been  a  deserved  reproach  to 
the  physician  who  made  it,  because  he  has  not  searched  for  tuberculosis  as  a  cause 
but  has  simply  prescribed  quinine. 

Another  type  of  onset  is  found  in  those  cases  which  present  insidious  pleural 
efl'usion.  (See  Pleurisy  with  Effusion.)  In  still  a  third  series  the  ])rimary  syni])- 
toms  are  laryngeal.  As  these  lines  are  written  I  am  sending  a  case  of  active  tuber- 
culosis of  the  lungs  to  New  Mexico.  He  was  told  by  several  skilled  laryngologists 
that  his  husky  voice  was  due  to  gout  of  the  larynx,  whereas  if  they  had  examineil 
his  chest  marked  signs  of  phthisis  would  have  made  the  diagnosis  evident.  All 
cases  presenting  signs  of  persistent  hoarseness  should  cause  the  physician  to  search 
for  tuberculosis,  syphilis,  papilloma  of  the  larynx,  and  aneurysm  of  the  aorta. 

In  the  fourth  type  the  very  earliest  sign  of  the  disease  is  spiff  inc/  of  blood.  There 
can  be  no  doubt  that  in  the  vast  majority  of  instances  the  bringing  up  of  blood 
from  the  bronchial  tubes  means  tuberculous  infection.  The  only  other  causes 
which  are  at  all  frequent  in  the  production  of  hemoptysis  are  acute  pneumonia 
or  pulmonary  infarction  due  to  cardiac  lesions.  It  not  infrequently  occurs  that 
hemoptysis  in  the  stage  of  onset  is  scanty  and  associated  with  no  demonstrable 
physical  signs,  the  lesion  being  situated  in  such  a  position  that  it  readily  perforates 
a  vessel.     (See  p.  261.) 

The  symptoms  of  pulmonary  tuberculosis  may  be  di\ided  for  study  into  those 
which  are  complained  of  by  the  patient,  those  which  can  be  readily  observed  by 
the  physician,  and  those  which  can  be  demonstrated  by  the  aid  of  physical  diagnosis. 
It  must  be  remembered,  however,  that  the  severity  of  the  symjrtoms  of  all  kinds 
varies  to  an  extraordinary  degree  in  different  cases  and  at  different  times  in  the 
same  case.  It  is  necessary,  therefore,  in  speaking  of  the  symjjtoms  to  adhere  to 
the  description  of  the  three  types  of  the  disease  named  when  discussing  its  path- 
ology. At  the  outset,  however,  it  may  be  said  that  two  symptoms  are  present  in 
all  cases  at  some  period,  namely,  loss  of  flesh  and  fever. 

It  may  be  said  of  the  femr  of  fubcrcidosis  that  it  is  usually  moderate,  varying 
from  100°  to  102°,  although  at  times  it  may  reach  103°.  When  the  temperature 
reaches  higher  than  this  it  is  probably  not  due  solely  to  the  tuberculous  infection, 
but  to  septic  or  hectic  fever,  depending  uixm  associated  staphylococcic,  pneumo- 
coccic,  or  streptococcic  infection.  In  all  instances  in  which  the  fever  is  high  it  is 
prone  to  run  a  A-ery  uncertain  and  aberrant  course,  sa^'e  that  it  is  high  at  night  and 
low  in  the  morning,  as  in  nearly  all  fevers,  particularly  that  due  to  sepsis.  It  is 
very  easily  broken,  as  a  rule,  by  the  use  of  any  antipyretic  medicine,  but  this 
effect  of  drugs  is,  of  course,  very  temporary. 

The  loss  of  weicjlif  depends  upon  several  causes  for  its  existence.  The  loss  of 
appetite,  the  cough,  which  is  exliausting  and  sleep-destroying,  the  sweats,  the 
disorders  of  digestion,  and  the  anemia  are  all  active  factors  in  decreasing  flesh. 
Last,  but  by  no  means  least,  as  a  cause  of  loss  of  weight,  is  to  be  considered  the 
to.remia  of  the  disease  itself. 

The  rajjidity  of  loss  of  flesh  is  sometimes  remarkable,  amounting  to  as  much 
as  four  or  five  pounds  a  week.  This  rapidity  of  loss  is  a  good  guide  to  the  activity 
of  the  tuberculous  process,  for  if  it  be  rapid  the  outlook  as  to  the  progress  of  the 
patient's  illness  is  gloomy.  On  the  other  hand,  gain  in  weight  is  correspondingly 
encouraging  in  that  it  indicates  a  very  slow,  or  arrested,  progress  of  the  disease. 

A  third  symptom,  often  of  very  great  annoyance  to  the  patient,  is  sweating,  which 
is  particularly  prone  to  occur  at  night.  These  sweats  vary  greatly  in  se\-erity, 
and  seem  to  occur  because  of  the  relaxation  of  sleep,  but  in  many  cases  their  true 
cause  is  the  hectic  or  septic  state  of  the  patient.  If  they  are  not  severe  enough  to 
exliaust  the  patient  or  disturb  his  rest,  they  are  to  be  regarded  as  an  effort  to 


TUBERCULOSIS  261 

fliminish  toxemia,  but  if  they  become  so  profuse  as  to  be  called  colliquative  they 
are  deleterious.  At  times  the  sweat  follows  a  sharp  rise  of  septic  temperature. 
It  is  hardly  necessarj'  to  add  that  profuse  night  sweats,  while  a  common  symptom 
in  well-developed  phthisis,  are  by  no  means  pathognomonic  of  this  disease. 

Aside  from  the  loss  of  flesh,  fever,  and  sweats,  the  most  constant  symptom  of 
pulmonary  tuberculosis  is  cough.  It  varies  in  its  character  and  in  its  degree  in 
different  cases  of  the  subacute  or  chronic  form  of  the  disease.  In  the  early  stages 
it  is  apt  to  be  worse  on  going  to  bed  or  on  getting  up  in  the  morning,  and  in 
these  stages  is  usually  annoyingly  unproductive  and  persistent.  As  the  disease 
advances  and  the  process  of  softening  begins  to  take  place  in  the  consolidated 
part  of  the  lung,  the  cough  becomes  less  dry  and  more  productive.  When  cavities 
are  formed,  marked  increase  in  morning  cough  is  very  prone  to  occur  in  order  that 
the  cavity  may  be  well  cleared  of  the  accumulations  which  have  occurred  in  it 
during  the  night.  Cough  is  to  be  regarded  as  a  useful  attempt  on  the  part  of  the 
system  to  keep  the  lungs  clear.  Only  when  it  provokes  hemorrhage  or  is  so  excessive 
as  to  cause  ejchaustion,  loss  of  sleep,  or  vomiting  is  it  to  be  regarded  as  an  evil. 

Aside  from  the  general  symptoms  of  tuberculosis  already  described,  patients 
with  pulmonary  tuberculosis  often  have  severe  pain  in  the  chest,  which  is  due  to  an 
extension  of  the  inflammation  to  the  visceral  layer  of  the  pleura.  They  also  suffer 
from  dyspnea  on  exertion  partly  because  of  the  diminished  area  of  lung  and  lessened 
ability  of  the  blood  to  carry  oxygen,  partly  from  cardiac  feebleness,  and  partly 
because  the  general  nervous  system  and  the  muscles  are  so  feeble  that  any  exercise 
leads  to  exhaustion. 

The  sputum  is  composed  of  mucopurulent  material  from  the  associated  chronic 
bronchitis,  or  if  the  lung  is  beginning  to  undergo  softening  the  expectorated  material 
is  thin,  with  small,  pale  and  greenish-looking  masses  in  it — the  so-called  "  nummular 
sputum."  Sometimes  when  a  cavitj^  is  being  emptied  or  there  is  a  marked  bron- 
chorrhea  the  sputum  is  very  purulent. 

The  quantity  of  sputum  varies  greatly.  The  average  amount  in  an  active 
case  varies  from  1  to  4  ounces  a  day,  but  I  have  known  a  patient  with  several 
cavities  to  raise  a  pint  or  more  in  twenty-four  hours. 

Complications. — ^A  frequent  symptom  of  the  ulcerative  tj-pe  of  pulmonary  tuber- 
culosis is  hemoptysis,  but  a  large  number  of  cases  pass  tlirough  all  stages  of  the 
disease  without  bringing  up  a  particle  of  blood.  It  is  absent,  according  to  West, 
in  from  20  to  30  per  cent,  of  cases.  Hemoptysis  is  more  than  tlu-ee  times  as  frequent 
in  males  as  in  females.  The  quantity  of  blood  lost  varies  from  a  mere  streak  in 
the  sputum  to  3  ounces  in  the  average  case.  Occasionally  it  amounts  to  4  or  6 
ounces,  but  a  little  blood  "goes  a  great  way,"  and  patients  will  state  that  they  have 
spit  a  quart  when  only  a  few  ounces  have  been  raised.  It  is  rare  for  as  large  an 
amount  as  a  pint  to  be  coughed  up  in  twenty-four  hours.  Very  rarely  a  large  gush 
causes  death  by  suffocation.  Sometimes  the  hemorrhage  is  concealed  and  unaccom- 
panied by  blood-tinged  sputum.  If  of  a  dribbling  type  it  may  inundate  a  large 
part  of  the  lung  or  even  fill  a  cavity  and  cause  death  without  any  external  manifes- 
tation; such  cases  are  rare.  A  free  hemorrhage  nearly  always  means  the  presence 
of  an  ulcerating  cavity.  The  blood  in  hemoptysis  may  come  from  the  pulmonary 
vessels  or  from  the  bronchial  vessels,  but  it  is  usually  from  the  former.  Flick, 
Ravenel  and  Iraan  believe  that  hemoptysis  is  usually  due  to  pneumococcus 
infection. 

All  ages  may  suffer  from  hemorrhage  from  the  lungs,  but  the  period  from  eighteen 
to  thirty-five  is  of  course  that  of  greatest  frequency.  HofFnung  has  recorded  a 
case  in  a  child  of  ten  months  and  Powell  one  in  a  child  at  seven  months  of  age. 
The  hemorrhage  occurs  most  frequently  at  night. 

The  blood  which  is  expelled  in  true  hemoptysis  is  usually  frothy  and  is  brought 
up  by  coughing.     It  is  also  usually  red  except  in  instances  of  slow  oozing  into  a 


262  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

cavity,  when  it  may  appear  as  a  dark  clot  or  clots.  When  the  bleeding  is  profuse 
the  blood  gushes  out  of  the  mouth.  Often  before  the  spitting  of  blood  actually 
takes  place  a  salty,  or  bloody,  taste  in  tiie  mouth  is  persistently  present  for  some 
time. 

Hemoptysis  due  to  pulmonary  tuberculosis  is  to  be  separated  from  hematemesis 
by  the  fact  that  the  first  occurs  with  coughing  and  the  secontl  with  retching  or 
vomiting.  It  is  further  differentiated  by  the  fact  that  the  blood  is  frothy  and 
filled  with  mucus  and  bubbles  and  is  usually  bright  red  in  hemoptysis,  whereas 
in  hematemesis  it  is  usually  pure  or  discolored  by  contact  with  the  gastric  juice. 
In  one  state  the  history  of  pulmonary  disease,  or  the  disco^■ery  of  lesions  in  the 
lungs,  reveals  the  seat  of  the  hemorrhage ;  in  the  other  gastric  symptoms  are  present. 
In  hemoptysis  the  blood  is  often  brought  up  in  small  degree  for  several  days, 
whereas  in  hematemesis  it  is  usually  brought  up  once  or  twice  on  one  day  and  then 
the  bleeding  ceases. 

In  this  connection  it  must  not  be  forgotten  that  hemoptysis,  or  blood-spitting, 
is  not  always  due  to  tuberculosis  of  the  lungs.  It  is  sometimes  present  in  the 
stage  of  onset  in  acute  croupous  pneumonia.  It  is  not  rarely  met  with  in  thoracic; 
aneurysm,  and  its  occurrence,  unless  it  be  very  profuse,  does  not  necessarily  mean 
immediate  death  in  the  latter  type  of  cases,  since  it  not  rarely  happens  that  the 
vessel  oozes  blood  for  several  days  before  it  finally  completely  gi^"es  way.  Some- 
times by  the  pressure  of  the  aneurysmal  sac  some  small  vessel  may  be  eroded  so 
that  the  blood  escapes  from  it  alone.  Slight  hemoptysis  occurs  in  some  cases  of 
malignant  intrathoracic  growth,  and  swollen  glands  by  pressme  may  rupture  a 
neighboring  vessel  and  cause  leakage  of  blood.  Again,  hemoptysis  often  develops 
in  mild  degree  as  a  result  of  pulmonary  infarction. 

Among  the  other  causes  of  hemoptysis  may  be  mentioned  hemorrhage  from  a 
superficial  vessel  in  a  bronchial  tube  in  bronchiectasis,  and  from  the  larynx  in 
malignant  and  non-malignant  growth  or  tuberculosis  of  this  organ.  Hemoptysis 
is  sometimes  due  to  a  varicose  condition  of  the  veins  at  the  root  of  the  tongue. 

A  peculiar  form  of  hemoptysis  which  lasts  in  some  cases  for  years  is  seen  in 
Formosa  and  Japan,  due  to  the  presence  of  the  parasite  Paragonimus  westermanni. 
(See  Parasitic  Hemoptysis.) 

Although  hemoptysis  in  the  great  majority  of  cases  indicates  pulmonary  tuber- 
culosis, it  must  not  be  forgotten  that  this  symptom  sometimes  occurs  for  years 
without  any  other  signs  of  the  disease  appearing.  I  ha\e  one  case  in  mind  in 
which  the  young  wife  of  a  student  at  the  Jefferson  College  had  repeated  hemorrhages 
during  an  entire  winter  without  any  physical  signs  being  present,  and  continued  to 
have  them  for  many  years  afterward.  Eight  years  after  they  began  she  still 
had  them  on  exertion,  but  was  the  picture  of  health,  had  no  signs  of  aneurysm  or 
tuberculosis,  and  had  gained  thirty-fi^'e  pounds. 

Many  of  the  other  complications  of  pulmonary  tuberculosis  in  addition  to 
vomiting,  diarrhea,  and  hemoptysis  have  already  been  considered  when  discussing 
the  disease  as  it  aft'ects  serous  membranes,  as  in  pleurisy  and  pericarditis.  The 
most  important  is  2mcumothora.x ,  which  follows  the  perforation  of  the  tuberculous 
lesion  into  the  pleura.  It  occurs  in  from  3  to  10  per  cent,  of  all  cases,  is  often 
fatal  if  sudden  in  onset,  and  may  cause  distressing  dyspnea.  ^Yest  says  that  of 
39  cases,  2  died  in  an  hour,  S  others  in  twenty-four  hours,  and  29  out  of  the  39 
inside  of  two  weeks.  The  mortality  is  about  90  per  cent.  Effusion  usually  speedily 
develops.  I  have  seen  great  relief  follow  gentle  aspiration  of  the  air  from  the  thorax, 
but  aspiration  is  to  be  avoided  save  when  the  pressure  produces  urgent  dyspnea. 
Sometimes  the  pneumothorax  develops  insidiously  without  severe  symptoms, 
producing  what  is  called  "latent  pneimiothorax."     (See  Pneumothorax.) 

A  still  more  rare  affection  seen  in  some  cases  of  the  chronic  forms  of  pulmonary 
tuberculosis  is  pulmonary  osteo-arthropathy  (which  see). 


TUBERCULOSIS  263 

Diagnosis. — Before  the  physical  signs  of  pulmonary  tuberculosis  are  dealt  with 
the  sites  of  the  lesions  usually  present  may  be  discussed,  so  that  they  may  be 
examined  with  particular  interest  in  every  case.  The  apices  are  the  parts  affected 
in  the  vast  majority  of  cases,  and  it  is  here  that  the  primary  lesion  is  usually  found, 
even  if  other  parts  become  more  severely  diseased  later  on.  The  process  as  it 
extends  is  prone  to  travel  backrsvard  rather  than  forward.  No  satisfactory  explana- 
tion of  this  fact  is  obtainable. 

Next  to  the  apices  the  upper  part  of  the  middle  lobe  on  the  right  side  is  most 
frequently  the  site  of  infection,  or  the  upper  part  of  the  lower  lobe  on  the  left  side 
is  diseased.  The  area  of  the  upper  part  of  the  middle  lobe  on  the  right  side  is  one 
which  is  often  overlooked,  owing  to  the  fact  that  it  is  covered  by  the  right  scapula. 
Only  when  this  scapula  is  raised  by  the  hand  being  placed  on  the  top  of  the  head  is 
the  spot  of  impaired  resonance  exposed  at  its  lower  margin. 

Tuberculosis  of  the  bases  rarely  occurs  except  after  the  disease  has  lasted  long 
enough  to  involve  the  whole  lung. 

Physical  Signs. — The  two  methods  of  physical  diagnosis  which  give  us  the 
most  information  in  cases  of  pulmonary  tuberculosis  are  percussion  and  auscultation. 
Throughout  that  period  in  which  there  is  infiltration  or  consolidation  of  the  lung 
■percussion  gives  impaired  resonance  or  dulness  over  all  the  part  affected,  unless  the 
lesion  be  deep-seated,  in  which  case  light  percussion  over  this  part  may  produce  a 
sound  which  is  high-pitched  or  slightly  tjTiipanitic.  It  is  of  the  utmost  importance 
that  the  physician  apply  the  light  percussion  test  skilfully,  as  infiltration  is  the 
first  or  early  lesion,  and  this  is  the  stage  when  a  cure  is  usually  possible.  The  most 
important  areas  to  be  so  tested  are  the  apices,  anteriorly,  below  and  abo^■e  the 
clavicles,  with  and  without  forced  inspiration,  and  on  the  top  of  the  shoulder. 

At  the  right  apex  the  resonance  on  percussion,  the  vocal  resonance  on  auscultation 
and  the  vocal  fremitus  on  palpation  are  all  greater  than  at  the  left  apex  in  most 
healthy  persons.  With  the  development  of  cavity  the  percussion  note  over  it 
undergoes  a  change  and  there  is  developed  a  high-pitched  tjTnpanitic  resonance, 
which  careful  percussion  will  show  to  be  surrounded  by  an  area,  or  ring,  of  impaired 
resonance  representing  the  surrounding  area  of  infiltrated  lung  tissue.  At  times 
in  the  neighborhood  of  tuberculous  lesions  in  the  lungs  hj-perresonance  is  developed 
on  percussion,  as  the  result  of  a  compensatory  emphysema  of  the  lung.  If  the 
cavity  communicate  with  a  bronchus  and  the  patient  takes  a  breath  and  holds  it, 
with  the  mouth  open,  percussion  may  develop  the  so-called  "cracked-pot  sound." 

Auscultation  reveals,  in  the  earliest  stages  of  infiltration,  prolongation  of  expira- 
tion in  the  part  involved.  This  is  a  physical  sign  of  very  great  importance.  Again, 
it  may  reveal  some  harshness  of  the  inspiratory  murmur  and  both  inspiration  and 
expiration  may  be  more  distinct  and  rougher  than  in  health. 

Occasionally  careful  auscultation  will  also  reveal  a  few  very  fine  rales  on  forced 
inspiration.  In  lesions  of  the  apex  on  the  left  side  such  a  forced  inspiration  not 
rarely  produces  an  inspiratory  soimd  which  is  interrupted  by  the  action  of  the  heart 
three  or  four  times  during  the  act  of  drawing  air  into  the  lung  and  forced  respirations 
followed  by  a  cough  may  develop  rales  or  cog-wheel  sounds  not  otherwise  demon- 
strated. 

It  must  not  be  forgotten  that  negative  signs  may  be  as  valuable  as  positive 
ones,  and  therefore  if  the  infiltration  produces  an  absence  of  breath  sounds  at  the 
infected  spot  this  may  indicate  disease  as  surely  as  do  the  more  positive  signs 
already  named. 

If  the  physician  listens  carefully  over  the  area  of  consolidation  with  his  disen- 
gaged ear  closed  by  his  finger-tip,  and  the  patient  will  say  one,  two,  three  in  a  stage 
whisper,  the  area  of  consolidation  will  give  greater  vocal  resonance  than  the  same 
area  in  the  healthy  lung. 

With  the  development  of  softening  the  fine  dry  rales  which  have  been  heard  at 


2G4  DISFASl'S  DVF.    TO  A   SI'I'CIFK'  IXFKCTIOS 

first  become  coarse  and  moist,  and  as  a  cavity  is  formed  they  may  become  even 
bubbling  or  gurgling.     These  rales  sometimes  possess  a  curious  metallic  sound. 

As  the  cavity  is  formed  the  \-ocal  resonance  o\'er  it  increases  and  may  become 
startlingly  clear,  so  that  when  the  patient  speaks  the  sound  of  the  voice  is  trans- 
mitted witli  great  clearness  through  the  chest  wall.     This  is  called  jiectoriloquy. 

Over  such  a  cavity  cavernous  breathing  is  often  heard,  or,  if  the  cavity  is  a 
small  one,  the  breathing  may  be  hollow,  tubular,  or  amphoric,  as  if  the  patient 
were  blowing  with  his  lips  over  the  mouth  of  an  open  bottle. 

Moist  cavities  also  present  on  auscultation,  in  addition  to  large  moist  rales, 
metallic  tinkling  due  to  the  dropping  of  fluid  from  their  walls.  This  metallic 
tinkling  is  to  be  separated  from  the  metallic  tinkling  of  hydropneumothorax  by 
the  absence  of  the  physical  signs  of  fluid  in  a  dependent  part  of  the  chest,  and  by 
the  fact  that  such  a  cavity  is  near  the  upper  part  of  the  Iimg  and  so  produces  this 
sign  in  the  upper  zone  of  the  chest. 

The  sounds  arising  from  a  tlry  ca\-ity  are  blo\\'ing  or  amphoric.  When  such  a 
cavity  has  existed  long  enough  for  marked  fibroid  change  to  occur  it  often  happens 
that  the  chest  over  the  affected  part  is  greatly  flattened,  and  it  may  be  decreased 
in  all  diameters.  Compensatory  hypertrophy  of  the  opposite  lung  causes  an 
increase  in  the  size  of  the  chest  on  that  side,  and  this  emphasizes  the  difl'erence 
between  the  two  sides.  Further  than  this,  the  contraction  process  may  greatly 
displace  nearby  organs.  Thus,  if  the  left  lung  undergoes  this  change,  the  rigiit 
lung,  partly  from  enlargement  and  partly  from  traction,  may  extend  as  far  as  three 
inches  to  the  left  of  the  sternimi,  the  heart  may  be  drawn  upward  and  tilted  to 
the  left  of  the  nipple  as  high  as  the  third  interspace.  E\-en  the  stomach  may  be 
drawn  upward.  On  the  other  hand,  when  the  right  lung  is  aft'ected  by  the  disease 
the  heart  may  be  drawn  to  the  right  under  the  stermmi,  the  liver  may  be  pulled 
upM'ard,  and  the  left  lung  drawn  well  over  to  the  right  side  of  the  chest.  ]\Iost  of 
these  marked  changes  are  due  to  associated  pleural  adhesions,  and  these  may  cause 
deformity  of  the  entire  chest. 

The  diagnosis  of  cavity  from  bronchiectasis  is  made  by  the  recollection  that  a 
cavity  is  usually  near  the  apex,  and  bronchiectatic  spaces  are  at  the  base,  as  a  rule, 
although  they  may  de-\'eIop  as  high  as  the  third  or  fourth  rib.  If  so,  they  are 
nearer  the  sternum  than  is  the  cavity.  Again,  in  cases  of  cavity  the  area  around 
the  hollow  space  is  usually  dull  on  percussion,  whereas  in  bronchiectasis  it  is  usually 
hyperresonant  from  emphysema. 

It  is  to  be  remembered  that  tuberculosis  may  occur  as  a  complication  of  bronchiec- 
tasis, but  that  well-developed  bronchiectasis  rarely  occurs  in  tuberculosis  excej^t 
in  old  chronic  cases  with  much  contraction  due  to  fibroid  change. 

Palimtion. — Palpation  over  that  portion  of  the  chest  which  is  infiltrated  by  a 
tuberculous  process,  or  in  which  a  ca^•ity  has  already  formed,  also  presents  very 
definite  physical  signs  when  the  patient  speaks,  namely,  a  marked  increase  in 
vocal  fremitus.  If  the  cavity  is  superficial  and  of  any  size  it  may  be  possible  to 
feel  the  bubbling  rales  which  are  produced  by  its  contents.  Hyperalgesia  to 
irritation,  heat  and  cold  sometimes  exists  in  the  skin  over  areas  in  the  lung  affected 
by  pulmonary  tuberculosis,  and  this  sign  may  decrease  as  convalescence  is  estab- 
lished. 

Inspection. — Inspection  of  a  well-advanced  case  of  pulmonary  tubercidosis 
occurring  in  one  whose  configuration  is  naturally  phthisical  reveals  a  very  typical 
picture,  but  in  those  with  well-de\-eloped  chests  very  adN'anced  lesions  of  the  lungs 
may  be  present  before  any  change  in  the  appearance  of  the  chest  is  manifest. 

The  physical  sifjns  of  acute  pneumonic  tuberculosis  are  at  first  the  same  as  those 
of  acute  pneumonia.  There  are  bronchial  or  tubular  breathing,  dulness  on  percus- 
sion, and  fine  crepitant  rales.     As  the  disease  progresses  these  signs  become  modified 


TUBERCULOSIS  205 

to  the  extent  that  the  rales  become  coarse  and  more  moist  in  character,  and  signs 
of  softening  are  therefore  developed. 

In  the  diagnosis  of  a  case  of  this  character  it  may  not  be  possible  to  state  accu- 
rately the  true  cause  of  the  disease  for  several  days,  but  the  following  points  are 
of  some  value,  namely,  the  discovery  in  the  history  of  the  patient,  or  in  tiie  Ijody 
at  the  time,  of  a  tuberculous  infection,  as  of  enlarged  cervical  glands,  or  of  tuber- 
culous masses  elsewhere,  as  in  a  Fallopian  tube  or  in  a  testicle  or  joint;  the  general 
appearance  of  the  patient  as  to  nutrition,  for  the  pale,  anemic  patient  with  the 
typical  slim  bones  and  large  joints,  large  orbital  spaces,  and  delicate  features  is 
more  apt  to  succumb  to  the  bacillus  tuberculosis  than  to  the  pneiunococcus.  On 
the  other  hand,  it  is  to  be  remembered  that  robust  and  hearty  persons  may  de^'el()p 
acute  tuberculous  pneumonia  and  die  in  a  short  period.  The  jiresence  of  the 
pneumococcus  in  the  sputum  is  of  little  diagnostic  value,  but  the  discovery  of  the 
tubercle  bacillus  will  be  of  great  aid  in  determining  the  cause  of  the  illness. 

Microscopic  Diagnosis. — An  examination  of  the  sputum  in  pulmonary  tuber- 
culosis by  the  aid  of  the  microscope  reveals  shreds  of  mucus  mixed  A\ith  particles 
of  caseous  substance  and  small  round  cells,  leukocytes,  and  pus  corpuscles.  Crystals 
of  the  triple  phosphates,  oxalates,  and  of  tyrosin  and  leucin  are  often  present.  All 
these  constituents  of  the  sputum  are,  however,  of  little  importance  as  comparerl  to 
two  others,  namely,  the  presence  of  elastic-tissue  fibres  possessing  the  morphology 
and  arrangement  of  pulmonary  reticulum,  showing  that  breaking  down  of  the  lung 
is  taking  place,  and  tubercle  bacilli,  the  presence  of  which  reveals  the  fact  that  they 
are  the  cause  of  this  condition.  The  bacilli  are  indisputable  evidence  of  the  pres- 
ence of  the  disease,  but  their  absence  from  a  specimen  of  sputum  does  not  exclude 
tuberculosis,  because  they  may  happen  to  be  absent  from  that  individual  sample, 
or  they  are  absent  because  the  sputum  does  not  come  from  a  part  of  the  lung  in 
which  breaking  down  is  taking  place.  Even  an  old  cavity,  if  it  is  well  drained, 
may  not  provide  bacilli  constantly. 

Yellow,  elastic  fibres  are  to  be  sought  for  by  spreading  the  sputum  in  a  thin 
layer  on  a  pane  of  glass  placed  over  a  blackened  surface.  A  second  sheet  of  glass 
is  placed  over  this  and  the  sputum  smeared  by  moving  the  upper  piece  laterally. 
The  particles  of  elastic  tissue  are  usually  contained  in  small  masses  of  yellowish- 
gray  material,  which,  if  crushed  and  placed  under  the  microscope,  are  found  to 
consist  of  characteristic,  double-contoured,  interlacing,  yellow,  elastic  fibres, 
having  the  arrangement  of  the  pulmonary  elastica.  Elastic-tissue  stains  are  of 
value  in  the  hands  of  experienced  microscopists.  As  many  meats  are  rich  in  elastic 
tissue  which  may  lodge  in  the  mouth,  the  mere  finding  of  such  structures  in  the 
sputum  does  not  justify  the  diagnosis  of  "breaking  down"  of  the  lung.  The 
recognition  of  pulmonary  elastica  must  be  based  on  the  shape  and  arrangement 
indicated.     Occasionally  small  pieces  of  calcareous  matter  are  found  in  the  sputum. 

The  bacilli  are  sought  for  in  the  following  manner:  A  microscope  slide  is  thor- 
oughly cleansed  and  dried.  From  the  sputum  spread  out  on  a  glass  plate,  or  in  a 
Petri  dish,  nummular  particles  if  present  are  selected,  or  if  absent  the  thicker 
portion  of  the  sputum  is  spread  in  a  thin  layer  over  the  surface  of  the  slide  and 
allowed  to  dry  spontaneously.  The  dried  film  on  the  slide,  surface  upward,  is 
passed  three  times  through  the  flame  in  order  to  fix  the  thin  layer  firmly  to  the 
slide.  Cover-glasses  may  be  used  instead  of  slides,  but  possess  no  special  advan- 
tages. Of  the  many  stains  recommended  Ziehl's  carbol-fuchsin  gives  satisfactory 
results.  It  is  prepared  by  dissolving  1  gm.  of  powdered  fuchsin  in  10  c.c.  of  alcohol; 
to  this  solution  90  c.c.  of  5  per  cent,  aqueous  solution  of  carbohc  acid  is  added; 
the  stain  is  ready  for  immediate  use,  and  if  prepared  from  proper  ingredients 
keeps  well.  The  prepared  stain  is  poured  over  the  slide,  which  is  then  heated 
over  a  Bunsen  burner  or  alcohol  lamp  until  steam  begins  to  rise,  when  the  heat 


266  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

is  withdrawn.  After  staining  five  minutes  the  excess  is  poured  off  and  the  slide 
freely  washed  in  clean  water.  It  is  then  flooded  with  Gat)l)ett's  solution,  wliich 
consists  of  1.5  gm.  of  methylene  blue  dissolved  in  100  c.c.  of  a  25  \)0t  cent,  aqueous 
solution  of  sulphuric  acid.  This  is  allowed  to  act  for  one  minute;  it  is  then  poured 
oft'  and  the  slide  washed  in  water;  if  any  of  the  red  dye  be  retained  the  application 
of  the  Gabbett  solution  is  repeated  until  all  macroscopic  evidence  of  the  fuchsin 
has  disappeared  from  the  thoroughly  washed  slide,  which  is  then  stooil  on  end  and 
allowed  to  dry.  Instead  of  Gabbett's  solution,  Pappenheim's  decolorizer  is  now 
preferred  by  many  laboratory  workers.  It  is  made  by  dissolving  1  gm.  of  coralin 
(known  also  as  rosolic  acid)  in  100  c.c.  of  absolute  alcohol,  saturating  the  mixture 
with  methylene  blue,  and  then  adding  20  gm.  of  glj'cerin.  This  reagent  follows 
the  carbol-fuchsin  without  washing  in  water.  Three  to  five  changes  of  the  fluid 
are  used,  the  film  then  washed  in  water  and  allowed  to  dry.  Pappenheim's  method 
has  the  advantage  that  in  urinary  specimens  it  will  better  difterentiate  between 
tubercle  and  smegma  bacilli. 

A  drop  of  immersion  oil  is  placed  on  the  stained  film  and  the  specimen  examined 
with  a  one-twelfth-inch  immersion  lens.  If  it  be  desired  to  preser\-e  the  specimen, 
balsam  is  applied  to  the  dried  slide  and  a  cover-glass  placed  on  it.  In  properly 
prepared  films  the  cellular  elements  and  bacteria,  other  than  the  tubercle  bacillus, 
will  have  selected  the  blue  dye;  the  tubercle  bacillus,  however,  will  appear  red  on 
the  bluish  background. 

Tubercle  bacilli  are  found  so  constantly  in  many  cases  of  tuberculosis  in  the 
feces  that  the  stools  should  always  be  examined  whenever  lack  of  sputum  prevents 
the  case  from  being  readily  diagnosticated.  In  acute  miliary  tuberculosis  Rosen- 
berger  found  them  constantly  in  the  stools.  The  presence  of  tubercle  bacilli 
in  the  stools  does  not  necessarily  indicate  the  presence  of  intestinal  ulceration. 

X-Rays. — A  valuable  aid  in  determining  the  presence  of  consolidation  of  the 
lung  in  tuberculosis  is  the  use  of  the  fluoroscope  or  x-ray  photograph,  for  a  very 
distinct  opacity  often  reveals  such  a  lesion. 

TuhercuUn. — Tuberculin  is  used  in  three  ways  as  a  diagnostic  agent:  By  hypoder- 
mic injection ;  by  instillation  into  the  eye  and  by  applying  it  to  the  broken  or  un- 
broken skin.  When  used  hypodermically  in  the  hands  of  inexperienced  men  it  has 
been  well  said  that  the  use  of  tuberculin  is  like  looking  for  a  leak  in  a  gas  main  with 
a  lighted  candle;  and  La^\Tason  Brown  well  says  that  none  of  the  indications  of 
the  test  as  yet  devised,  difi'erentiate  clearly  clinical  tuberculosis  that  demands 
vigorous  treatment  form  non-clinical  tuberculosis  that  reciuires  onlv  a  God-fearing 
life. 

In  the  diagnosis  of  pulmonary  tuberculosis  there  can  be  no  doubt  that  tuberculin 
when  properly  employed  is  a  valuable  agent,  although  I  believe  that  in  the  majority 
of  instances  it  should  not  be  used,  since  careful  examination  of  the  patient  and 
consideration  of  his  history  will  in  most  instances  reveal  the  presence  of  tubercu- 
losis, or  point  to  its  presence  with  such  a  degree  of  certainty  that  the  patient 
should  certainly  be  sent  away  for  his  health  on  the  ground  that  he  is  a  fair  mark 
for  a  tuberculous  infection,  and  that  his  lung  is  in  such  a  condition  that  he  is  at 
all  times  liable  to  the  rapid  devekipment  of  a  true  tuberculous  process.  It  is 
thought  by  some  that  the  reaction  which  is  produced  may  actually  increase  the 
rapidity  of  the  tuberculous  process. 

Old  tuberculin,  which  is  used  hypodermically,  for  diagnostic  purposes  is 
usually  given  to  adults  in  the  dose  of  yV  to  5  milligrams,  and  if  tuberculosis 
is  present  it  causes  a  reaction  in  the  form  of  a  rise  in  temperature  of  two  or  three 
degrees  within  a  few  hours.  If  the  dose  is  larger  than  0.0001 ,  susceptible  persons 
may  have  a  violent  reaction.  If  the  patient  fails  to  react  to  the  smaller  doses, 
before  deciding  that  the  tuberculin  test  has  proved  him  free  from  tuberculosis, 
doses  of  2  mg.  or  3  mg.  or  even  more  should  be  given  at  intervals  of  a  week,  but 


TUBERCULOSIS  267 

a  reaction  is  not  positive  proof  of  tuberculosis,  for  it  is  to  be  remembered  that  the 
tuberculin  reaction  sometimes  occurs  in  persons  who  have  syphihs  and  rheumatoid 
arthritis.  It  is  thought  by  some  tliat  tiie  reaction  which  is  produced  may  actually 
increase  the  rapidity  of  the  tuberculous  process. 

The  use  of  tuberculin  for  diagnostic  purposes  has  a  larger  field  in  cases  of  suspected 
renal  or  abdominal  tuberculosis  than  it  has  in  the  diagnosis  of  pulmonary  lesions, 
in  which  the  physical  signs  can  usually  be  demonstrated. 

In  order  that  a  careful  record  of  its  effects  may  be  obtained  the  temperature 
of  the  patient  should  be  taken  after  the  injection  at  intervals  of  every  two  hours 
for  six  hours,  and  after  that  every  hour  for  tweh-e  hours.  Before  the  test  is  marie 
it  must  be  determined  that  the  patient  is  afebrile  by  a  careful  record  of  his  tempera- 
ture for  several  days,  as  otherwise  the  usual  fever  maj'  be  mistaken  for  a  reaction. 
The  subcutaneous  diagnostic  use  of  tuberculin  is  contra-indicated  if  there  are  active 
signs  of  disease  and  these  also  render  its  use  unnecessary  as  a  rule. 

In  addition  to  fever,  when  the  test  is  positive  there  is  usually  backache  and  pain 
in  the  limbs  so  that  the  patient  may  feel  as  if  suffering  from  an  attack  of  grippe. 
As  a  rule  the  reaction  begins  in  from  sLx  to  twelve  hours,  reaches  its  acme  in  from 
twelve  to  twenty-four  hours,  and  the  patient  recovers  by  the  end  of  thirty-six 
hours.     Rarely  the  reaction  may  persist  for  as  long  as  twelve  days. 

It  has  been  urged  against  Tuberculin  R.  that  there  is  a  possibility  of  its  containing 
living  bacilli  which  may  infect  the  patient.  For  this  reason  many  clinicians  employ 
a  tuberculin  prepared  by  filtration  and  subsequent  concentration  of  sterilized 
bouillon  cultures,  whereby  a  germ-free  produce  is  assured.     (See  Treatment.) 

The  opthalmotuberculin  test  depends  upon  the  fact  that  when  a  1  per  cent,  solution 
of  tuberculin,  prepared  by  precipitating  it  with  alcohol  and  washing  it  with  water, 
is  dropped  into  the  eye  of  a  patient  who  has  tuberculosis  in  any  part  of  his  body 
an  inflammatory  reaction  develops  in  the  conjunctiva  so  that  this  membrane 
becomes  infected  and  red.  For  this  test  tuberculin  is  made  up  in  tiny  tablets, 
each  of  which  contains  5  milligrams.  This  tablet  when  dissolved  in  0.33  c.c.  of  water 
(or  5  minims)  represents  in  each  minim  1  milligram  or  a  single  dose  for  the  test. 
As  with  the  injection  method  so  with  this,  a  reaction  is  not  absolutely  positively 
diagnostic.  There  are  two  important  facts  to  be  recalled  about  this  test.  First, 
that  if  tuberculin  is  dropped  into  the  eye  and  fails  to  produce  reaction  it  is  not 
possible  to  use  the  same  eye  for  a  subsequent  test  with  a  larger  dose,  since  the  eye 
has  become  sensitized  to  tuberculin  by  the  first  application.  Second,  it  is  generally 
considered  by  opthalmic  surgeons  that  this  test  may  cause  dangerous  ocular  inflam- 
mation if  the  patient  is  very  susceptible. 

The  cutaneous  method  of  von  Pirquet  consists  in  abrading  the  epiderm  of  the 
arm,  or  elsewhere,  as  in  vaccination,  in  two  adjacent  spots.  Upon  one  of  these 
abraded  areas  is  placed  a  drop  of  old  tuberculin,  25  per  cent,  strength.  The  other 
abraded  area  is  treated  by  a  drop  of  50  per  cent,  glycerin  in  water  containing 
one-tenth  per  cent,  of  carbolic  acid  and  is  used  as  a  control  spot.  If  the  reaction 
is  positive  the  area  which  has  received  the  tuberculin  becomes  reddened  after 
about  three  hours.  This  redness  reaches  its  height  in  twenty-four  hours  and  is 
nearly  gone  in  forty-eight  hours.  A  slight  papule  may  also  be  felt  or  seen.  In 
cases  of  delayed  but  more  severe  reaction  the  redness  may  not  appear  for  two  or 
three  days  and  may  persist  for  twenty-one  days  or  more,  the  papules  being  distinct 
and  constant.  The  part  may  itch  and  the  axillary  glands  become  a  little  swollen 
if  the  arm  is  the  limb  used  in  the  test.  If  these  various  changes  do  not  occur  the 
test  is  negative.  The  objection  to  this  test  in  adults  is  that  many  who  are  not 
suspected  of  having  the  disease  react.  If  the  patient  is  exceedingly  ill  from  tuber- 
culosis these  reactions  may  fail,  particularly  in  miliary  tuberculosis  and  tuberculous 
meningitis.  Von  Pirquet  also  states  that  it  is  often  negative  in  the  first  week  of 
measles.     (For  the  Moro  test  see  Tuberculous  Meningitis.) 


268  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

Prognosis. — It  is  not  long  since  it  was  almost  universally  thought  that  subacute 
pulmonary  tuberculosis  was  an  utterly  hopeless  and  incurable  disease.  At  present 
we  know  that  it  is  in  many  instances  a  curable  aH'ection,  even  when  it  is  not 
possible  to  obtain  the  very  best  conditions  for  cure.  Further,  we  know  that 
hundreds  of  persons  have  the  disease  and  get  \\-eIl  without  even  knowing  that  they 
have  had  it.  It  is  manifest,  however,  that  only  those  cases  can  recover  in  which 
the  disease  is  not  far  advanced  and  in  which  the  ^ital  resistance  of  the  individual 
can  be  maintained  at  such  a  level  that  the  protecti\e  processes  of  combat  and 
repair,  already  described  may  be  carried  out  to  completion. 

The  degree  of  vital  resistance  of  the  patient  is  of  very  great  importance  in  deciding 
the  prognosis.  Often  the  most  powerfully  built  individual  falls  a  \-ictim  to  rajjid 
phthisis  while  his  comparatively  feeble  comrade  manifests  the  most  remarkable 
vitality.  Additional  factors  in  determining  the  outlook  in  an  individual  case  are 
the  maintenance  of  the  body  weight,  the  absence  of  anemia  (but  red  cheeks  do 
not  necessarily  mean  good  blood),  and  the  presence  of  a  good  digestion,  particularly 
in  respect  to  starches  and  fats.  A  good  family  history  is  not  as  important  a  factor 
for  good  as  a  bad  history  is  important  for  evil. 

Considerable  work  has  been  done  to  determine  the  value  of  Arneth's  blood 
picture  as  a  prognostic  sign  in  the  way  of  estimating  the  reaction  of  the  jKitient. 
Arneth  makes  five  divisions  of  the  polynuclear  leukocytes  based  on  the  lobes  of  the 
nucleus,  from  one  irregular  lobe  up  to  five  distinct  lobes.  He  finds  the  average 
number  of  these  fi\'e  types  in  each  hundred  cells  in  healthy  persons  to  be  5,  35,  41, 
17,  and  2,  respectively.  The  postulate  is  that  the  fewer  the  lobes  the  younger 
and  less  efficient  the  cell.  A  shift  to  the  left,  that  is  an  increase  in  number  of  the 
first  two  groups  (the  sum  of  which  is  the  Arneth  index),  is  regarded  as  an  unfa\-orable 
sign.  Not  all  observers  are  agreed  upon  the  \'alue  of  this  method,  which  may  be 
partly  due  to  personal  equation  in  grouping  the  leukocytes.  It  appears  worthy 
of  further  testing  in  cases  under  treatment,  as  possibly  being  corroborative  of  the 
clinical  picture. 

A  large  number  of  statistics  as  to  the  curability  of  this  disease  by  climate  and 
feeding  and  by  out-door  life  are  now  obtainable,  and  some  statistics  will  be  found 
discussed  under  Treatment. 

F.  C.  Wood  belie\-es  that  the  diazo  reaction  can  be  used  to  aid  in  determining 
the  question  of  prognosis,  stating  that  if  no  reaction  occurs  and  the  kidneys  are 
intact  the  outlook  is  fa^•orable,  but  that  if  the  urine  re\'eals  a  strong  and  persistent 
reaction  the  outlook  is  evil. 

The  average  duration  of  life  in  a  case  of  pidmonary  phthisis  is  limited  to  two 
years. 

Marriage  should  be  forbidden  for  either  sex  if  suffering  from  tuberculosis,  even 
if  it  be  in  a  mild  form.  The  woman  who  is  tubercidous  may  sur\'ive  her  first 
pregnancy  only  to  pass  into  a  hurried  decline  after  the  birth  of  her  cliild  or  during 
lactation.  Se\"eral  pregnancies  almost  always  destroy  her.  The  man  not  infre- 
quently loses  ner\-ous  \-igor  by  marriage,  and  this  is  the  more  prone  to  occur,  as 
it  is  notorious  that  tuberculous  men  are  ciu-sed  with  a  degree  of  sexual  desire  which 
is  in  excess  of  that  of  health. 

The  prognosis  of  hemoptysis  so  far  as  its  causing  immediate  death  is  concerned 
is  favorable.  Patients  rarely  die  during  the  hemorrhage  unless  it  takes  place  in 
those  who  are  already  very  feeble  and  anemic.  Ilarely  the  hemorrhage  is  so  profuse 
as  to  cause  death  by  suffocation.  West  gives  the  proportion  of  deaths  from  this 
cause  as  but  1  or  2  out  of  every  100  cases  that  die  of  this  disease,  whereas  GO  per 
cent,  of  tuberculous  cases  are  supposed  to  suft'er  from  hemoptysis  at  some  period 
of  the  malady. 

The  secondary  effects  of  hemorrhage  may,  however,  be  disastrous,  for  if  the 
neighboring  part  of  the  lung  is  inundated  with  blood  and  with  bacilli,  the  bronchioles 


TUBERCULOSIS  269 

in  that  part  become  filled  with  the  extravasation  and  a  traumatic  tuberculous 
pneumonia  speedily  ensues. 

Treatment  of  Pulmonary  Tuberculosis. — The  treatment  of  pulmonary  tuberculosis 
in  its  subacute  or  chronic  forms  may  be  considered  in  se^'eral  parts. 

1.  Its  treatment  by  proper  diet,  proper  exercise,  and  rest. 

2.  Its  management  by  suitable  out-door  life,  and  particularly  by  climate. 

3.  The  emplojTiient  of  drugs  to  control  or  modify  symptoms  which  are  se\-ere 
enough  to  demand  attention. 

4.  The  use  of  tuberculin  as  a  curative  remedy. 

5.  The  a^'oidance  of  the  use  of  drugs  with  the  idea  that  they  can  cure  the  disease; 
for  he  who  tries  to  cure  pulmonary  tuberculosis  by  drugs  does  not  know  the  morbid 
anatomy  of  the  malady. 

It  is  of  vital  importance  in  the  treatment  of  pulmonary  tuberculosis  that  the 
disease  be  recognized  at  the  earliest  possible  moment  and  that  curative  measures 
be  immediately  instituted.  The  possibility  of  cure  depends  solely  upon  the  limita- 
tion of  the  lesion,  and  this  is  difficult  to  accomplish  in  direct  proportion  to  its 
size  and  the  degree  to  which  degenerative  changes  have  advanced. 

Diet. — There  can  be  no  doubt  that  the  proper  nourishment  of  the  patient  is 
the  most  important  matter  demanding  the  attention  of  the  physician;  for  tuber- 
culosis is  not  only  a  disease  in  which  emaciation  progresses  rapidly,  but  it  is  one 
in  which  the  outlook  depends  entirely  upon  the  ability  of  the  patient  to  carry  oyt 
protective  processes  through  which  alone  he  can  hope  to  reco\'er  his  health.  Under 
these  circumstances  it  is  evident  that  the  physician  must  do  e^"er^•thing  in  his 
power  to  keep  the  digestion  in  the  best  possible  order,  to  administer  foods  which 
are  easily  digested  and  readily  absorbed,  and,  equally  important,  to  prescribe 
no  drugs  or  foods  which  by  disordering  the  stomach  will  interfere  \\'ith  the  function 
of  this  important  viscus.  It  must  also  be  remembered  that  the  digestion  of  food 
requires  nervous  energy  just  as  does  the  performance  of  any  other  vital  function, 
and  care  must  be  taken  that  food  is  not  ingested  at  a  time  when,  by  reason  of 
exercise  or  other  cause,  a  considerable  quantity  of  nervous  energy  has  been  recently 
expended.  The  physician  is,  therefore,  in  the  difficult  position  of  knowing  that 
the  patient  must  take  large  quantities  of  nutriment  if  recover j-  is  to  be  expected, 
and  at  the  same  time  be  careful  that  the  digestion  is  not  o\'erburdened  by  the  too 
frequent  administration,  or  too  free  emplojTnent,  of  nutritious  articles.  If  the 
patient's  digestion  is  moderately  strong,  he  may  follow  a  line  of  diet  about  as  follows  • 

Before  getting  up  in  the  morning  he  should  receive  a  teacupful  of  hot  milk,  which 
should  be  sipped  and  not  gulped  down  in  one  or  two  large  swallows.  After  taking 
this,  he  should  rest  in  bed  for  fifteen  or  twenty  minutes;  should  then  bathe,  or  be 
bathed,  and  clothed,  and  for  his  breakfast  have  wheaten-grits,  oatmeal,  or  some 
of  the  more  modern  cereal  preparations  which  are  kno\Mi  to  possess  real  nutritive 
value.  If  his  appetite  is  good  he  may  also  ha^•e  at  this  time  a  tender  chop  or  a 
small  piece  of  steak,  and  if  accustomed  to  the  use  of  tea  or  coffee,  these  beverages 
may  be  allowed  unless  it  is  found  that  they  increase  nervous  irritability.  In  some 
instances  the  patient  may  desire  to  take  an  orange  or  some  other  fruit  with  his 
breakfast,  and  to  this  there  can  be  no  objection.  The  meal  should  be  adequate, 
but  not  large  enough  to  be  heavy. 

Half-way  between  his  breakfast  and  his  mid-day  meal  the  patient  should  receive 
some  light  luncheon,  consisting  of  a  cup  of  broth,  a  piece  of  toast,  a  glass  of  koumyss, 
or  a  sandwich  made  of  scraped  beef;  or,  if  he  tires  of  this,  one  made  with  toast  and 
anchovy  or  caviar.  Often  an  egg,  cooked  or  raw,  may  be  taken  between  meals 
with  advantage.  If  desired,  a  glass  of  sherry  or  some  red  wine  may  also  be  taken 
at  this  time;  or,  in  its  place,  Scotch  or  rye  whiskey  may  be  given. 

The  dinner  should  be  the  heaviest  meal  of  the  twenty-four  hours,  and  should 
be  taken  between  twelve  and  two  o'clock.     It  should  consist  of  a  nutritious  and 


270  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

somewhat  stimulating  soup  which  is  easily  digested  and  absorbed;  one  of  the  clear 
soups  being  preferred  rather  than  a  puree,  unless  it  is  known  that  the  patient  readily 
digests  thickened  and  rich  soups.  This  may  be  followed  by  a  small  piece  of  fresh 
fish,  great  care  being  taken  that  the  fish  is  really  fresh,  and  then  by  a  hearty  course 
of  any  one  of  the  roast  or  broiled  meats,  accompanied  by  two  or  three  wholesome 
vegetables,  such  as  potatoes,  string  beans,  asparagus,  spinach,  carrots,  macaroni, 
and  similar  substances.  With  this  meal  it  may  be  well  for  the  patient  to  take  a 
little  sherry  wine  or  whiskey  and  water,  particularly  if  he  is  accustomed  to  stimu- 
lants with  his  meals.  Some  plain,  nutritious  dessert  like  cornstarch  or  rice-pudding 
may  also  be  taken. 

During  the  afternoon  a  light  luncheon  should  be  given  him,  somewhat  similar 
to  that  which  has  been  taken  in  the  middle  of  the  forenoon,  two  or  three  hours 
after  his  dinner.  In  the  evening  another  light  meal  should  be  taken,  which  should 
consist  of  arrow-root  or  an  egg  cooked  in  some  simple  form,  or  a  few  stewed  oysters 
or  milk-toast  may  be  used,  and  again  before  going  to  bed  at  night  a  cup  of  broth, 
a  glass  of  koumyss,  a  cup  of  hot  milk,  or  some  curds  and  whey  may  be  given. 

The  patient  who  is  able  to  take  the  quantity  of  food  which  has  just  been  described 
is,  of  course,  one  whose  digestion  is  in  fairly  good  condition.  But  if  careful  attention 
is  paid  to  the  digestive  tract  by  the  administration  of  aids  to  digestion,  such  as 
pepsin,  pancreatin,  and  taka-diastase,  if  the  bowels  are  moved  regularly  by  the 
use  of  proper  laxatives,  and  if,  above  all,  the  patient  is  required  to  conserve  his 
nervous  energy  in  order  to  expend  it  upon  his  digestive  apparatus,  it  is  quite  remark- 
able what  large  quantities  of  food  may  be  taken,  e^'cn  by  the  consumptive  who 
otherwise  seems  quite  feeble. 

The  actual  quantity  of  the  food  at  each  feeding  must  be  varied  from  day  to 
day  ^\ith  the  patient's  appetite  and  with  the  conditions  which  may  arise.  If  the 
patient  has  passed  a  restless  and  feverish  night,  the  quantity  of  food  at  each 
feeding  should  be  small;  whereas,  if  he  has  had  a  restful  night,  and  therefore  has 
been  able  to  gain  nervous  energy,  larger  cjuantities  may  be  gi\-en.  So,  too,  limited 
quantities  should  be  ordered  A\'hen  the  tongue  is  at  all  foul,  and  larger  quantities 
ordered  when  it  is  comparati\'ely  clean.  It  is  of  vital  importance  that  these  daily 
variations  should  be  made  in  the  diet,  for  the  digestive  apparatus  of  no  one  is 
prepared  day  in  and  day  out  to  take  exactly  the  same  quantity  of  food,  and  digest 
it  satisfactorily.  Both  the  physician  and  the  patient  must  remember  that  profes- 
sional advice  as  to  food  and  digestion  is  much  more  important  for  the  patient  than 
advice  as  to  the  treatment  by  drugs. 

Exercise. — The  majority  of  cases  of  pulmonary  tubercuk)sis  do  not  require 
much  exercise  pro\'ided  they  are  su[)plied  with  sufficient  fresh  air.  Patients, 
howe\'er,  differ  very  greatly  in  regard  to  this  matter."  Some  of  them  seem  capable 
of  taking  moderate  exercise  with  great  ach'antage,  and  others  cannot  take  any 
exercise  A\'ithout  suffering  either  from  a  disordered  digestion  or  from  a  restless  night 
caused  by  inordinate  fatigue.  In  many  instances  the  patient's  health  can  best 
be  preser\'ed  by  gi\'ing  him  fresh  air,  and  supplanting  exercise  by  massage  and 
gentle  Swedish  mo\-emcnts.  Of  course,  these  remarks  do  not  hold  true  of  those 
cases  in  which  a  small  area  of  the  lung  is  invoh"ed,  with  almost  no  impairment  of 
the  general  health  and  muscular  strength.  These  patients  should  take  healthy 
exercise,  being  careful  to  a\'oid  excessive  fatigue,  and  they  shoiikl  be  impressed 
with  the  idea  that  exercise  in  sufficient  degree  to  ajjproach  exhaustion  is  not  only 
bad  on  general  jjrinciples,  but  actually  diminishes  their  aliility  to  prevent  the 
spread  of  the  infection  in  their  hmgs.  The  whole  question  of  exercise  must,  there- 
fore, be  gauged  in  each  case  by  the  real  strength  of  the  indi^•idual  rather  than  by 
his  ambition  to  be  up  and  about. 

Clim.\te  and  Out-door  Life. — In  these  two  factors  we  have  a  great  aid  in 
the  treatment  of  pulmonary  tuberculosis,  although,  of  course,  these  agents  must 


TUBERCULOSIS  271 

be  prescribed  with  the  same  care  that  governs  our  employment  of  ordinary 
remedies.  There  can  be  no  doubt  whatever  that  an  out-door  existence  is  capable 
of  curing  pulmonary  tuberculosis  under  certain  circumstances,  even  when  the 
climate  is  by  no  means  theoretically  suitable  for  pulmonary  cases.  This  is  a  matter 
of  importance  when  it  is  remembered  that  a  very  large  proportion  of  consumpti\-es 
find  it  impossible  to  travel  great  distances  to  obtain  those  climatic  conditions 
which  are  most  favorable  to  them. 

At  every  modern  resort  for  consumptives  every  measure  is  taken  to  keep  the 
patients  for  many  hours  each  day  in  the  open  air,  the  essentials  being  that  they 
shall  be  exposed  to  sunlight,  and,  if  possible,  to  the  direct  rays  of  the  sun,  and 
be  protected  from  high  winds.  These  conditions  can  be  obtained  by  the  erection 
of  suitable  sheds  facing  the  sun,  and  providing  wind  guards  which  will  place  the 
patient  in  a  quiet  atmosphere.  Even  should  the  patient  be  unable  to  go  to  the 
country  for  fresh  air,  good  results  have  been  found  to  follow  this  plan  of  treatment 
while  he  remains  in  a  city  residence,  either  in  a  suitably  arranged  room  or  in  a 
tent  or  shed  erected  upon  the  roof  of  his  house. 

The  climate  to  which  the  patient  should  resort,  if  it  is  possible  for  him  to  travel, 
should,  in  the  great  majority  of  instances,  be  one  which  is  found  at  an  altitude  vary- 
ing from  3000  to  6000  feet.  There  are  two  great  essentials  in  such  a  climate:  first, 
that  there  shall  be  an  unusual  number  of  hours  of  sunshine  in  the  course  of  the 
year,  and,  second,  that  the  atmosphere  shall  be  dry.  A  third  point  of  importance, 
but  by  no  means  an  essential  one,  is  that  the  atmosphere  shall  be  quiet,  in  order 
that  there  may  be  little  dust.  The  temperature  is  of  comparatively  little  import- 
ance, provided  it  is  not  accompanied  by  humidity,  for  it  is  quite  remarkable  how 
patients  suffering  from  this  disease  often  thrive  in  temperatures  which  in  winter 
are  far  below  the  freezing  point,  and  in  summer  are  often  as  high  as  90°.  At  those 
altitudes  of  from  5000  to  6000  feet  which  are  suited  to  this  class  of  patients  the 
8.tmosphere  is  so  clear  that  the  sun's  rays  are  not  interfered  with,  and  even  if  the 
thermometer  shows  that  a  zero  temperature  is  present,  the  patient,  if  properly  clad 
and  protected  from  wind,  can  very  frequently  lie  out-of-doors  all  day,  warmed  by 
the  heat  of  the  sun.    This  is  beneficial  to  an  extraordinary  degree. 

A  high  altitude  is  advantageous  for  the  tuberculous  patient,  not  only  for  the 
reasons  which  we  have  given,  but  also  because  the  rarity  of  the  atmosphere  requires 
that  he  use  all  possible  portions  of  the  lung  tissue,  and  this  being  the  case,  he 
gradually  expands  and  calls  into  functional  activity  all  those  parts  of  the  lung 
in  the  neighborhood  of  the  tuberculous  lesion  which  have  a  tendency  to  become 
functionally  inactive.  This  development  of  active  circulation  of  air  and  blood  does 
much  toward  aiding  nature  in  walling  off  the  tuberculous  focus  and  preventing 
its  further  spread.  A  high  altitude  is  also  advantageous  because  it  seems  to  increase 
the  quantity  of  hemoglobin  in  the  blood.  Whether  it  increases  the  number  of  red 
blood  cells  is  still  a  matter  of  debate,  some  asserting  that  the  increased  number 
of  corpuscles,  found  in  the  superficial  bloodvessels  after  a  patient  has  been  some 
weeks  at  a  high  altitude,  depends  more  upon  an  altered  distribution  of  blood  than 
upon  any  actual  increase. 

Of  the  high-altitude  resorts  which  are  most  popular  because  of  their  excellent 
climate  for  consumptives  may  be  mentioned  Colorado  Springs,  Colorado,  certain 
parts  of  Arizona  and  New  Mexico,  and  parts  adjacent  in  America,  and  the  so- 
called  Engadine,  in  Switzerland,  of  which  the  most  celebrated  places  are  Davos, 
Pontresina,  and  San  Moritz. 

A  high,  dry  climate  is  contra-indicated  in  tuberculous  patients  who  are  suffering 
from  tuberculous  laryngitis,  since  the  dry  air  increases  the  laryngeal  irritation. 
It  is  also  contra-indicated  in  patients  who  have  dilatation  or  degeneration  of  the 
heart  muscle,  and  great  care  should  be  taken  to  determine  the  state  of  the  heart 
in  all_tuberculous  patients  before  sending  them  away  from  home.    A  persistently 


272  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

high  pulse  rate  is  a  distinct  contra-indication  to  altitudes.  If  valvular  disease 
exists,  and  there  is  a  tendency  to  failure  of  compensation,  a  liigii  altitude  is  also 
contra-indicated;  but  where  compensation  is  adecjuate,  the  mere  presence  of  a 
murmur  does  not  necessarily  contra-indicate  resort  to  an  altitude,  provided  the 
patient  is  cautious  not  to  overexert  himself. 

Emphysema  associated  with  pulmonary  tul)erculosis  usually  contra-indicates 
a  high  altitude. 

It  has  been  taught  by  some  that  a  tendency  to  hemoptysis  also  renders  a  high 
altitude  inadvisable,  but  very  eminent  phthisiologists,  on  the  contrary,  have 
asserted  that  a  tendency  to  hemorrhage  does  not  contra-indicate  health  resorts  of 
this  character.  ]My  own  personal  feeling  is  that  the  patient  who  has  a  tendency 
to  hemoptysis  should  approach  a  high  altitude  very  gradually  in  order  that  his 
heart  and  lungs  may  become  accustomed  to  the  altered  atmospheric  conditions, 
and  certainly,  for  the  first  few  Aveeks  after  his  arrival,  should  rest  constantly. 

Still  another  contra-indication  to  such  an  altitude,  unless  perchance  the  climate 
is  very  mild  and  the  temperature  fairly  constant,  is  renal  disease  of  any  kind,  or 
tuberculosis  of  the  genito-urinary  tract.  Should  any  of  these  contra-indications 
exist,  the  climate  of  choice  is  one  which  is  represented  by  San  Diego,  California, 
where  the  air  is  pure,  where  sudden  changes  of  temperature  do  not  occur,  and  where 
a  flood  of  sunshine  is  constantly  obtainable. 

In  those  cases  which  have  a  great  deal  of  secretion,  excessive  cough,  and  exces- 
sive expectoration,  dry  climates,  such  as  are  found  near  Phoenix,  Arizona,  and 
Silver  City,  New  Mexico,  are  the  climates  of  election. 

For  those  who  are  unable  to  take  a  long  journey,  and  for  those  who  are  not 
thought  to  be  suitable  cases  for  high  altitudes,  the  Adirondacks  in  the  neighbor- 
hood of  Saranac  Lake,  New  York;  White  Haven,  Pennsylvania;  or  Asheville, 
North  Carolina,  can  be  recommended.  These  altitudes  are  in  the  neighborhood 
of  2500  feet.  Lower  altitudes  which  ha\'e  been  found  advantageous  for  these  cases 
exist  at  Thomasville,  Georgia,  and  Lakewood,  New  Jersey,  where  the  curative 
elements  are  the  sunshine  and  pure  air. 

It  is  interesting  to  note,  in  regard  to  the  treatment  of  pulmonary  tuberculosis 
by  fresh  air,  proper  diet,  and  moderate  or  high  altitudes,  that  a  large  percentage 
of  cases  can  be  cured.  Thus,  Trudeau  reported,  at  the  Adirondack  Cottage  Sani- 
tarium, where  the  altitude  is  less  than  2500  feet,  cures  in  72  per  cent,  of  incipient 
cases  and  17.8  per  cent,  in  advanced  cases;  and  Clapp  and  Bowditch,  of  the 
sanatorium  at  Rutland,  report  cures  in  72.5  per  cent,  of  incipient  cases  and  46.11 
per  cent,  in  advanced  cases. 

Still  more  recently  Trudeau  has  presented  the  results  obtained  by  an  analysis 
and  study  of  all  the  cases  under  his  observation  in  seventeen  years.  Of  the  1500 
cases  under  consideration,  whicli  have  been  discharged  from  two  to  seventeen 
years,  434  could  not  be  traced,  leaving  lOGO  which  have  been  traced.  Of  these 
1066,  46.7  per  cent,  are  still  li\ing,  31  per  cent,  are  known  to  be  well  at  present, 
in  6.5  per  cent,  the  disease  is  still  arrested,  4  per  cent,  have  relapsed,  5.2  per  cent, 
are  chronic  invalids,  and  53.3  per  cent,  are  dead.  As  to  the  influence  of  the  stage 
of  the  disease  on  the  permanency  of  the  results  obtained,  he  found  66  per  cent,  of 
the  258  incipient  cases  discharged  are  well  at  present.  Of  the  563  advanced  cases 
28.6  per  cent,  are  well,  and  of  the  far-advanced  cases  2.5  per  cent,  only  remain 
cured.  Thus  we  learn  that  31  per  cent,  of  all  cases  discharged  from  two  to  seven- 
teen years  ago  have  remained  well,  and  that  66  per  cent,  of  the  incipient  cases  dis- 
charged during  the  same  time  continue  well  at  present.  Surely  these  results 
are  encouraging  and  he  has  shown  us  the  way  in  a  great  work.  Thirty  years  ago 
physicians  were  of  the  opinion  that  cures  did  not  take  place  from  pulmonary  tuber- 
culosis in  more  than  2  per  cent,  of  cases. 

Sea  voyages,  which  at  one  time  were  very  popular  in  the  treatment  of  tuber- 


TUBERCULOSIS  273 

culosis  of  the  lungs,  are  no  longer  regarded  with  much  favor.  The  possibilities  of 
seasickness,  bad  weather,  and  of  consequent  close  confinement  are  naturally  not 
looked  upon  with  favor,  when  we  consider  that  free  feeding  and  fresh  air  are  abso- 
lutely essential  for  these  patients.  Further  than  this,  the  atmosphere  at  sea  is 
never  dry,  but  always  more  or  less  damp.  Again,  there  are  practically  no  comfort- 
able sailing  ships  at  the  present  time,  and  steamers  make  such  rapid  voyages  that 
the  patient  is  not  long  enough  at  sea  to  he  materially  benefited. 

Before  the  physician  decides  to  send  his  patient  away  from  home  for  the  climatic 
treatment  of  his  disease,  he  should  determine  whether  such  treatment  really  ofl'crs 
fair  chance  of  benefit;  for  it  is  a  vital  mistake  to  exhaust  the  strength  and  finances 
of  the  individual  in  a  vain  endeavor  to  arrest  an  inevitable  process.  If  it  is  decided 
that  the  disease  has  advanced  so  little  that  such  a  trip  can  promise  good,  the  next 
question  which  arises  is  as  to  whether  the  patient  is  strong  enough  to  stand  the 
journey,  and,  again,  if  he  can  stay  away  long  enough  to  be  benefited;  for  in  all 
instances  it  is  useless  for  a  patient  to  leave  home  with  any  expectation  of  returning 
in  less  than  six  months  or  a  year,  and  usually  he  had  better  give  up  the  hope  of 
returning  except  for  a  visit,  if  he  wishes  to  preserve  his  health  after  the  climate 
has  done  its  good  work.  It  is  also  a  grave  mistake  to  send  such  patients  far  from 
home  unless  they  can  be  accompanied  by  some  relative  or  friend,  as  homesickness 
exercises  a  deleterious  influence  upon  vitality. 

Drugs. — I  have  already  mentioned  the  use  of  the  various  digestants  when  speak- 
ing of  the  diet.  The  ever-present  anemia  of  many  of  these  patients  is  to  be 
overcome  by  the  careful  administration  of  iron  and  arsenic.  Arsenic  for 
many  years  has  had  the  reputation  of  being  a  drug  of  great  value  in  tuberculosis. 
Iron  is  also  very  useful,  but  it  should  not  be  given  in  the  large  doses  ordinarily 
employed.  As  I  have  repeatedly  pointed  out,  the  quantity  of  iron  in  the  body  is 
exceedingly  small,  not  more  than  about  30  grains,  and  therefore  the  administration 
of  2  or  3  grains  of  reduced  iron  two  or  three  times  a  day  provides  in  twenty-four 
hours  far  more  iron  than  can  possibly  be  utilized,  and  at  the  same  time  tends  to 
produce  constipation  and  so  disturb  digestion.  Most  cases  will  do  better  if  they 
are  given  in  the  neighborhood  of  yV  to  |  grain  of  reduced  iron  three  times  a  day. 

Strychnine  may  be  used  in  moderation  as  a  bitter  and  as  a  nervous  tonic,  but 
it  is  a  mistake  to  use  it  as  a  circulatory  stimulant,  as  it  is  only  an  irritant  to  the 
nervous  system,  and  produces  fictitious  strength.  Quinine  cannot  be  given  in 
doses  which  are  adequate  to  control  hectic  fever,  and  if  any  attempt  of  this  kind 
is  made  it  disorders  the  stomach  and  produces  headache;  2  or  3  grains,  twice  or 
thrice  a  day  as  a  bitter  tonic,  are  quite  sufficient  for  the  average  patient. 

The  syrups  of  the  hypophosphites  and  lactophosphates  have  been  popular  with 
the  profession  for  many  years.  In  many  instances  the  improvement  w'hich  follows 
their  use  depends  upon  the  iron  or  strychnine  which  they  contain,  and  too  fre- 
quently these  syrupy  preparations  disorder  the  stomach  and  spoil  the  appetite. 
If  it  is  desired  to  administer  calcium,  potash,  and  soda  to  such  patients,  it  is  better, 
in  the  writer's  experience,  to  give  an  elixir  of  the  glycerophosphates  in  the  dose  of 
a  dessertspoonful  three  times  a  day  to  an  adult. 

When  the  heart  is  weak,  particular  care  should  be  taken  in  regard  to  rest,  and 
digitalis  may  be  given,  but  it  should  be  used  in  small  doses  over  a  long  period  of 
time  rather  than  in  full  doses  for  a  short  period.  It  is  quite  remarkable  what  good 
results  follow  the  use  of  2  or  3  minims  of  a  physiologically  tested  tincture  of  digi- 
talis three  times  a  day.  These  doses,  maintained  for  some  time,  produce  a  true 
improvement  in  the  heart  muscle  and  do  not  disorder  the  stomach;  whereas, 
larger  doses  soon  upset  the  cardiac  balance,  and  almost  certainly  disturb  digestion, 
and  even  produce  vomiting. 

For  the  control  of  night  sweats-  no  remedy  equals  camphoric  acid  in  my  experi- 
ence, given  in  the  dose  of  15  to  20  grains,  two  or  three  hours  before  the  time  that 
18 


274  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

the  sweat  usually  comes  on.  The  best  way  to  administer  it  is  in  cachet  or  capsule, 
or  dissolved  in  a  little  brandy.  The  difficulty  in  the  use  of  atropine  for  this  pur- 
pose is  that  it  checks  other  secretions  and  sometimes  by  so  doing  renders  the  cough 
more  dry  and  annoying. 

Fever,  as  a  rule,  requires  treatment  only  if  it  becomes  excessive.  The  patient 
may  be  sponged  with  tepid  water  and  alcohol,  and  even  cool  water  may  be  used. 
But  care  must  be  taken  that  the  temperature  does  not  break  rapidly  and  become 
subnormal.  The  use  of  the  coal-tar  antipyretics  is  entirely  inexcusable.  They 
diminish  vital  resistance,  are  apt  to  produce  profuse  sweats,  and  increase  cyanosis 
and  dyspnea  when  the  pulmonary  lesions  are  well  developed. 

The  use  of  creosote  or  of  any  of  its  derivati\'es,  with  the  idea  that  they  are 
beneficial  for  pulmonary  tuberculosis,  is  based  upon  an  utterly  erroneous  view  of 
the  disease  and  of  the  action  of  these  drugs.  When  bronchitis  is  present  as  a  com- 
plication their  value  as  stimulating  expectorants  is  worthy  of  consideration,  and 
under  these  circumstances,  by  improving  the  condition  of  the  bronchial  mucous 
membrane  and  aiding  expectoration,  they  may  eventually  help  the  patient,  but 
they  certainly  do  not  exercise  any  influence  upon  the  tuberculous  process  itself. 
Worse  than  this,  in  many  instances  they  do  not  even  act  as  expectorants,  unless 
given  in  doses  so  large  as  to  disorder  the  stomach.  The  number  of  unfortunate 
consumptives  whose  struggle  with  their  disease  has  been  lost  through  disorder  of. 
the  digestion  arising  from  the  administration  of  expectorants  is  not  comforting 
to  contemplate. 

Cough  is  to  be  controlled  by  the  use  of  such  cough  sedatiA-es  as  heroin  in  the  dose 
of  Y4  to  yV  of  a  grain  three  or  four  times  in  twenty-four  hours.  A  very  useful  plan 
of  treatment  under  these  circumstances  is  the  administration  of  the  elixir  of  terpin 
hydrate  and  heroin  in  the  dose  of  a  teaspoonful  every  four  hours.  In  some  instances 
cannabis  indica  is  useful  as  a  cough  sedative.  In  still  other  cases,  if  the  cough  seems 
to  be  due  to  a  dry  and  irritable  condition  of  the  bronchial  tubes,  quiet  and  sleep 
is  obtainable  if  there  is  disengaged  in  the  air  of  a  room,  from  a  bronchitis  kettle, 
steam  which  arises  from  water  into  which  is  poured  creosote,  oil  of  pine,  and  oil 
of  eucalyptus,  equal  parts,  to  the  extent  of  |  to  1  drachm.  Care  should  be  taken 
that  the  patient  does  not  go  out-of-doors  into  the  cold  atmosphere  after  inhaling 
the  warm,  steam-laden  atmosphere. 

When  a  laryngeal  hiherculosis  develops,  these  steam  inhalations  are  often  exceed- 
ingly valuable. 

Sometimes  an  excessive  cough  at  night  can  be  stopped  by  giving  the  patient 
a  drachm  of  Hoffmann's  anodyne,  or  a  little  spirit  of  camphor.  In  other  instances 
morphine  in  the  dose  of  ^'ij  to  y^  of  a  grain  is  required,  but  opiates  are  to  be  carefully 
avoided  if  other  measures  of  relief  are  sufficient. 

When  the  cough  depends  upon  the  accumulation  of  large  quantities  of  material 
in  the  bronchial  tubes  or  in  cavities,  it  is  of  vital  importance  that  it  should  not 
be  arrested  by  the  administration  of  drugs;  for  it  is  an  effort  on  the  part  of  nature 
to  get  rid  of  materials  which,  if  they  are  retained  in  the  lung,  will  greatly  increase 
septic  poisoning.  This  is  particularly  true  of  morning  cough,  which,  though  it 
is  often  exceedingly  annoying,  is  really  an  ctl'ort  to  empty  a  cavity  whicii  has  be- 
come filled  during  the  night.  Such  coughing  can  frequently  be  aided  by  ]>lacing 
the  patient  in  such  a  position  that  the  cavity  will  readily  drain  into  its  supplying 
bronchus. 

Whenever  the  physician  in  the  treatment  of  pulmonary  tuberculosis  is  tempted 
to  employ  a  drug,  the  question  of  its  influence  upon  the  stomach  and  digestion 
should  be  carefully  decided,  even  though  the  indications  for  the  use  of  the  remedy 
which  exist  in  other  portions  of  the  body  seem  very  clear  and  conclusive.  Thus, 
the  use  of  cod-liver  oil  in  the  treatment  of  pulmonary  tuberculosis  is  undoubtedly 
to  be  commended,  provided  the  patient  can  digest  it,  and  at  the  same  time 


TUBERCULOSIS  275 

take  ordinary  food.  Even  a  healthy  man  cannot  exist  on  cod-ii\er  oil  alone;  and 
it  is  a  vital  mistake  to  impair  the  appetite  and  digestion  by  giving  full  doses  of  this 
sometimes  valuable  drug.  Any  sign  of  indigestion  of  the  oil,  as  in  eructations,  or 
in  the  passing  of  oily  stools,  should  be  the  signal  for  stopping  its  use  at  once.  The 
digestion  of  good  food  does  more  for  a  patient's  vitality  than  the  digestion  of 
good  oil. 

Serum  Therapy. — An  endeavor  has  been  made  to  treat  tuberculosis  by  means 
of  antitubercle  serum,  but  so  far  the  results  which  have  been  obtained  have  not 
been  encouraging. 

Antistreptococcic  serum  has  been  used  on  the  ground  that  nearly  all  cases  of 
tuberculous  cavity  are  infected  by  the  streptococcus  as  well  as  the  tubercle  bacillus, 
and  that  if  the  former  malign  organism  were  removed,  or  its  toxins  antagonized, 
the  patient  could  the  better  combat  the  original  cause  of  the  illness.  If  strepto- 
cocci are  found  in  the  sputinu  in  large  numbers  it  may  be  used  to  aid  the  patient, 
but  otherwise  its  use  is  futile. 

Tuberculin. — The  employment  of  tuberculin  as  a  specific  remedy  for  pul- 
monary tuberculosis  has  not  as  yet  received  general  professional  endorsement.  It 
is  true  that  a  very  large  number  of  physicians  who  are  especially  engaged  in  the 
treatment  of  tuberculous  patients  have  written  papers  in  which  they  have  highly 
praised  the  employment  of  this  substance,  and  that  statistics  are  numerous  which 
tend  to  show  that  it  produces  advantageous  results.  It  must  be  admitted,  therefore, 
that  at  times  it  does  good.  But,  on  the  other  hand,  it  is  a  good  rule  in  practice  to 
follow  the  majority  in  the  use  of  new  remedies;  for  new  remedies  which  really  are 
advantageous  are  taken  up  and  constantly  employed  by  e^'eryone.  Probably  the 
conclusions  as  reached  by  Trudeau,  in  regard  to  tuberculin,  represent  the  real  facts 
of  the  case  when  he  says:  "My  experience  with  tuberculin  treatment  at  the 
Sanitarium  thus  far  has  led  me  to  believe  that  when  carefully  tried,  in  suitable 
cases,  it  has  proved  apparently  free  from  danger,  and  that  it  has  seemed  to  have 
some  favorable  influence  in  bringing  about  the  healing  of  the  lesions,  probably  by 
inciting  the  formation  of  fibrous  tissues." 

The  tuberculin  which  should  be  employed  is  that  which  is  prepared  by  the  more 
modern  methods.  It  is  now  made  and  marketed  by  a  number  of  reliable  concerns, 
and  it  can  be  obtained  both  in  this  country  and  abroad.  This  remedy  is  not  one 
which  is  suitable  to  all  cases  and  should  only  be  given  by  an  expert  in  its  use. 

Before  speaking  of  the  use  of  tuberculin  it  is  important  that  its  several  forms,  as 
used  today,  should  be  understood.  A  very  large  number  of  products  have  been 
made  and  given  this  name  but  practically  only  three  are  generally  used.  The 
first  of  these  is  that  originally  proposed  by  Koch  in  1890;  it  is  often  called  "Old 
Tuberculin."  This  is  prepared  from  pure  cultures  of  tubercle  bacilli  made  upon  a 
5  per  cent,  glycerin-bouillon  medium.  This  culture  medium  is  evaporated  to  one- 
tenth  of  its  bulk  and  then  filtered  through  porcelain  to  remove  all  bacilli.  Old 
tuberculin  is,  therefore,  a  product  which  contains  all  the  edticts  of  the  bacilli  in 
a  50  per  cent,  solution  of  glycerin.  The  dose  varies  from  ytott  to  yrro  o^  ^  milli- 
gram for  curative  use.  The  second  form  is  called  "Tuberculin  R."  (T.  R.),  an 
abbreviation  of  the  words  "Tuberculin  Residuatum."  Tubercidiji  residuatum  is 
prepared  in  the  following  manner: 

The  live  virulent  germs  are  dried  thoroughly  and  then  ground  in  a  ball  mill  for 
a  considerable  time.  The  resultant  dry  powder  is  taken  up  with  sterile  water  and 
centrifugalized.  The  supernatant  clear  liquid,  which  is  called  Tuberculin  T.  O., 
is  thrown  away.  The  remaining  portion,  the  residue,  is  the  material  from  which 
T.  R.  is  now  made.  This  is  done  by  repeatedly  grinding  and  extracting  with  water. 
The  process  of  drying,  grinding,  taking  up  in  water  and  centrifugalizing  is  repeated 
until  there  is  no  residue  left.  The  united  extracts  of  this  T.  R.  residue  constitute 
the  Tuberculin  R.  of  commerce.    In  T.  R.  two  ends  are  supposed  to  have  been 


27G  DISEASES  DUE  TO  A  SPECIFIC  IiXFECTIOX 

accomplished,  viz.:  (1)  The  removal  of  the  toxic  and  otherwise  deleterious  con- 
stituents of  the  germs;  (2)  the  bringing  into  solution  of  the  immunizing  substance. 
The  dose  of  the  T.  R.  is  always  measured  on  the  basis  of  the  amount  of  dry  germ 
material  in  it — each  cubic  centimeter  of  the  dilute  product  contains  rtiVtr  of  3- 
milligram.  The  doses  used  ^'ary  with  the  different  workers.  Koch  recommends 
-gjjff  milligram  to  20  milligrams,  but  the  modern  tendency  is  to  use  smaller  doses. 
Wright,  of  London,  uses  -^^stj  to  -jxny  milligram;  some  begin  as  low  as  xirniTii  ""'' 
gradually  increase  the  dose.  The  T.  R.  is  always  administered  hypodermically  and 
if  aseptic  precautions  are  observed  will  be  absorbed  jimmptly  and  without  local 
trouble.  This  is  a  much  more  powerful  preparation  than  old  tuberculin  and  is 
the  one  commonly  used  for  curative  purposes.  The  object  is  to  develop  a  gradual 
resistance  to  infection,  and  a  reaction  such  as  is  sought  when  tuberculin  is  used  in 
diagnosis  is  always  avoided,  if  possible.  It  appears  on  the  market  in  glass  bulbs, 
holding  1  c.c.  of  normal  salt  solution  which  also  contains  tuVi7  of  a  milligram  of 
"T.  R." 

The  third  tuberculin,  often  called  Koch's  new  tuberculin,  or  Bacillen 
Emulsion  (B.  E.),  is  a  finely  powdered  virulent  culture  of  tubercle  bacilli,  the 
strength  being  5  mOligrams  of  dried  powder  in  each  cubic  centimeter  of  gly- 
cerin and  water  equal  parts.  This  is  also  a  very  powerful  product  and  is  often 
used  for  curative  purposes.  The  beginning  dose  is  usually  yoVir  of  a  milligram. 
The  use  of  these  products  should  not  cause  reaction.  If  it  occurs  the  dose  must  be 
cut  down  and  a  further  use  postponed  until  no  trace  of  a  reaction  remains.  The 
treatment  must  be  continued  for  months  and  the  doses  are  increased  as  time  goes 
by.    Usually  in  the  absence  of  reaction  the  injection  is  given  twice  a  week. 

The  dose  is  injected  into  the  tissues  of  the  back  by  means  of  a  sterilized  syringe 
on  every  alternate  day.  It  is  desirable  to  avoid  reaction,  and  all  felirile  movement 
that  may  be  induced  by  one  injection  must  have  disappeared  before  another 
dose  is  given.  After  repeated  doses  the  patient  may  be  able  to  stand  very  large 
doses  without  any  reaction  and  with  good  effect. 

AVhen  vmniiinq  complicates  pulmonary  tuberculosis,  its  cause  must  be  discovered. 
If  it  follows  excessive  cough,  the  cough  must  be  controlled  in  the  manner  already 
described.  If  it  arises  from  gastric  irritability,  2  to  5  grains  of  subnitrate  of  bis- 
muth and  1  to  2  grains  of  oxalate  of  cerium  may  be  given  an  hour  before  meals. 
In  other  instances,  where  the  stomach  is  depressed  rather  than  irritated,  1  or  2 
drops  of  Fowler's  solution  before  meals  is  advantageous. 

The  treatment  of  hemoptysis  consists  in  the  administration  of  a  hypodermic 
injection  of  |  of  a  grain  of  morphine  if  the  patient  shows  great  mental  ]ierturbation 
because  of  the  hemorrhage.  It  does  not  have  any  direct  influence  upon  the  flow 
of  blood,  but  by  producing  nervous  quiet  it  relieves  the  patient's  mind  and  so 
quiets  the  circulation.  If  the  flow  of  blood  is  profuse,  the  patient  should  be  allowed 
to  occupy  that  position  in  which  it  is  most  easy  for  him  to  rid  his  bronchial  tubes  of 
fluid.  I  have  seen  relief  produced  by  permitting  him  to  lie  flat  on  his  chest  with 
his  head  resting  on  the  edge  of  the  mattress  in  such  a  way  that  the  lilood  readily 
flowed  from  his  mouth  without  violent  efforts  at  coughing. 

When  hemoptysis  is  recurrent  artificial  pneumothorax  is  to  be  considered  (see 
below) . 

A  multitude  of  measures  have  been  recommended  for  the  control  of  the  hemor- 
rhage. Manifestly,  none  of  them  can  exercise  much  power  for  good.  No  one 
would  think  of  attempting  to  control  the  hemorrhage  from  a  ruptured  varicose 
vein  in  the  leg,  or  from  a  small  artery  on  the  surface  of  the  body,  by  the  internal 
administration  of  any  drug  of  which  we  have  knowledge.  Such  indirect  styptics 
as  tannic  and  gallic  acid  are  useless.  When  the  hemorrhage  ceases  after  the  admin- 
istration of  these,  or  other  styptics,  by  the  stomach,  it  is  evident  that  the  arrest 


TUBERCULOSIS  277 

must  be  due  to  the  natural  dotting  of  the  blood  rather  than  to  any  efl'ect  of  drugs. 
That  this  is  the  correct  view  of  the  case  is  still  further  emphasized  by  the  fact  that 
the  pulmonary  bloodvessels  are  very  poorly  supplied  with  vasomotor  nerves  and 
with  muscular  fibres,  and  therefore  drugs  which  act  by  contracting  bloodvessels 
cannot  exercise  any  powerful  influence  in  this  area.  Finally,  absorption  is  so  slow 
from  the  stomach  that  it  is  incredible  that  styptics  can  exercise  a  material  efl'ect 
before  the  hemorrhage  destroys  the  patient  or  is  stopped  by  clotting.  If  the  cir- 
culation is  bounding,  a  dose  of  chloral  or  aconite  may  be  given  as  a  circulatory 
sedative.  Nitroglycerin  hypodermically  is  also  of  value  and  amyl  nitrite  ma^\'  be 
given  by  inhalation  to  diminish  the  blood  pressure  in  the  lung  by  dilating  the 
systemic  vessels  elsewhere. 

The  use  of  adrenalin  by  the  stomach  is  of  doubtful  value,  first,  because,  as 
just  pointed  out,  the  pulmonary  bloodvessels  are  poorly  supplied  with  muscular 
fibres  upon  which  the  adrenalin  can  act,  and,  second,  because  when  adrenalin  is 
placed  in  the  stomach  it  is  decomposed.  The  use  of  astringent  substances  in 
atomizers  is  equally  futile.  All  of  the  fluid  strikes  against  the  pharyngeal  wall, 
and  may  run  down  into  the  stomach,  but  it  does  not  reach  the  lungs. 

Some  practitioners  have  recommended  the  application  of  ice  upon  the  perineum 
in  cases  of  hemoptj-sis,  believing  that  in  some  reflex  manner  it  diminishes  hemor- 
rhage from  the  lungs,  and  others  have  applied  a  small  ice-bag  o^■e^  the  ca^■ity  from 
which  the  hemorrhage  takes  place.  There  is  much  more  danger  of  these  measures 
adding  to  shock  by  chilling  the  patient  than  there  is  chance  of  their  doing  good. 
As  already  stated,  hemoptysis  rarely  produces  death  as  the  immediate  result  of  the 
loss  of  blood,  and  remedies  which  receive  credit  for  arresting  the  flow  are  probably 
unworthy  of  the  confidence  imposed  in  them. 

Artificial  pneumothorax,  induced  by  the  injection  into  the  pleural  cavity  of 
nitrogen  gas  or  air,  has  become  a  recognized  therapeutic  procedure  in  pulmonary 
tuberculosis,  provided  the  disease  is  well  advanced,  is  progressive,  is  largely  or 
entirely  unilateral  and,  still  more  important,  provided  that  adhesions  do  not  exist 
to  such  an  extent  as  to  prevent  an  adequate  collapse  of  the  lung  to  be  caused  by 
the  procedure.  The  advantages  gained  are:  an  arrest  of  the  disease  in  the  lung, 
a  diminution  in  the  cough  and  expectoration,  and  often  a  decrease,  or  disappear- 
ance, in  the  systemic  symptoms.  This  method  of  treatment  has  also  proved  of 
distinct  value  in  persistent  or  repeated  hemoptysis,  as  the  collapse  and  inactivity 
of  this  lung  permits  arrest  of  the  hemorrhage.  A  special  apparatus,  whereby  the 
rapidity  and  force  of  the  flow  of  gas  or  air  is  controlled  is  needed,  provided  with  a 
gauge  by  which  the  operator  can  determine  the  pressure  in  the  chest.  Such  an 
apparatus  is  now  manufactured  by  several  instrument  makers.  The  quantity 
of  gas  injected  depends,  of  course,  upon  the  size  of  the  chest  and  the  condition  of 
the  patient  during  the  injections.  Any  evidence  of  shock,  great  oppression  or 
collapse  necessitates  the  immediate  arrest  of  the  procedure.  Commonly  about  200 
to  300  c.c.  of  nitrogen  gas  are  used  every  other  day,  as  a  considerable  amount  of  gas 
is  absorbed.  The  question  is  not  so  much  one  of  how  much  gas  as  of  how  much  is 
needed  to  collapse  the  lung  and  cause  nearly  complete  pneumothorax.  This  is 
determined  by  the  usual  methods  of  diagnosing  pneumothorax  and  by  the  aid  of 
the  a:-rays.  The  frequency  of  repetition  of  the  injection  and  the  length  of  time 
they  are  resorted  to  depend  upon  the  maintenance  of  pulmonary  collapse.  Nitrogen 
gas  is  used  because  it  is  less  rapidly  absorbed  than  ordinary  air.  Under  rigid 
asepsis  a  needle  attached  to  a  rubber  tube  leading  to  the  apparatus  is  inserted  in 
the  fifth  or  sixth  intercostal  space  in  the  midaxillary  line,  the  patient  lying  on  the 
unaffected  side.  After  it  is  in  place  it  must  be  quietly  moved  about,  as  one  would 
move  a  probe,  to  determine  that  there  are  no  adhesions,  before  the  injection  is 
attempted.  Death  rarely  has  resulted  from  this  method  when  proper  cases  have 
been  selected  and  proper  precautions  taken.    Indeed  some  patients  very  far  ad- 


278  DISEASES  DUE  TO  A   SPECIFIC  INFECTION 

vanccd  in  the  disease  and  apparently  near  death  have  liecn  greatly  benefited.  It 
is  rather  to  he  tried  in  desperate  cases  with  cavity  formation  and  profuse  exjieetora- 
tion  than  in  mild  ones.  In  urgent,  persistent  hemojitysis  air  may  he  injected  hy 
producing  a  positive  pressure  in  an  ordinary  aspirating  apparatus  if  no  special 
ajipariitiis  is  at  hand. 

Tuberculosis  of  the  Alimentary  Canal. — Tul)ereulosis  of  the  alimentary  canal 
may  occur  in  any  of  its  parts  from  the  tonsils  to  the  amis,  and,  while  its  develop- 
ment is  a  comparatively  rare  primary  form  of  the  infection,  it  is  nevertheless  met 
with  in  sufficient  frequency  to  make  it  of  importance.  In  an  analysis  of  5142 
autopsies,  \\'iiliam  Hunter,  the  Government  bacteriologist  of  Ilong  Kong,  found 
that  this  condition  was  rarely  ]:)resent  in  children  under  five  years,  notwithstanding 
the  very  great  pre\alence  of  tuberculosis  among  the  Chinese. 

Tuberculosis  of  the  Tonsils. — The  tonsils  may  contain  tubercle  bacilli,  on  their 
way  to  the  infection  of  neighboring  lymphatic  glands,  or  they  may  be  actually 
tuberculous  themselves,  containing  in  their  substance  miliary  tubercles  or  caseous 
foci.  These  lesions  are  more  frequently  met  with  in  children  than  in  adults,  and 
may  depend  upon  auto-infection — that  is,  the  tonsils  may  be  infected  by  tubercu- 
lous sputum  which  is  expectorated  (secondary),  or  they  may  become  infected  by 
the  entrance  of  tubercle  bacilli  in  dust  by  the  nose  or  mouth  or  perhaps  in  the  milk 
of  tuberculous  cows  (primary).  Koplik  has  recently  made  an  interesting  report 
on  this  subject  in  the  American  Journal  of  the  Medical  Sciences. 

Even  more  important  than  tuberculosis  of  the  tonsils  is  tuberculosis  of  the  so- 
called  third  or  pharyngeal  tonsil,  constituting  the  "postnasal  adenoid."  As  is 
well  known,  these  growths  are  not  rarely  tuberculous.  From  these  adenoids  the 
bacilli  may  pass  through  the  lymphatics  and  so  cause  tuberculosis  of  the  media- 
stinal and  bronchial  lymph  nodes. 

Tuberculosis  of  the  Pharynx  and  Esophagus. — The  pharyngeal  wall  is  not  uncom- 
monly the  site  of  miliary  tubercles,  in  the  course  of  chronic  pulmonary  tr.berculosis, 
and  even  more  commonly  tuberculous  ulceration  extends  from  the  larjiix  and 
epiglottis  to  the  pharynx  and  adds  greatly  to  the  discomfort  of  the  patient.  Tuber- 
culosis of  the  esophagus  is  exceedingly  rare,  but  some  cases  have  been  recorded. 
It  may  complicate  general  miliary  tuberculosis,  being  a  part  of  the  systemic  infec- 
tion, or  it  may  arise  from  the  swallowing  of  tuberculous  sputum,  or,  again,  from 
the  extension  of  the  disease  from  a  tuberculous  lymph  node  or  vertebra.  The 
ulceration  may  lead  to  perforation  from  within  or  the  reverse. 

Tuberculosis  of  the  Stomach. — Tulierculosis  of  the  stomach  rarely  occurs,  prob- 
ably liecause  its  juices  protect  it  from  infection.  AVhen  it  does  occur,  it  appears  as 
a  miliary  tuberculosis  due  to  circulatory  infection,  or  as  single  or  multiple  tuber- 
lous  ulcers  involving  the  mucous  membrane.  These  ulcers  are  usually  the  result 
of  a  process  starting  from  an  ulcerating  gland  which  becomes  attached  to  the 
stomach  and  so  causes  disease  by  the  extension  of  the  inflammatory  process.  Van 
Wart  has  reported  an  instance  of  solitary  tubercle  in  the  muscular  layer  of  the 
stomach  which  is  lielieved  to  be  unique. 

Tuberculosis  of  the  Intestines. — Tuberculosis  of  the  intestines  is  a  much  more 
common  condition,  and  in  tJie  great  majority  of  instances  is  secondary  to  infection 
elsewhere.  Primary  intestinal  tuberculosis  occurs  usually  in  cliildren,  and  as 
the  result  of  the  ingestion  of  milk  which  is  infected  by  the  specific  bacillus.  This 
primary  form  has  been  denied  an  existence  by  such  excellent  men  as  Leube  and 
others,  but  so  many  other  pathologists,  of  whom  Bollinger  may  be  taken  as  a  leader, 
have  observed  it  that  its  existence  is  proved. 

The  secondary  or  common  type  of  intestinal  tuberculosis  is  usually  the  result 
of  pulmonary  tuberculosis,  and  arises  from  the  swallowing  of  tuberculous  sputum. 
When  the  pulmonary  lesions  have  lasted  for  a  long  time  intestinal  infection  wull 
be  found  at  autopsy  in  a  large  proportion  of  cases,  about  25  per  cent.    Statistics 


TUBERCULOSIS  2?9 

have  been  published  by  certain  pathologists  giving  over  50  per  cent.  The  lesions 
are  found  chiefly  in  the  ileum  (SO  per  cent,  of  the  intestinal  cases)  just  before  it 
joins  the  cecum,  or  in  the  ileum  and  colon  45  per  cent.,  in  the  colon  alone  3  per 
cent,  and  in  the  rectum  7  per  cent.,  according  to  Frerichs.  These  statistics  as 
to  the  relative  frequency  of  the  various  lesions  hold  true  of  the  disease,  as  it  ap- 
pears in  children  as  well  as  adults,  even  when  the  malady  appears  as  a  primary 
aft'ection. 

Tuberculous  infection  of  the  intestine  primarily  involves  the  lymph  nodes  of  the 
bowel,  causing  them  to  become  swollen  by  reason  of  the  characteristic  cell  prolifera-  ' 
tion  which  the  tubercle  bacillus  always  produces.  The  solitary  glands  project 
markedly  above  the  surface  as  yellowish-white  masses  which  finally  undergo  casea- 
tion and  softening,  and  then  the  mucous  membrane  covering  them  breaks  down, 
forming  an  ulcer  which  is  surrounded  by  somewhat  overhanging  edges.  The  ulcers 
are  not  very  numerous;  at  times  only  one  node  may  be  involved.  If  the  agminated 
glands,  or  Peyer's  patches,  are  infected,  separate  caseous  masses  develop,  several 
ulcers  form,  and  finally  coalesce,  forming  a  large  necrotic  surface  of  very  irregular 
outline.  It  is  interesting  to  note  that  this  condition  is  quite  different  from  the  pro- 
cess in  enteric  fever,  in  which  disease  the  glands  are  affected  generally  and  the 
individual  agminated  mass  is  uniformly  infiltrated.  Tuberculous  ulcers  of  the 
agminated  glands  usually  extend  transversely  across  the  gut  because  the  process 
does  not  remain  confined  to  the  patch,  whereas  the  lesion  of  enteric  fever  extends 
longitudinally. 

The  overlying  serosa  is  commonly  thickened,  often  contains  distinct  tubercles, 
and  at  operation  the  diagnosis  of  tuberculous  ulcer  may  be  made  without  opening 
the  bowel.  Fibrosis  and  thickening,  with  associated  contraction  may  cause  stricture 
and  symptoms  of  obstruction;  perforation  is  not  common  and  is  usually  overlooked. 

Tuberculosis  of  the  cecum  in  the  neighborhood  of  the  appendix  may  give  rise 
to  the  belief  that  appendicitis  or  tumor  of  the  bowel  is  present.    (See  Symptoms.) 

When  the  rectum  is  affected  the  ulceration  is  preceded  by  infiltration  and  casea- 
tion in  the  submucosa,  it  often  encircles  the  bowel,  and  the  tissues  near  the  seat 
of  the  ulcer  are  frequently  dotted  with  small,  yellowish  or  whitish,  tubercles  which 
add  to  the  area  of  the  ulcer  as  they  undergo  degenerative  change.  They  also  give 
rise  to  tuberculous  infection  of  the  peritoneum  and  perirectal  tissues  and  to  tuber- 
culous abscesses  and  fistulse. 

With  the  distinct  and  specific  lesions  just  described  tuberculous  disease  of  the 
bowel  presents  an  associated  condition  of  acute  and  chronic  catarrh  or,  in  other 
words,  a  true  enterocolitis. 

Of  recent  years  much  has  been  written  of  chronic  hyperplastic  tuberculosis  of 
the  intestine.  In  this  form  the  intestinal  wall  is  greatly  thickened,  the  lumen 
commonly  narrowed  and  sausage-like.  Distinct  cylindrical  segments  of  the  in- 
volved tissue  may  be  recognized  through  the  thin  abdominal  walls.  Neoplastic 
masses  which  may  attain  the  size  of  a  fetal  head  occasionally  develop,  and  polypoid 
growths  may  occur  on  the  interior  of  the  bowel.  The  condition  is  most  common  in 
the  ileocecal  region,  and  is  rarely  restricted  to  the  small  intestine,  but  may  involve 
one  or  more  parts  or  the  whole  of  the  colon,  causing  strictures  with  interposed 
dilated  areas,  although  actual  dilatation  is  rare.  The  stenosis  may  be  almost 
complete.  Histologically  there  is  marked  hyperplasia  of  the  connective  tissue  of 
the  intestinal  wall,  and  the  great  thickening,  sometimes  attaining  5  cm.,  is  due 
largely  to  this  cause.  Caseous  areas  and  even  typical  tubercles  may  be  absent. 
The  newly  formed  tissue  is  often  but  scantily  supplied  with  bacilli. 

Symptoms  of  Intestinal  Tuberculosis. — The  symptoms  of  intestinal  tuber- 
culosis consist  chiefly  in  the  manifestations  met  with  in  most  cases  of  enterocolitis. 
The  patient  complains  of  looseness  of  the  bowels,  or  diarrhea,  and  a  considerable 
amount  of  colicky  pain.    With  these  signs  there  is  wasting  and  decrease  in.  strength. 


280  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

The  tongue  may  l)e  coated,  but  it  is  often  unduly  clean  and  the  normal  roughness  of 
its  mucous  membrane  is  replaced  by  a  raw-beef  appearance.  Palpation  of  tiie  abdo- 
men may  reveal  tenderness  at  certain  points,  which  is  now,  however,  very  well 
marked,  and  auscultation  will  show  an  exccssi\e  amount  of  peristaltic  movement 
and  rumbling.  At  times  the  appetite  may  be  excessive  owing  to  the  fact  that  the 
diarrhea  causes  starvation  of  the  tissues,  which  is  recognized  by  the  system  and 
shown  in  a  desire  for  more  food.  At  such  times,  in  particular,  the  stools  may 
contain  undigested  particles  of  food.  There  are,  however,  no  symptoms  in  this 
early  stage  that  can  be  considered  typical,  and  the  presence  of  tuberculosis  else- 
where may  be  the  chief  reason  for  believing  that  the  alimentary  canal  is  involved. 

When  ulceration  occurs  the  presence  of  mucopus,  blood,  and,  more  important, 
the  discovery  that  tubercle  bacilli  are  in  the  stools  make  it  possible  for  us  to  state 
positively  the  cause  of  the  disease.  If  the  disease  develops  farther,  as  it  is  prone 
to  do  if  life  is  prolonged  a  sufficient  length  of  time,  the  peritoneal  coat  of  the  intes- 
tine is  involved  and  gradually  a  general  adhesive  peritonitis,  such  as  was  described 
in  the  article  on  peritoneal  tuberculosis,  is  produced,  with  its  characteristic  thick- 
ening of  the  peritoneum  and  cicatricial  contraction  of  the  omentum  and  mesentery. 
This  produces  constrictions  in  the  intestine,  which  may  be  due  to  the  peritonitis 
or  to  the  ulcerative  process  inside  the  bowel. 

In  some  cases  the  inflammatory  process  produced  by  tuberculosis  of  the  caput 
coli  is  so  intense  that  pain  in  the  region  of  the  appendix  may  give  rise  to  the  belief 
that  an  acute  appendicitis  or  appendicular  abscess  is  present.  In  a  case  known  to 
be  tuberculous  the  possibility  of  this  condition  is  manifest,  but  in  one  which  has 
a  small  and  unrecognized  tuberculous  focus  elsewhere,  as  in  the  lungs,  operative 
procedures  for  appendicitis  may  be  hurriedly  resorted  to  when  no  necessity  for 
them  exists. 

So,  too,  the  finding  of  a  mass  in  this  region,  without  sharp  pain,  may  mislead 
the  physician  into  a  diagnosis  of  malignant  growth  if  the  rest  of  the  body  be  not 
well  investigated  for  a  tuberculous  focus.  Such  a  mass  may  be  differentiated 
from  carcinoma  by  the  fact  that  there  is  a  focus  of  tuberculosis  elsewhere.  If 
the  growth  be  slow  it  is  probably  tuberculous;  whereas  if  rapid  it  is  probably 
cancerous,  for  cecal  tuberculosis  may  last  two  years  and  cecal  cancer  rarely  lasts 
longer  than  eight  months.  Further  than  this,  if  the  patient  is  below  thirty  years 
of  age  tuberculosis  is  more  likely  than  cancer;  whereas  after  forty  years  the  reverse 
is  true.  The  tumor  when  outlined  by  palpation,  in  tuberculosis  is  elongated  and 
the  thickened  intestine  can  l)e  felt,  whereas  in  cancer  it  is  usually  sharply  circum- 
scribed and  the  re.st  of  the  bowel  cannot  be  outlined.  Fever  is  usually  present  in 
tuberculosis  and  absent  in  cancer.  The  presence  of  tubercle  bacilli  in  the  stools 
will,  of  course,  decide  the  diagnosis,  and  even  if  they  cannot  be  found,  the  presence 
of  a  tuberculous  focus  elsewhere,  in  a  person  below  forty  years,  should  be  considered 
as  pointing  strongly  to  this  l)acillus  as  the  cause  of  the  growth,  ])ut  if  active  pul- 
monary changes  are  present  it  is  to  be  recalled  that  nearly  all  such  patients  have 
virulent  tubercle  bacilli  in  their  stools. 

At  times  the  tumor  found  at  the  ileocecal  region  results  in  obstruction  of  the 
ileocecal  valve,  and  the  colon  l)ecomes  greatly  distended  with  gas,  appearing  as 
a  large  mass  in  the  sides  and  in  the  eijigastrium.  In  other  cases  the  colon  undergoes 
atrophy,  and  can  be  felt  through  the  emaciated  belly  wall  as  a  narrow,  thickened 
band.  I  have  seen  the  entire  colon  in  a  case  of  this  character  shrunken  to  such 
an  extent  that  it  was  smaller  than  the  ileum.  In  doubtful  cases  resort  may  be  had 
to  tuberculin  to  determine  the  true  nature  of  the  mass. 

Prognosis  in  Intestin.\l  Tuberculosis. — The  prognosis  in  intestinal  tuber- 
culosis is  not  as  grave  as  in  pulmonary  tuberculosis,  as  far  as  early  death  is  con- 
cerned. In  the  majority  of  instances  the  patient  dies  of  the  primary  focus  before 
the  state  of  the  bowel  is  grave  enough  to  cause  death.    Such  cases  often  last  for 


TUBERCULOSIS  281 

several  years  and  have  periods  of  improvement  followed  by  relapse,  and  are  char- 
aeterized  by  gradual  loss  of  vitality.  If  death  is  caused  by  the  intestinal  state, 
it  comes  as  a  direct  result  of  profound  feebleness  and  exhaustion. 

Treatment  of  Intestinal  Tubexiculosls. — The  treatment  of  intestinal 
tuberculosis,  as  in  tuberculosis  of  the  lungs,  consists  to  a  great  extent  in  the  main- 
tenance of  the  greatest  degree  of  nutrition  and  vitality  that  is  possible,  and  thi.s 
can  only  be  accomplished  by  an  out-door  life,  plenty  of  sunshine,  the  avoidance  of 
fatigue,  and  the  use  of  such  foods  as  are  easily  digested  in  the  stomach  or  in  the 
duodenum,  so  that  the  greater  part  of  the  nourishment  wiU  be  absorbed  Ijcfore 
the  lower  part  of  the  ileum  is  reached.  In  those  cases  in  which  excessive  peristalsis 
rapidly  carries  the  contents  of  the  small  intestine  to  the  large  bowel  before  absorp- 
tion can  occur,  it  is  needful  to  insist  on  small  quantities  of  food  being  taken  at  a 
time,  and  to  order  that  no  water  be  taken  at  meals.  It  is  also  essential  that  the 
patient  shall  immediately  after  taking  food  lie  down  and  rest,  in  order  to  apply  all 
the  nervous  energy  possible  to  the  process  of  digestion  and  to  prevent  stimulation 
of  the  bowel  to  active  movement.  For  the  purpose  of  arresting  peristalsis  and 
diarrhea  the  salicylate  of  bismuth  in  the  dose  of  10  to  15  grains  three  or  four  times 
a  day  may  be  given,  or  salol  and  the  subnitrate  of  bismuth  may  be  used.  Another 
valuable  drug  is  eudoxine  in  the  dose  of  10  to  20  grains  three  times  a  day  in  cap- 
sule, or  bismuth  subgallate  may  be  given  in  the  same  dose.  In  some  instances  iodo- 
form may  be  given  in  keratin-coated  pills  in  the  dose  of  5  grains  four  times  a  day 
to  exercise  the  influence  of  this  substance  on  the  tuberculous  lesions ;  or  if  the  dis- 
ease is  in  the  rectum  or  colon,  20  grains  may  be  injected  dissolved  in  4  ounces  of 
olive  oil,  or  5  to  10  grains  may  be  given  in  suppository.  Some  relief  and  comfort 
can  also  be  obtained  by  the  use  of  a  hot-water  bag  over  the  abdomen  and  by 
painting  the  belly  wall  every  few  days  with  tincture  of  iodine. 

Tuberculosis  of  the  Liver. — Tuberculosis  of  the  liver  occurs  as  part  of  a  general 
miliary  tuberculosis,  and  as  a  form  characterized  by  the  formation  of  fairly  large 
aggregations  of  tubercles  in  which  the  nodules  may  be  as  large  as  a  walnut.  Tuber- 
culosis of  this  organ  is  practically  always  secondary  to  disease  elsewhere.  (See 
Tuberculosis  of  the  Peritoneum.) 

The  miliary  form  is  characterized  by  the  formation  of  miliary  tubercles  which 
are  intralobular  or  interlobular  in  position.  They  may  even  be  in  the  walls  of 
the  biliary  ducts,  and  vary  in  size  from  those  so  small  that  they  cannot  be  seen 
with  the  naked  eye  to  others  which  are  several  millimeters  in  diameter.  When  the 
tubercles  are  massed  together  so  that  they  form  small  nodules,  the  cells  of  the  liver 
are  of  course  destroyed,  the  surrounding  cells  sufi^er  coagulation  necrosis  and  infil- 
tration with  spheroidal  cells,  and  tubercle  bacilli  may  be  found  in  large  numbers 
in  the  cheesy  masses. 

Tuberculosis  of  the  Genito-urinary  System. — ^Tuberculosis  may  involve  any 
part  of  the  genito-urinary  tract,  and  is  by  no  means  rarely  met  with  in  the  testicle, 
the  Fallopian  tube,  the  bladder,  and  the  kidneys. 

Tuberculosis  of  the  Testicle. — ^^^'hen  tuberculosis  appears  in  the  testicle  it  develops 
in  one  of  two  forms.  In  one  of  these  the  onset  is  abrupt  and  accompanied  by 
acute  inflammation,  and  in  the  other  type  the  disease  develops  slowly,  with  no 
inflammation  and  without  pain.  When  the  acute  inflammation  of  the  flrst  type 
disappears  the  testicle  presents  irregular  nodules,  which  also  develop  in  the  chronic 
form.  In  a  large  proportion  of  cases  the  disease  is  secondary  to  lesions  elsewhere, 
but  it  may  be  primary,  particularly  if  it  begins  in  the  epididymis.  Verneuil  believes 
with  others  that  infection  may  occur  during  coitus  if  tuberculous  disease  of  the 
uterus  exists,  but  that  state  is  very  uncommon.  Babes  has  found  tubercle  bacilli 
in  the  vagina. 

In  nearly  all  cases,  whether  the  disease  be  primary  or  secondary,  the  lesion  begins 
in  the  head  of  the  epididymis,  forming  nodules  which  undergo  caseous  changes. 


282  DISEASES  DUE  TO  A  SPECIFIC  IXFECTIOX 

The  infection  spreads  to  the  vas,  which  becomes  thiclcened  and  nothdar,  and  to 
the  testicle,  the  vaginal  tunic  of  which  is  infected.  In  more  than  tiiree-fourths 
of  the  cases  this  secondary  infection  of  the  testicle  takes  place. 

When  i)rimary  infection  of  the  testicle  occurs  the  tubercles  also  produce  nodules, 
which  soften  and  may  form  a  sac  of  cheesy  matter.  Sinuses  may  form  after  adhe- 
sion to  the  scrotum  has  taken  place  and  discharge  externally. 

SiTviPTOMS  OF  Tuberculosis  of  the  Testicle. — In  the  form  of  the  disease 
characterized  by  sudden  onset  the  symptoms  closely  resemble  those  caused  by 
gnvorrhecd  orchitis,  for  sickening  pain  and  swelling  are  present.  Instead  of  sub- 
siding in  the  course  of  a  week  or  ten  days,  the  swelling  persists,  although  the  pain 
disappears;  but  before  many  days  have  passed  softening  occurs  and  the  so-called 
abscess  is  formed,  escaping  by  one  or  more  sinuses.  The  siceUing  is  often  bilateral, 
and  in  some  instances  massive  caseation  does  not  take  place,  but  hydrocele 
develops.  In  the  chronic  painless  form,  there  is  gradual  enlargement,  usually  of 
one  testicle,  with  the  development  of  one  or  more  nodules  and  a  sense  of  weight. 
In  place  of  caseation  a  fibroid  process  may  develop. 

Diagnosis. — The  diagnosis  of  acute  tuberculosis  of  the  testicle  can  be  made 
only  after  care  has  been  exercised  to  exclude  the  possibility  of  injury,  metastasis 
"in  mumps,  gonorrhea,  syphilis,  and  the  orchitis  of  some  of  the  acute  infectious 
diseases  such  as  typhoid  fever.  A  previous  history  of  gonorrheal  orchitis  is,  how- 
ever, of  importance,  for  this  condition  predisposes  to  tuberculosis  of  this  part. 
The  absence  of  any  of  these  causes,  the  presence  of  tuberculous  lesions  else- 
where, as  in  the  seminal  vesicles  or  prostate,  or  in  organs  farther  removed,  and 
the  fact  that  the  patient  is  in  young  adult  life,  all  fa\or  the  diagnosis  of  this 
disease  being  present.  The  de\elopment  of  suppuration  and  the  finding  of  the 
bacilli  in  the  cheesy  pus  will,  of  course,  decide  the  diagnosis. 

The  chronic  type  must  be  separated  from  sarcoma  and  from  the  thickening 
following  gonorrheal  orchitis.  The  absence  of  any  recent  history  of  gonorrhea,  or 
of  urethral  discharge,  and  the  presence  of  an  irregular  tumor  which  increases  in 
size,  all  point  to  tuberculosis  as  the  cause.  The  finding  of  the  bacilli  pro\es  tuber- 
culosis, but  the  presence  of  the  gonococcus  does  not  pro^'e  the  absence  of  tuber- 
culosis, for  obvious  reasons.  If  hydrocele  is  present  the  injection  of  some  of  the 
fluid  into  the  peritoneal  cavitj^  of  a  guinea-pig  may  decide  the  diagnosis  by  produc- 
ing tuberculosis  in  that  animal. 

Treatment. — In  most  cases  it  is  far  safer  to  remove  the  gland.  The  palliative 
treatment  consists  in  the  ordinary  hygienic  measures  used  in  tuberculosis  and,  if 
the  disease  is  locaHzed,  in  incision  and  drainage  with  iodoform  gauze;  or  in  other 
cases,  after  the  abscess  is  evacuated,  the  cavity  maj'  be  injected  with  iodoform  in 
glycerin  or  in  olive  oil  to  the  extent  of  1.5  drops.  In  other  cases  a  few  drops  of  this 
mixture  may  be  injected  into  the  gland  at  different  points  every  three  or  four  days, 
care  being  taken  that  antisepsis  is  preserved. 

Tuberculosis  of  the  Bladder. — This  condition  may  be  either  primary  or  secondary, 
anil  when  secondary  it  may  be  due  to  infection  through  the  bloodvessels  from  a 
distant  point,  or  by  direct  extension  from  the  prostatic  urethra,  which  is  diseased 
through  infection  of  the  prostate  gland,  which  is  affected  in  97  per  cent,  of  cases 
of  genito-urinary  tuberculosis  according  to  Kazywicki.  In  other  instances  the 
tuberculous  lesions  are  transferred  from  the  kidney  by  the  ureter  to  the  bladder. 
In  still  other  instances  the  infection  passes  from  the  vas  deferens  or  epididymis 
or  seminal  vesicles  to  this  viscus.  Primary  vesical  tuberculosis  is  quite  rare,  and 
when  it  occurs  is  due  to  infection  from  tuberculous  female  genitals  (Fournier). 
In  many  instances  a  case  of  tuberculosis  of  the  bladder  which  is  seemingly  jirimary 
is  really  secondary  to  an  unrecognizable  infection  of  the  kidney.  The  renal  con- 
dition in  other  instances  may  be  known  to  exist  during  life,  but  it  may  develop 
so  synchronously  with  the  vesical  lesions  that  it  is  difficult  to  tell  which  organs 


TUBERCULOSIS  283 

were  first  affected.  In  many  other  cases  the  primary  lesion  may  really  exist  in 
the  prostate  or  in  the  seminal  vesicles. 

The  bladder,  when  affected  by  tuberculosis,  develops  grayish  miliary  tul)ercles 
in  its  epithelial  lining,  which  can  rarely  be  seen  through  the  cystoscope  as  small 
gray  spots,  which,  like  all  other  tuberculous  growths  of  small  size,  tend  to  amalga- 
mate and  form  patches  which  in  turn  may  ulcerate,  and  so  destroy  the  mucous 
membrane.  The  ulcers  may  be  single  or  multiple,  and,  like  tuberculous  ulcers 
of  the  bowel,  may  have  irregular  outlines  with  the  base  covered  by  greenish  or 
grayish  pus.  Sometimes  they  are  deep,  at  others  superficial,  and  in  the  severe 
cases  they  may  penetrate  the  walls  of  the  bladder  and  cause  abscesses,  which  in 
turn  may  perforate  the  rectum,  the  vagina,  or  e\en  the  tissues  in  the  suprapubic 
area.  The  chief  lesions  are  usually  in  the  area  of  the  trigonum.  Tubercle  bacilli 
may  be  foimd  in  the  pus  in  the  urine. 

SiTviPTOMS. — The  symptoms  of  tuberculosis  of  the  bladder  are  usually  not  well 
marked  in  the  early  stages,  and  the  onset  of  the  malady  may  be  so  gradual  that 
the  disease  is  well  developed  before  it  is  recognized.  At  first  nothing  more  than 
a  little  vesical  irntahilify  may  appear,  and  the  urine  remains  dear  and  normal  in 
appearance.  The  microscope  may,  however,  re\eal  a  few  red  blood  cells,  and  later 
distinct  hematuria  develops,  which  is  characterized  by  the  appearance  of  a  few 
drops  of  clear  blood  at  the  end  of  urination.  As  soon  as  the  mucous  membrane 
of  the  bladder  becomes  eroded  infection  is  prone  to  occur  and  cystitis  develops, 
and  with  the  appearance  of  cystitis  pain  comes  to  be  a  prominent  symptom,  asso- 
ciated with  tenesmus  and  a  coitstant  desire  to  urinate,  which  exliausts  the  patient 
and  preAcnts  sleep.  The  earliness  with  which  these  sj-mptoms  develop  depends 
upon  the  seat  of  the  disease.  If  it  be  in  the  trigonum,  they  arise  promptly;  if 
elsewhere,  they  may  be  postponed  for  months.  Retention  of  urine  may  follow 
ulceration,  or  in  other  cases  as  the  neck  of  the  bladder  ulcerates  incontinence  is 
produced. 

Often  the  symptoms  vary  greatly  in  severity;  from  gra^e  severity  at  one  time 
to  almost  complete  relief  at  another.    Fever  is  often  absent. 

Diagnosis. — The  diagnosis  of  vesical  tuberculosis  depends  upon  the  presence 
of  these  symptoms  and  the  finding  of  the  bacillus  in  the  urine,  or  by  inoculation 
of  a  rabbit  or  guinea-pig  with  the  urine,  with  the  subsequent  deA^elopment  of  the 
disease  in  that  animal;  but  the  failure  of  either  of  these  tests  does  not  exclude 
tuberculosis.  Hematuria  is  rare,  but  pyuria  is  constant,  and  pyuria  without  the 
presence  of  ordinary  pus-producing  germs  is  very  suggestive.  Failiu-e  to  find 
tubercle  bacilli  does  not  negative  the  diagnosis.  The  cystoscope  usually  decides 
the  diagnosis.  If  gonorrhea,  stone  in  the  bladder,  stricture  of  the  urethra,  or  a  his- 
tory of  the  use  of  irritating  drugs  can  be  excluded,  and  if  no  spinal  disease  exists 
to  cause  secondary  bladder  trouble,  tuberculosis  should  be  suspected.  The  pres- 
ence of  tuberculosis  elsewhere,  of  course,  suggests  that  this  disease  is  the  cause 
of  the  bladder  trouble. 

Treatment. — For  the  general  plan  of  treatment  in  these  cases  reference  must 
be  made  to  treatises  on  genito-urinary  disease.  The  bladder  must  be  soothed  by 
alkaline  diuretics  if  the  urine  is  acid,  hyoscyamus  may  be  given  for  vesical  irri- 
tability, and  if  the  disease  is  active  iodoform  in  olive  oil  may  be  injected  into  the 
bladder  every  day,  using  a  10  per  cent,  solution.  The  bladder  should  be  care- 
fully emptied  before  the  iodoform  is  injected.  In  other  cases  corrosive  sublimate 
1  :  5000  may  be  employed  by  injection.  In  severe  cases  perineal  drainage  is  to 
be  resorted  to. 

Tuberculosis  of  the  Kidneys. — With  regard  to  the  pathway  by  which  the  bacillus 
reaches  the  kidnejs  two  views  have  generally  been  held.  Hematogenous  infection 
is  admitted.  Until  recently  an  ascending  infection  has  been  thought  not  uncom- 
mon, but  there  is  at  present  a  decided  tendency  to  doubt  that  infection  travels 


284  DISEASES  DUE  TO  A  SPECIFIC  IXFECTIOX 

from  below  upward;  it  has  been  shown  by  many  observers  that  tubercle  bacilli 
are  occasionally  present  in  the  urine  of  tuberculous  patients,  even  when  sui)se(|uent 
examination  at  autopsy  discloses  no  tuberculosis  of  the  genito-urinary  organs,  and 
hence  it  is  not  necessary  to  invoke  ascending  infection  to  explain  renal  lesions 
secondary  to  tuberculosis  elsewhere. 

Tuberculosis  of  the  kidneys  appears  in  an  acute  and  chronic  form.  The  former 
is  of  the  miliary  type  and  is  associated  with  the  signs  of  tuberculous  infection 
elsewhere,  and  cannot  be  treated  separately  from  the  general  state.  The  chronic 
form  may  arise  as  a  primary  lesion,  or,  far  more  commonly,  as  a  secondary  process 
due  to  disease  of  the  lower  genital  tract.  When  the  disease  is  primary  the  bacillus 
probably  gains  access  to  the  kidney  through  the  blood;  this  type  is  that  usually 
met  with  in  children.  But  the  form  ascending  from  the  genitals  is  that  met  with 
in  adults,  as  a  rule.  Males  are  more  frequently  affected  than  females.  The  disease 
is  most  freciuent  between  twenty-fi\'e  and  forty  years  of  age,  but  it  has  occurred 
in  an  infant  at  the  breast  and  in  very  old  men.    The  lesions  are  often  bilateral. 

The  pathological  process  is  primary,  and  secondary  renal  tuberculosis  is  cjuite 
different.  In  the  primary  form,  in  which  the  infection  comes  by  the  blood,  the 
bacilli,  resting  in  the  vessels  of  the  tufts  and  tubules,  form  small  tubercles,  which 
gradually  undergo  necrosis  and  so  cause  a  spread  of  the  disease  to  other  parts 
of  the  kidney,  particularly  the  calices  and  the  pelvis.  The  necrosis  of  tuberculous 
nodes  gives  rise  to  areas  of  softening  or  abscess  cavities,  and  these  are  filled  with 
cheesy  material  which  rarely  contains  blood  and  urine,  although  lime  salts  are 
freciuently  present  in  the  dead  tissue.  Not  only  tubercle  liacilli  but  pyogenic  and 
other  micro-organisms  are  often  present.  The  capsule  of  the  kidney  is  thickened 
and  may  show  scattered  tubercles.  The  size  of  the  organ  is  considerably  increased 
by  the  growth  of  the  tubercles  and  the  associated  inflammation,  forming  the  so- 
called  massive  tuberculosis  of  the  kidney.    Finally,  the  kidney  may  be  shrunken. 

As  the  tuberculous  process  in  the  pehas  of  the  kidney  increases  the  ureter  is 
usually  infected,  and  as  a  result  is  often  partly  occluded.  This  produces  a  reten- 
tion of  urine  in  the  kidney  and  so  a  secondary  hydronephrosis  de^'elops,  or  it  may 
be  a  pyonephrosis.  Sometimes  in  the  early,  and  much  more  frequently  in  the 
later  stages  of  the  affection  the  tissues  surrounding  the  kidney  become  more  or 
less  affected  and  a  perinephritic  tuberculosis  may  appear  from  rupture  of  a  softened 
area  through  the   capsule  of  the  kidney. 

When  that  form  of  renal  tuberculosis  which  is  secondary  to  tuberculosis  in  the 
lower  genito-urinary  tract  develops,  the  ureter  is  first  involved,  and  thence  the 
pelvis  of  the  kidney.  The  disease  then  attacks  the  tips  of  the  pyramids  and  so 
gradually  the  entire  gland  is  involved,  but  to  a  less  degree  than  in  the  form  first 
described.  Pyonephrosis  is  very  common  in  these  cases,  and  obstruction  in  the 
flow  of  urine  is  usual. 

Symptoms. — Often  no  symptoms  appear  until  the  ])elvis  of  the  kidney  is  diseased, 
when  pain  becomes  a  marked  symptom.  This  pain  may  be  dull  or  acute,  as  if 
due  to  a  renal  calculus,  with  the  characteristic  radiation  of  the  pain  to  the  penis 
and  inner  sitle  of  the  thigh.  The  urinary  symptoms  are  frequent  urination,  slight 
incontinence,  and,  later,  distinct  signs  of  cystitis  de\cloi5.  These  symptoms  often 
mislead  the  physician  into  a  diagnosis  of  disease  of  the  bladder.  Before  the  pelvis 
of  the  kidney  is  afiected  the  urine  may  be  normal,  but  afterward  it  contains  pus  and 
l)loo(l,  the  pus  coming  from  this  area  or  from  the  necrotic  ulcerating  tubercle. 
Attacks  of  violent  pain,  arising  from  acute  hydronephrosis  due  to  blocking  of  the 
ureter  by  cheesy  masses,  may  occur,  followed  by  a  free  flow  of  purulent  urine  as 
the  obstruction  gives  way.  Tubercle  bacilli  can  usually  be  found  in  the  urine,  but 
care  must  be  taken  that  the  smegma  bacillus  is  not  mistaken  for  the  specific  bacillus, 
and  as  indicated  above,  the  demonstration  of  the  tubercle  bacillus  does  not  prove 
that  the  infection  is  in  the  genito-urinary  organs. 


TUBERCULOSIS  285 

The  associated  symptoms  are  those  of  anemia,  dehility,  and  loss  nf  flesh.  A 
lumbar  tumor  may  also  appear. 

When  the  case  is  grave  the  question  of  operation  must  be  considered,  and  it  is 
important  to  discover  if  the  disease  is  bilateral  or  unilateral  before  operating. 
This  may  be  done  by  ureteral  catheterization. 

Tuberculosis  of  the  Fallopian  Tubes,  Ovaries,  and  Uterus. — The  frequency  of 
tuberculosis  of  the  Fallopian  tubes  is  notable.  It  forms  the  largest  part  of  all 
statistics  involving  the  female  genitalia,  for,  as  stated  below,  the  ovary  and  uterus 
are  rarely  affected.  Tuberculosis  of  these  parts  was  recognized  and  reported  as 
early  as  1744  by  Morgagni.  In  1886  Hegar  published  an  important  paper  on  this 
subject  which  marked  an  epoch  in  its  study.  To  illustrate  the  great  frequency 
of  tuberculosis  of  the  female  genital  tract  the  statistics  of  eight  European  patho- 
logists may  be  cited.  In  8627  cases  of  tuberculosis  in  females,  this  disease  had  in- 
fected the  genitals  208  times.    These  relative  proportions  are  probably  too  small. 

Unlike  tuberculous  disease  elsewhere,  tuberculosis  is  quite  frequently  a  primary 
lesion  in  these  parts,  the  infection  being  received  in  some  cases  from  the  male 
during  coitus  (Verneuil,  Cohnheim),  but  in  the  majority  of  instances  taking  place 
through  the  blood  or  lymphatics.  According  to  the  statistics  of  Schramm,  Spaeth, 
Hosier,  and  Frerichs,  genital  tuberculosis  is  found  to  be  primary  in  about  IS  per 
cent,  of  cases  of  genital  tuberculous  disease. 

Genital  tuberculosis  is  most  common  during  the  period  of  sexual  life.  Patho- 
logically the  condition  under  these  circumstances  is  like  that  of  an  ordinary  salpingi- 
tis, the  tubes  being  thickened  and  filled  with  cheesy  material.  Because  of  the  inflam- 
mation associated  ^^ith  the  tuberculous  process  the  fimbriated  extremity  of  the 
tubes  becomes  adherent  to  the  ovaries  and  the  uterus  may  become  infected.  This 
condition  may  develop  in  children  as  well  as  in  adults,  and  it  is  usually  bilateral. 
True  abscess  of  the  tube  may  arise  from  this  cause  and  a  tuberculous  parametritis 
and  peritonitis  often  start  from  this  nidus.  In  some  cases  a  miliary  tuberculosis 
of  the  tube  develops. 

The  ovary  is  rarely  in\olved,  but  when  this  occurs  it  is  always  a  secondary 
infection  from  an  infected  tube  or  other  adjacent  parts  or  from  the  blood.  The 
uterus  is  affected  only  in  very  rare  instances. 

Prognosis. — The  prognosis  in  tuberculosis  of  the  female  genitalia  is  more  favor- 
able than  would  be  imagined,  pro^•ided  an  early  diagnosis  is  made  and  operative 
treatment  resorted  to.  It  is,  of  course,  more  favorable  in  these  instances  if  the 
lesion  be  a  primary  one,  for  if  severe  disease  is  present  elsewhere,  operation  may 
be  contra-indicated  and  general  recovery  impossible. 

Treatment. — The  treatment  is  entirely  surgical. 

Tuberculosis  of  the  Heart. — The  heart  very  rarely  becomes  tuberculous  but  myo- 
cardial changes,  due  to  the  disease  elsewhere,  are  not  uncommon,  consisting  chiefly 
in  fragmentation  of  the  myocardium,  brown  induration  and  interstitial  myocarditis. 
Fatty  degeneration  also  occurs.  The  pericardium  suffers  from  tuberculosis  in  the 
pulmonary  form  of  the  disease  only  slightly  more  frequently  than  the  heart  muscle 
Norris  found  it  recorded  only  thirty-one  times  in  7646  cases  of  pulmonary  tuber- 
culosis. General  endocarditis  arising  from  this  cause  is  exceedingly  rare.  Some- 
times a  general  endocarditis  arises  from  an  associated  terminal  infection.  An 
endocarditis  producing  mitral  stenosis  is,  however,  more  common  but  is  not  directly 
due  to  tubercular  infection,  but  to  toxemia.  Ferrend  and  Rathery  have  reported 
a  case  of  tuberculous  A'egetative  endocarditis  folloT\-ing  primary  tuberculosis  of 
the  spleen.  Tubercle  bacilli  were  found  in  these  vegetations  and  in  the  clotted 
heart  blood. 

Tuberculosis  of  the  myocardium  is  very  rare.  In  1902  Anders  collected  71 
cases  of  tuberculosis  of  the  myocardium,  and  reported  one  of  his  own,  which  were 
all  he  could  find  in  literature. .  Out  of  3999  autopsies  reported  by  Valentin  and 


286  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

Sangelli  this  condition  was  found  in  only  nine  instances.  Weij;ert,  however,  states 
that  he  has  found  minute  tul)ercles  in  different  portions  of  the  heart  in  nearly  ail 
his  aut()])sics  on  jiaticnts  wlio  died  from  acute  miliary  tuberculosis. 

Tuberculosis  of  the  Thyroid  Gland. — Fracnkel  and  Chiari  in  480  autopsies  on 
tuIxTciiliiiis  sul)jeets  found  tlie  thyroid  "-hind  afl'ccted  thirteen  times. 

Tuberculosis  of  the  Brain  and  Cord. — Tulicrculnsis  of  the  meninges  of  the 
brain  and  cord  lias  already  been  mentioned  when  discussing  the  tuberculous  infec- 
tion of  the  .serous  membranes.  The  tissues  of  the  brain  and  cord  are,  comparatively 
speaking,  very  rarely  affected.  When  tuberculous  lesions  occur  in  these  parts 
they  are  practically  always  secondary  to  tuberculous  lesions  elsewhere,  but  there 
are  a  few  exceptions  to  this  rule.  Thus,  Demme  has  recorded  a  unique  case  of 
tuberculous  tumor  of  the  cerebellum  in  a  child  of  twenty -three  days,  and  he  has 
also  had  a  case  in  which  infection  seemingly  took  place  through  the  nose. 

When  tuberculous  tumors  de\'elop  in  these  parts  of  the  nervous  system  they 
appear  as  solid  or  caseous,  rounded  masses,  which  resemble  the  ordinary  tuber- 
culous growth  as  it  is  seen  elsewhere.  They  vary  in  size  from  a  millet-seed  to  an 
orange.  When  incised  they  are  caseous,  fibrocaseous,  or  hyaline  and  calcareous, 
or  all  of  these  changes  may  be  found  associated.  The  surface  of  the  growth  is 
sometimes  soft  and  translucent,  and  the  adjacent  brain-tissue  may  be  filled  with 
miliary  tubercles,  which,  coalescing  with  the  main  growth,  in  this  way  increase 
its  size.  The  growth  docs  not  undergo  the  rapid  changes  usually  met  with  else- 
where. Sometimes  these  nodules  become  encapsulated  by  fibrous  tissue  just  as 
does  the  ordinary  tuberculous  growth  in  the  lung,  or  rapid  softening  in  the  surround- 
ing tissues  develops  and  suppuration  takes  place. 

These  tuberculous  growths  do  not  tend  to  infiltrate  the  surrounding  tissues. 
They  generally  occur  in  the  brain  tissue  itself,  and  while  it  has  been  asserted  that 
they  always  spring  from  the  pia  mater,  this  view  is  of  doubtful  value.  As  they 
often  project  above  the  surface,  the  cerebrospinal  fluid  is  readily  infected.  One- 
third  of  these  tuberculous  growths  occur  in  the  cerebellum,  in  one  of  its  hemispheres 
or  in  the  middle  lobe.  After  the  cerebellum,  the  cerebrum  is  the  most  common 
site,  and  after  this  Gowers  gives  the  following  order:  the  pons,  the  cerebral  ganglia, 
the  quadrigeminal  bodies.  As  a  rule,  more  than  1  growth  exists:  but  sometimes 
2  and  sometimes  as  many  as  10  or  12  are  present.  Thus,  Trevelyan  found  them 
multiple  in  17  out  of  3.3  cases,  which  is  a  smaller  proportion  than  is  usual,  and  the 
largest  number  in  any  one  case  was  4.  In  a  case  reported  by  Middleton  there 
were  20,  and  in  a  case  reported  by  Homen  there  were  12.  West  and  Henoch  have 
each  reported  a  case  in  which  there  were  12  tuberculous  tumors.  There  are  a 
few  cases  recorded  in  which  recovery  has  taken  place  notwithstanding  the  presence 
of  a  tuberculous  tumor  in  the  brain,  and  without  operation.  (For  literature  see 
Tre\-elyan's  article  in  the  Lancet  for  November  7,  1903.)  The  symptoms  and 
treatment  of  tubercle  of  the  brain  are  discussed  under  Brain  Tumor. 


HODGKIN'S  DISEASE. 

Definition. — Ilodgkin's  disease  is  a  condition  in  which  there  is  marked  swelling 
and  overgrowth  of  the  lymphatic  glands,  both  internal  and  external,  with  a  moderate 
degree  of  anemia  which  is  in  no  way  peculiar  to  this  malady.  The  spleen  is  usually 
enlarged.  The  overgro\\-th  of  the  lymph  nodes  and  lymphatic  tissues  generally 
is  closely  allied  to  malignant  lymphadenoma.  Another  name  for  the  disease  is 
"  pseudoleukemia." 

History. — Although  a  difference  between  this  state  and  scrofulous  enlargement 
of  the  lymph  nodes  had  been  made  prior  to  1830,  it  was  not  until  Ilorlgkin  in  1832 
described  cases  seen  at  Guj-'s  Hospital  that  it  was  generally  recognized.     In 


HODGKIN'S  DISEASE  287 

1856  Wilkes,  in  London,  and  Bonfils,  in   France,  still   further  illuminated  the 
subject. 

It  was  not  until  Virchow  completed  his  work  on  the  histology  of  the  hlooil  that 
Hodgkin's  disease  became  clearly  differentiated  from  leukemia  of  the  lymphatic 
type.  The  fact  that  changes  of  a  peculiar  character  exist  in  the  l\-mph  notles 
was  not  known  until  1897,  when  several  in\'estigators,  notably  Fischer,  flescribed 
them. 

Etiology. — Within  the  last  few  years  the  view  that  Hodgkin's  Disease  was  a 
peculiar  condition  due  to  infection  by  the  Badlhis  hibercvlosis  gained  a  number  of 
adherents,  and  there  are  without  doubt  certain  facts  connected  with  the  malady 
which  tend  to  substantiate  this  view.  On  the  other  hand,  Doroth\-  Reed,  Longcope 
and  Simmons  have  published  careful  in\^estigations  to  prove  that  Hodgkin's  disease 
possesses  definite  pathological  characteristics  peculiar  to  itself.  In  1913  Negri 
and  Mieremet  described  a  pleomorphic  organism  obtained  from  the  enlarged 
nodes  in  cases  of  the  disease  to  which  they  ga\'e  the  name  of  Conjnebacierium 
granuhviatis  maligni.  Later  Bunting  and  Yates  isolated  it  in  pure  culture  from 
three  cases,  found  it  in  two  others  not  in  pure  culture,  and  stained  it  in  the  intestinal 
lesions  of  a  sixth.  They  suggest  for  it  the  name  of  Corynebacterium  hodqhlni. 
Billings  and  Rosenow  recently  report  finding  this  organism  in  12  cases,  in  pure 
culture  in  3,  with  a  staphylococcus  in  the  others.  They  describe  it  as  a  Gram- 
staining,  non-acid-fast,  polymorphous,  diphtheroid  organism,  growing  on  blood 
agar,  blood  serum,  and  ascites-dextrose  agar.  These  findings  appear  significant, 
though  actual  proof  that  this  organism  is  the  cause  of  Hodgkin's  disease  has  not 
yet  been  adduced.  The  disease  is  more  frequent  in  males  than  in  females,  and  in 
adults  than  in  childhood. 

Pathology  and  Morbid  Anatomy. — The  changes  which  are  most  marked  are  en- 
largement of  the  lymphatic  glands  at  first  in  limited  areas  and  later  all  over  the 
body.  The  cervical  and  inguinal  glands  are  usually  the  most  prominent,  and  the 
outlines  of  the  neck  may  be  completely  obliterated.  At  autopsy  the  retrobronchial 
and  retroperitoneal  glands  may  be  found  enormously  increased  in  size,  forming  a 
mass  as  large  as  the  arm,  and  pressing  on  adjoining  tissues  such  as  the  thoracic 
duct  and  the  bloodvessels.  The  affected  nodes  are  discrete  and  regularly  enlarged. 
Their  consistency  varies.  Sometimes  they  are  firm  and  dense,  at  others  so  soft 
as  to  fluctuate.  The  cut  surface  of  these  glands  is  translucent,  gray,  or  more  rarely, 
yellowish,  and  the  tissues  of  the  glands  bulge  forward.  An  overgro-ni;h  of  lymphoid 
tissue  may  take  place  at  the  apices  of  the  lungs  and  lead  to  a  diagnosis  of  tuber- 
culosis. Death  may  be  due  to  pressure  on  the  thoracic  bloodvessels,  and  perhaps 
to  pulmonary  infiltration  and  exudation.  Osier  asserts  that  infiltration  of  the 
lung  does  not  occur  in  this  disease,  and  that  when  such  an  infiltration  does  take 
place  the  disease  is  true  lymphosarcoma.  There  is  also  enlargement  of  the  spleen 
with  overgrowth  of  the  Ijonphoid  bodies,  which  are  grayish  white  in  appearance, 
and  consist  of  lymph  follicles  held  together  by  a  reticulum  of  connective  tissue. 
The  marrow  of  the  long  bones  may  be  lymphoid  or  purulent  in  appearance,  as  it  is 
in  some  cases  of  myelogenous  leukemia.  The  liver  and  kidneys  may  also  be 
enlarged  and  contain  lymphoid  masses. 

The  characteristic  microscopic  lesions  of  Hodgkin's  disease  are  an  early  increase 
in  the  lymphadenoid  tissues  with  a  proliferation  of  endothelial  cells,  the  formation 
of  uninuclear  and  multinuclear  giant  cells,  thickening  of  the  reticulum,  and  lastly 
an  overgrowth  of  the  connective  tissue  of  the  lymph  nodes  to  the  development 
of  which  the  increased  density  of  these  masses  is  due.  Eosinophile  cells  in  most 
cases  are  present  in  very  large  number  in  the  lymph  nodes  and  in  the  bone- 
marrow.  Not  only  is  the  disease  characterized  by  these  changes  in  the  pre-existing 
lymph  nodes,  but  there  is  a  constant  formation  of  new  nodes  which  soon  become 
similarly  affected. 


288 


DISEASES  DUE  TO  A  SPECIFIC  INFECTION 


Tlic  blood  changes  are  most  variable.  In  some  cases  tliey  are  morlerate,  in 
others  severe,  in  that  the  red  cells  may  be  decreased  in  number,  but  even  when 
the  patient  is  at  death's  door  there  may  be  fully  3,000,000  cells  present.  The 
red  cells  are  not  altered  in  a  manner  which  is  in  any  wa.\-  cluiracteristic.  The 
changes  consist  solely  in  a  diminution  in  number  to  a  moderate  degree,  and  in  a 
reduction  of  the  amount  of  hemoglobin.  The  leukocytes  are  not  increased  as  in 
true  leukemia,  but  are  often  actually  diminished.  Pinkus  thought  a  relative 
increase  of  the  lymphocytes  constant,  but  this  change  was  present  in  but  1  of 
Longcope's  7  cases,  although  a  very  large  proportion  of  the  white  cells  may  be 
of  this  variety.  Occasionally  the  increase  of  wJiite  cells  may  rise  to  the  number 
seen  in  certain  inflammatory  states,  as  from  30,000  to  40,000.  In  the  later  stages 
the  blood  picture  may  assume  all  the  characteristics  of  an  intense  secondary  anemia. 


Hodgkin's  disease. 


Symptoms. — The  symptoms  of  pseudoleukemia  are  those  of  ordinar\-  se\-ere 
secondary  anemia,  with  shortness  of  breath  and  jxilpitation  of  the  heart  on  exertion. 
The  enlarged  masses  of  glands  in  the  neck  and  groins  may  be  very  characteristic 
in  appearance,  associated  as  they  are  with  pallor  and  puffincss  of  the /ace.  When 
the  internal  glands  are  primarily  and  chiefly  invoh'cd  the  diagnosis  from  tuber- 
culosis may  be  difficult  because  the  pressure  may  cause  consolidation  with  patches 
of  dulness  on  percussion,  and  becau.se  a  distinct  febrile  movement  is  often  present. 

These  masses  by  producing  pressure  may  give  rise  to  paroxysms  of  cough  or  of 
pain  or  constant  dyspnea.  A\nien  the  inguinal  glands  are  affected  edema  of  the 
hxcer  extremities  may  de^•elop,  and  shooting  pains  may  be  felt  in  the  legs.     After 


LEPROSY  289 

the  glandular  masses  become  very  large,  superficial  sloughing  may  occur,  and  there- 
fore the  resemblance  to  a  suppurating  tuberculous  mass  may  be  increased  (Fig. 
59).  I  have  seen  an  actinomycosis  of  the  neck  produce  similar  symptoms.  Bronz- 
ing of  the  skin  may  occur.  Moderate  fever  is  often  present.  It  may  be  low  and 
regular  or  high  and  irregular  in  type.  Occasionally  it  has  an  intermittent  char- 
acter with  sharp  exacerbations,  so  that  it  resembles  intermittent  or  remittent 
malarial  fever.     Jaundice  due  to  pressure  on  the  bile-ducts  may  appear. 

Additional  symptoms  met  with  in  some  cases  are  murmurs  in  the  great  vessels, 
produced  partly  by  the  anemia  but  chiefly  by  the  pressure  caused  by  the  gro^\'ths. 
Deafness  due  to  closure  of  the  Eustachian  tubes  by  growths  in  the  pharynx  and 
unequal  pupils  due  to  pressure  on  the  cervical  sympathetic,  may  be  present. 

Diagnosis. — From  true  leukemia  pseudoleukemia  is  to  be  separated  by  the 
absence  of  the  large  excess  of  leukocytes,  and  the  lack  of  the  leukocji;es  peculiar 
to  that  disease.  From  enlargement  of  the  lymph  glands  due  to  tuberculosis  it 
is  to  be  separated  by  the  test  with  tuberculin  (see  Tuberculosis),  and  by  the  fact 
that  tuberculosis  rarely  produces  enlargement  of  the  cervical  glands  on  both  sides 
and  in  both  groins,  and  by  the  absence  of  a  tuberculous  focus  elsewhere.  When 
doubt  exists  a  part  or  all  of  an  enlarged  mass  of  glands  may  be  excised  and  examined 
microscopically  to  determine  the  character  of  the  disease. 

In  many  cases  the  clinical  diagnosis  is  most  difficult.  I  have  seen  the  most 
eminent  cHnicians  mistake  this  malady  for  tuberculosis,  ^^ery  rarely  a  form  of 
multiple  lipoma  distributed  in  the  IjTnph-node  areas  closely  resembles  Hodgkin's 
disease;  the  picture  may  further  be  confused  by  the  presence  of  glandular  and 
calcific  masses  in  fatty  tiunors;  such  a  case  has  been  observed  in  the  Jefferson 
Medical  College  Hospital;  Chantemesse  and  Podwyssotskj'  figure  such  a  case 
under  the  name  adenolipomatosis. 

Prognosis. — The  prognosis  in  Hodgkin's  disease  is  absolutely  bad.  Not  one 
recovers.  These  patients  ha^'e  periods  of  improvement  when  courage  runs  high, 
but  after  all  the  inevitable  progress  is  downward.  Death  comes  from  interference 
with  circulation  or  respiration  or  by  general  asthenia. 

Treatment. — The  best  treatment  is  the  use  of  arsenic  in  full  doses.  Excellent 
results  have  been  obtained  in  some  of  these  cases  by  the  use  of  .r-raj's,  the  parts 
invoh'ed  being  exposed  to  the  rays,  repeatedly,  over  a  long  period  of  time.  Billings 
and  Rosenow  report  improvement  (wdth  one  apparent  recovery)  in  several  cases 
treated  with  vaccines  made  from  the  organism  described  under  Etiology.  They, 
however,  used  the  vaccine  as  an  addition  to  the  a:-rays  and  other  usual  methods  of 
treatment. 

LEPROSY. 

Definition. — Leprosy  is  a  chronic  infectious  disease  caused  by  a  specific  bacillus, 
and  is  characterized  by  the  occurrence  of  granulomatous  new  gro^"ths  in  the  skin, 
mucous  membrane,  peripheral  nerves,  and  viscera.  The  lesions  are  partly  anes- 
thetic and  there  is  a  marked  tendency  to  destructive  ulceration  and  trophic  lesions. 

History. — The  history  of  leprosy  is  as  old  as  the  ^Titten  history  of  the  human 
race.  The  earliest  known  records  are  in  two  Egj^tian  papyri  of  4260  B.C.  and 
2400  B.C.  The  detailed  description  of  leprosy  in  the  third  book  of  Moses  is  familiar 
to  all.  In  India  and  China  the  earliest  writings  that  unmistakably  describe  leprosy 
appeared  about  700  B.C.  The  disease  appears  much  later  in  European  history. 
It  was  not  mentioned  by  Hippocrates,  and  we  may  assume  that  it  was  unknown 
in  his  time.  It  appeared  in  Greece  before  375  B.C.  and  gradually  spread  over  all 
Europe,  its  extensions  being  generally  along  the  track  of  conquering  armies.  Its 
extensive  distribution  in  the  Middle  Ages  finally  brought  about  stringent  restrictive 
regulations  which,  beginning  in  the  thirteenth  century,  served  to  gradually'  decrease 
the  disease  until  now  it  occurs  only  in  isolated  centres  of  infection. 
19 


290  DISEASES  DCE  TO  A   SPECIFir  ISFEC'llOX 

Distribution. — At  present  tlie  distribution  of  leprosy  is  very  extensive,  principally 
ill  tn)])i(al  and  subtropical  countries.  It  is  a  mistake  to  consider  that  lejjrosy  is 
essentially  a  <lisease  of  warm  climates.  In  Europe  it  appears  only  in  small,  scattered 
centres  or  in  isolated  cases.  It  prevails  in  greatest  numbers  in  Finland,  Sweden, 
Iceland,  and  Norway,  particularly  the  latter.  In  Russia  it  is  found  in  forty-nine 
provinces,  most  frequently  in  the  Baltic  provinces  of  Lifu  with  <)()9,  and  Kurland 
with  201  cases.  Isolated  cases  occur  in  England,  Germany,  Brittany,  and  Italy. 
The  total  number  of  cases  in  Western  Europe  at  present  is  estimated  at  ;iOOO. 
The  disease  is  found  all  over  tropical  Asia.  In  British  India  the  number  of  lepers 
is  estimated  at  105,000,  or  one  in  every  two  thousand  of  population.  It  is  believed 
that  leprosy  prevails  in  the  southern  provinces  of  China  more  than  anywhere  else, 
although  no  accurate  figures  are  available.  It  is  very  common  in  Japan,  the  number 
of  cases  being  estimated  at  23,660  (Souton),  and  in  Ceylon,  Persia,  Arabia,  and 
the  Malayan  country.  In  the  Philippines  there  are  probably  1.5,000  lepers.  The 
disease  is  widely  distributed  in  Africa,  particularly  along  the  upper  Nile  and  the 
countries  bordering  along  the  Red  Sea  and  the  ^Mediterranean.  Leprosy  was 
introduced  into  the  Sandwich  Islands  in  1859,  and  at  one  time  one  in  thirty  of 
the  population  was  affected. 

Much  has  been  said  of  the  early  existence  of  leprosy  in  America.  There  is  no 
evidence  to  show  that  the  disease  existed  prior  to  the  Spanish  discovery.  The 
so-called  evidence  of  pre-Columbian  leprosy  in  America  is  entirely  too  vague  to 
justify  any  deductions.  In  point  of  fact  it  suggests  syphilis  or  sacrificial  mutilation 
more  strongly  than  leprosy.  At  present  lepers  are  found  in  large  numbers  in 
Mexico  and  many  countries  of  South  America.  In  Colombia  there  are  said  to  be 
seven  in  every  one  thousand  in  the  population.  There  are  some  cases  in  New 
Brunswick  and  British  Columbia.  Cuba  and  the  Antilles  are  severely  infected; 
the  latest  figures  give  1297  lepers  in  Cuba.  In  the  United  States  the  disease  is 
generally  distributed.  A  recent  official  report  shows  that  nearly  e\'er\-  large  city 
has  at  least  one  case,  the  aggregate  number  for  the  United  States  reaching  o\'er 
900.  The  disease  occurs  in  three  main  foci,  namely,  one  in  Louisiana,  which  has 
existed  since  1785,  and  has  lately  been  estimated  as  containing  about  500  cases; 
another  in  California,  the  infection  having  been  brought  in  by  the  Chinese,  and  a 
third  in  ^Minnesota,  where  it  has  been  estimated  that  there  were  170  lepers,  the 
number  being  almost  entirely  made  up  of  emigrants  from  the  infected  districts  in 
Norway,  from  which  region  infected  persons  also  carried  the  disease  into  the  Mormon 
settlements  of  Utah.  These  settlements  in  Utah  ha\e  also  been  infected  from 
Hawaii. 

Etiology. — The  specific  cause  of  leprosy  is  the  Bacillus  leprae,  disco\erefl  by 
Hansen  in  1871.  This  bacillus  is  about  the  same  size  and  has  the  same  morphology 
as  the  tubercle  bacillus.  Like  it,  it  is  also  acifl-fast;  that  is  to  say,  when  stained 
with  an  aniline  dye  it  does  not  decolorize  readily  in  the  presence  of  mineral  acid. 
It  stains  a  little  more  easily  than  the  tubercle  bacillus  and  decolorizes  more  rapidly. 
It  has  been  grown  successfully  on  artificial  culture  media  in  the  presence  of  typhoid 
or  cholera  organisms.  It  is  found  packed  in  very  great  numbers  inside  the  leprosy 
cells,  but  it  does  not  invade  the  nucleus.  It  is  also  found  in  zooglea  masses  in 
the  lymph  sj)aces,  in  the  granulomatous  lesions,  and  in  the  infiltrated  nerve  tissues. 
A  number  of  cases  Ikivc  been  reported  in  which  the  bacillus  has  been  found  in 
the  circulating  blood. 

Manner  of  Infection. — There  is  one  case  of  experimental  inoculation  on  record 
in  the  jjcrson  of  a  Hawaiian  convict  reported  by  Arning.  Four  weeks  after  inocula- 
tion the  disease  began  to  develop  with  acute  {)ain  and  thickening  of  the  nerve 
trunks,  and  a  little  while  after  a  typical  leprous  nodule  appeared  at  site  of  inocula- 
tion. The  patient  died  of  the  disease  in  sLx  years.  Unfortunately  this  experiment 
was  inadi'  in  a  leprosy  country  and  the  man  had  a  leprous  family  history,  so  that 


LEI' ROSY  2!)1 

the  evidence  derived  from  it  cannot  be  regarded  as  absolutely  conclusive.  There 
can  be  no  doubt  that  in  a  large  luimber  of  instances  the  bacillus  gains  admission 
through  abrasions  of  the  skin  and  mucous  meml)ranes,  and  possibly  also  from  the 
friction  of  infected  clothing. 

Corroboration  of  the  idea  that  the  bacilli  gain  entrance  through  local  lesions  is 
found  in  the  fact  that  where  people  go  habitually  without  shoes,  as  in  trojjical 
countries,  the  disease  first  appears  in  the  feet  in  a  large  proportion  of  cases.  Elder 
states  that  in  Iceland  the  face  and  hands  are  most  frequently  attacked  because  the 
remainder  of  the  body  is  so  fully  protected  by  clothing.  Boinet,  in  Hanoi,  con- 
sidered infected  earth  to  be  the  probable  carrier  of  the  disease  to  the  feet  of  the 
natives.  lie  found  the  earth  saturated  with  sputa,  crusts,  and  discharges  of  the 
lepers.  He  was  able  to  demonstrate  that  the  soil  of  the  cemetry  at  Hanoi  was 
highly  charged  with  bacilli,  but  this  e\'idence  is  of  little  value,  as  acid-fast  bacilli 
are  widely  distributed.  Carasaquilla  believes  that  leprosy  may  be  conveyed  by 
the  bite  of  fleas,  and  infection  by  the  mosquito  must  also  be  borne  in  mind,  since 
the  bacilli  are  sometimes  found  in  the  blood  and  have  also  been  demonstrated  in 
mosquitoes.  Scabies  may  transfer  the  infection.  A  large  proportion  of  cases  are 
undoubtedly  infected  in  sexual  intercourse.  The  contagion  of  leprosy  is,  however, 
feeble. 

The  immunity  of  physicians  and  nurses  is  proverbial,  although  several  striking 
instances,  as  that  of  Father  Damien,  are  on  record  in  which  attendants  on  lepers 
have  fallen  victims  to  the  disease.  It  would  seem  that  long  intimate  contact  were 
necessary  to  contract  it.  Hutchinson  suggests  that  leprosy  may  be  conveyed  from 
person  to  person  by  commensal  contagion;  that  is  to  say,  by  eating  food  prepared 
by  the  sore  hands  of  a  leper,  and  by  eating  out  of  infected  dishes  and  utensils. 
Von  Bergmann,  in  a  study  of  106  cases  of  leprosy  in  Riga,  found  that  60  per  cent, 
occurred  in  people  who  had  li\'ed  in  intimate  contact  ^^  ith  lepers.  In  the  workhouse 
at  Riga  there  were  23  cases:  4  who  entered  \\ith  it,  19  who  contracted  it  in  the 
house;  9  cases  developed  in  women  whose  neighbors  in  the  next  beds  had  leprosy, 
but  McCoy  and  Goodhue  of  the  United  States  Public  Health  Service  in  JNIolokai, 
basing  their  statistics  upon  cases  exposed  not  less  than  five  years,  found  that  out 
of  23  Causasian  males  constantly  exposed  3  were  infected,  and  that  of  12  Caucasian 
females,  none  were  infected. 

Great  significance  was  formerly  attached  to  the  factor  of  heredity  in  leprosy, 
but  recent  studies  of  the  epidemiology  of  the  disease  ha^-e  disproved  its  importance. 
Boinet  cites  a  case  in  which  grandfather  and  grandmother  were  lepers,  while  the 
father  and  five  children  escaped,  although  living  in  a  leprous  community.  Children 
of  lepers  removed  soon  after  birth  from  the  infected  districts  do  not  develop  leprosy, 
while  their  brothers  and  sisters  who  continue  to  live  in  the  leper  community  may 
contract  it.  None  of  the  children  of  Norwegian  lepers  who  have  emigrated  to  the 
United  States  have  developed  the  disease.  Tonkin,  in  a  careful  study  of  lepers 
in  Algeria,  found  that  only  10  per  cent,  of  the  cases  had  any  leprous  taint  in  their 
ancestr^y;  so  that  90  per  cent,  at  least  must  have  derived  the  disease  from  other 
sources.  He  found,  further,  that  less  than  10  per  cent,  of  the  children  of  lepers 
developed  the  disease,  which  is  certainly  a  low  percentage  of  contagion  for  persons 
living  in  close  intercourse  with  lepers,  even  disregarding  the  question  of  heredity. 
There  is  nowhere  a  record  of  a  leprous  fetus,  although  one  or  two  cases  of  infants 
born  with  leprosy  have  been  reported. 

The  disease  is  exceedingly  rare  under  one  j^ear;  and,  in  fact,  before  the  fifth 
or  sixth  year.  It  must  be  recognized  as  very  feebly  contagious,  therefore,  when 
close  and  prolonged  contact  is  eliminated.  Of  the  various  types  the  tuberculous 
is  far  more  contagious  than  the  anesthetic. 

Many  writers  have  maintained  that  defective  nutrition  and  diet  play  an 
important  role  in  this  disease.     Hutchinson   was  the  foremost  exponent  of  the 


292  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

theory  that  the  disease  is  conveyed  by  food  and  that  the  germs  gain  entrance  to 
the  body  through  the  stomach.  He  believes  that  tainted  fisli  carry  the  infection, 
although  leper  bacilli  have  never  been  found  in  them.  This  idea  of  fish  serving 
as  the  medium  for  the  infection  of  leprosy  is  not  a  new  one.  They  ha\-e  been 
suspected  in  all  ages,  and  it  is  true  that  leprosy  occurs  chiefly  in  countries  where 
fish  forms  a  staple  article  of  food,  and  where  a  large  proportion  of  the  inhabitants 
are  engaged  in  fishing.  There  is  nothing  inherently  improbaljle  in  the  theory 
that  fish  may  carry  the  infection,  or  that  a  fish  diet  may  represent  a  common 
additional  factor  in  the  development  of  the  disease.  x\s  against  this  theory,  Hansen 
maintains  that  it  is  necessary  to  demonstrate  the  bacilli  in  fish.  He  states  that 
the  people  of  Norway  are  using  more  fish  than  ever  at  present,  but  ne\'ertheless 
leprosy  is  constantly  decreasing. 

Morbid  Anatomy. — In  tuberculous  leprosy  the  lesions  consist  in  granulomatous 
gro\rths  or  diffuse  infiltration  of  the  skin  and  mucous  membranes.  The  granulo- 
matous gro^^■ths  are  built  up  of  small  round  and  fusiform  cells  and  large  vacuolated 
cells,  called  by  Virchow  leprosy  cells.  These  cells  are  probably  of  endothelial 
origin  and  are  packed  full  of  bacilli.  They  frequently  develop  into  giant  cells. 
The  bloodvessels  are  increased.  In  diffuse  leprous  infiltration  the  same  histological 
elements  are  observed.  The  new  groAAlh  in^'ades  the  bloodvessels,  hair  follicles, 
and  sweat  glands.  The  bacilli  are  found  everywhere,  but  in  greatest  numbers  in 
the  giant  and  leprosy  cells. 

In  the  macular  lesions  there  is  a  larger  proportion  of  connective  tissue,  the 
bacilli  are  fewer,  and  none  of  the  large  types  of  cells  are  seen.  In  the  anesthetic 
type,  diffuse  or  nodular  infiltrations  are  found  in  the  nerve  trunks.  The  nerves 
are  firmer  than  normal  and  darker  in  color.  The  interstitial  connective  tissue  is 
markedly  increased  and  the  axis  cylinders  are  atrophied. 

Leprous  nodules  and  infiltrations  are  found  in  the  liver,  spleen,  testicle,  intestines, 
and  kidney's.  In  the  bones  osteomyelitis  necrosis,  and  atrophy  are  olxserved, 
the  bone  being  replaced  in  many  instances  of  leprous  mutilations  by  connective 
tissue.  In  the  larger  joints  changes  occasionally  are  obser\'ed  that  are  \'ery  similar 
to  the  trophic  joint  changes  of  tabes. 

Symptoms  and  Clinical  Forms. — Leprosy  shows  itself  under  an  extreme  variety 
of  forms.  Its  beginning  is  very  insidious  and  at  first  the  progress  is  very  slow. 
Even  after  a  number  of  years  the  lesions  may  be  verj^  insignificant  and  not  at  all 
conclusive  to  the  casual  observer.  The  incubation  period  is  uncertain,  and  is 
usually  accepted  as  very  long.  The  average  incubation  is  assiuned  to  be  between 
two  and  three  years,  although  cases  are  reported  in  which  it  is  supposed  to  have 
lasted  from  ten  to  twenty-se^'en  years;  these  prolonged  instances  must  be  viewed 
with  suspicion  as  to  their  accuracy.  In  many  other  cases  periods  as  l>rief  as  from 
three  or  four  weeks  to  three  or  four  months  are  gi\en.  It  will  be  recalled  that  the 
incubation  of  the  Hawaiian  inoculation  case  was  four  weeks. 

Another  disputed  point  in  the  symptomatology  of  leprosy  is  the  existence  of 
the  primary  sore  or  the  leprous  chancre,  as  it  has  been  called.  It  has  been  shown 
that  all  e\-idence  points  to  direct  inoculation  as  the  source  of  leprosy,  and  it  is  not 
unreasonable  to  assume  a  primary  sore  at  the  point  of  inoculation  of  the  germ. 
]\Iany  observers  hold  that  such  a  sore  does  occur,  and  that  in  a  large  majority 
of  cases  it  is  located  on  the  7iasal  septum.  Thus,  Stickler  \A'as  able  to  demonstrate 
ulceration  of  the  septum  in  128  out  of  153  early  cases. 

Leprosy  begins  with  marked  prodromata,  of  which  fever  is  the  most  common. 
It  comes  in  crises  of  several  days'  duration  and  is  usually  mistaken  for  malaria. 
It  is  entirely  analogous  to  the  pre-emptive  fever  of  syphilis.  Head  and  joint 
pains  are  common  as  well  as  general  malaise,  with  frequent  drenching  and  exhausting 
sweats  unassociated  with  fever.  Epi-staxis  is  a  common  and  early  sjTiiptom  and 
corroborates  Stickler's  observation  of  the  existence  of  a  primary  ulcer  in  the  nose. 


LEPROSY  293 

After  lasting  from  a  few  months  to  two  years,  an  unusually  severe  attack  of  fe\-er 
ushers  in  the  primary  eruiAion  or  macular  stage  of  leprosy. 

Macular  eruptions  consist  in  erythematous  patches,  smooth,  shiny,  and  slightly 
elevated.  They  occur  all  over  the  body,  but  are  more  profuse  on  the  face,  the 
backs  of  the  hands,  and  forearm.  The  supraorbital  ridges  and  malar  prominences 
are  commonly  affected.  The  hairy  scalp  is  not  invaded.  The  patches  come  and 
go,  although  the  later  crops  show  a  tendency  to  persist  and  for  the  skin  to  become 
slightly  thickened.  When  the  macules  invade  the  hairy  portion  of  tlie  Ijody,  the 
hair  is  lost  or  becomes  white  and  downy.  The  macules  are  anesthetic,  particularly 
in  the  centre  of  the  patches. 

Next  follows  the  stage  of  development  of  the  leprous  nodules  or  the  deposit 
of  specific  leprous  infiltration.  Here  the  disease  may  be  broadly  divided  into  three 
clinical  types:  first,  tuberculous  or  nodular  leprosy,  in  which  the  skin  and  mucous 
membranes  are  invaded  by  the  specific  new  growth;  second,  the  anesthetic  or  nerve 
leprosy,  where  the  leprous  deposits  take  place  in  the  nerve  trunk:  third,  the  mixed 
type  of  leprosy,  "R'hich  combines  both  of  the  foregoing  and  to  \\  hich  class  all  cases 
idtimately  tend. 

Tubercular  or  nodular  leprosy  may  begin  with  or  without  the  macular 
stage.  The  leprous  nodules  appear  under  the  skin,  particularly  about  the  face 
and  ears;  the  nodules  are  palpable  as  distinct,  tough,  flattened  masses  under  the 
skin.  They  have  a  peculiar,  rubbery  consistency,  are  painless,  and  freely  mo\'able. 
Diffuse  infiltration  of  the  skin  takes  place,  and  large,  flat,  leprous  patches  are  formed. 
The  leprous  lesions  grow  steadily  larger,  until  on  the  face  large  folds  and  masses 
of  tissue  are  formed,  producing  the  condition  known  as  Leontiasis,  or  the  lion-like 
face  of  leprosy.  New  nodules  appear  and  other  portions  of  the  body  are  invaded 
until  practically  the  leprous  lesions  cover  the  entire  skin  surface.  In  the  early 
stages  the  nodules  occasionally  diminish  in  size  or  may  be  entirely  absorbed.  Later 
they  break  down  and  extensive  ulceration  occurs.  At  this  stage  the  mucous 
membrane  becomes  extensively  involved.  The  cartilaginous  structures  of  the 
nose  are  completely  lost,  and  leprous  ulcerations  of  the  larynx  occur,  with  loss  of 
voice  and  ultimately  cicatricial  stenosis,  which  may  cause  intense  dyspnea.  Exten- 
sion of  the  leprous  ulceration  into  the  corneal  structures  may  cause  blindness. 
The  ulcerations  produce  horrible  and  characteristic  deformity. 

Death  takes  place  from  exhaustion  or  intercurrent  infection. 

Anesthetic  Leprosy. — Anesthetic  leprosy  shows  a  very  different  picture  from 
the  foregoing.  The  macular  stage  continues  and  is  marked  by  increased  pigmenta- 
tion and  complete  anesthesia  of  the  macule.  Gradually  extensive  neuritis  is  de- 
veloped in  the  trunks  of  various  nerves,  causing  pain,  severe  and  neuralgic  in 
character,  and  later  large  areas  of  anesthesia  or  numbness.  The  superficial  nerve 
trunks,  the  posterior  auricular,  and  the  ulnar  where  it  winds  about  the  internal 
condyle,  are  palpably  thickened.  Bullous  eruptions  occur  on  the  hands,  feet,  and 
elbows,  and  along  the  course  of  the  nerves  breaking  down  and  leaving  extensive 
spreading  and  destructive  trophic  ulcers.  As  a  further  result  of  these  trophic 
disturbances  extensive  contractures  develop,  and  fingers  and  toes  slough  away. 
In  the  older  cases  the  areas  in  the  distribution  of  the  affected  nerves,  which  at 
the  beginning  of  the  disease  were  painful  or  numb,  become  completely  anesthetic 
and  the  muscles  become  extensively  atrophied.  When  this  condition  occurs  in  the 
hand,  a  typical  claw-like  hand  of  leyrosy  is  produced.  The  atrophied  skin  is  particu- 
larly prone  to  injuries  and  to  extensive  ulceration.  The  course  of  this  type  of 
leprosy  is  excessively  chronic. 

The  mixed  leprosy  presents  a  combination  of  the  features  of  tuberculous  and 
anesthetic  leprosy.  In  all  cases  of  extensive  tuberculous  leprosy  the  nerve  trunks 
eventually  become  involved,  and  the  evidences  of  neuritis  and  trophic  disturbances 
are  added  to  the  clinical  picture. 


294  DISEASES  DUE  TO  A   SPECIFIC  IXFECTIOX 

Diagnosis. — In  advanced  cases  leprosy  could  hardly  lie  mistaken  for  any  other 
(liscasc.  The  lesions  are  too  striking  and  distinctive.  I)i(ii<  iilties  in  diagnosis 
arise  in  early  undeveloped  ea.ses,  particularly  in  the  niaeuhir  and  anesthetic  types. 
Here,  as  JNIanson  says,  the  touchstone  of  diagnosis  is  the  anesthesia.  It  should 
be  sought  for  in  the  centre  of  macular  areas,  and  in  the  centre  of  recent  nodules, 
if  any  exist.  Advantage  may  also  he  taken  of  the  fact  that  leprous  areas  do  not 
perspire.  Baelz  uses  an  ingenious  plan  not  only  for  diagnosis,  hut  also  for  mapping 
out  the  in\'olved  areas.  Aniline  is  ruhhed  on  the  skin  and  jjilocarpin  is  admin- 
istered hypodermically.  The  leprous  areas  do  not  sweat  and  consequently  remain 
unstained. 

The  most  satisfactory  diagnosis  consists  in  identification  of  the  bacilli.  For 
this  purpose  a  leprous  nodule  may  be  clamped,  punctured  \\ith  a  neerlle,  and  the 
exuding  drop  of  fluid  properly  stained  and  examined.  Even  in  the  very  earliest 
cases,  long  before  other  symptoms  appear,  leprous  thickening  can  be  demonstrated 
in  the  ulnar  or  posterior  auricular  nerves.  In  doubtful  cases  the  miiuite  fragment 
of  one  of  these  nerves  should  be  excised  and  stained  for  the  bacilli. 

Morrow  calls  attention  to  the  fact  that  leprosy  and  nasal  catarrh  go  liand  in 
hand,  and  that  in  the  large  proportion  of  cases  bacilli  can  be  demonstrated  in  the 
nasal  secretion.  It  has  also  been  shown  that  where  nasal  secretion  is  scanty  a 
few  doses  of  potassium  iodide  will  cause  a  sharp  catarrhal  flow,  in  which  the  l)acilli 
may  be  demonstrated. 

Prognosis. — In  the  vast  majority  of  cases  leprosy  slowly  tends  to  a  fatal  ending 
from  exhaustion  or  intercurrent  infection.  Isolated  cases,  however,  occur  in  which 
the  disease  is  arrested  or  cured.  These  instances  of  arrest  are  more  common  in 
anesthetic  leprosy  than  in  the  tuberculous  type.  Many  of  these  eases  survive 
twentv'  or  thirty  years,  and  in  a  large  projiortion  of  these  the  specific  process  is 
probably  ended,  although  the  extensive  damage  by  nerve  invoh'ement  and  trophic 
lesions  remain.     Even  tuberculous  leprosy  has  been  known  to  disappear. 

Many  eases  are  arrested,  and,  after  a  long  period  of  years,  death  occurs  from 
some  other  disease  not  associated  with  the  leprosy.  These  reported  cures  must, 
however,  be  accepted  with  extreme  caution.  It  is  probably  more  fair  to  sjieak  of 
them  as  arrests.  Mention  must  also  be  made  of  the  marked  amelioration  that 
occasionally  follows  the  removal  of  a  leper  from  the  country  in  which  he  has  de- 
veloped the  disease. 

Treatment. — The  treatment  of  leprosy  comprises  careful  attention  to  cleanliness, 
pro\'ision  of  good  hygienic  surroundings,  abundance  of  nourishing  food,  proper 
clothing,  hygienic  dwellings,  and  light  occupation.  As  special  remedies  gurgun 
oil  and  chaulmoogra  oil  have  been  extensively  used.  The  former  has  been  aban- 
doned. Chaulmoogra  oil  (oleum  gynocardii)  may  be  administered  by  the  mouth 
in  doses  of  2  drachms,  or  by  the  rectum,  in  an  emulsion  with  hot  milk,  when  it  is 
badly  borne  by  the  stomach.  In  some  cases  this  drug  seems  to  ha\e  almost  a 
specific  action.  In  a  few  cases  apparent  cures  and  in  a  great  many  cases  very 
marked  improvement  is  observed.  The  oil  may  also  be  administered  hypoder- 
mically. 

Uima  advises  the  internal  use  of  massive  doses  of  ichthyol  combined  with  inunc- 
tion of  pyrogallic  and  chrysophanic  acid  externally.  This  treatment  is  supple- 
mented by  hot  baths.  Several  cures  have  been  reported  following  this  plan. 
Crocker  reports  improvement  from  .subcutaneous  injection  of  the  bichloride  of 
mercury,  and  I)e  Luca  from  intravenous  injections  of  mercury  according  to  Bacelli's 
methofl.  Raynaud  reports  markefl  improvement  following  the  administration 
of  sodium  cacodylate.  Roussel  reports  an  apparent  cure  following  the  adminis- 
tration of  potassium  chlorate,  and  Manson  a  case  of  nerve  leprosy  apparently 
cured  by  thyroidin.  Tuberculin,  antivenene,  and  the  iodides  have  been  used  and 
do  more  harm  than  good.     Danielsen  recommends  salicylate  of  soda  in  ascending 


MILK  SICKNESS  295 

doses  combined  with  tonics.  He  believes  that  it  cures  leprosy  if  administered 
early.  Baelz  uses  salicylic  acid  locally.  He  treats  about  one  square  foot  of  skin 
at  a  time  by  rubbing  the  diseased  area  with  pumice  stone  until  blood  ajjpears. 
Salicylic  acid  is  then  applied  in  a  20  per  cent,  ointment  with  lanolin  and  vaselin. 
This  treatment  is  combiner!  with  the  oil  of  gynocardium  internally  and  hot  baths. 

Nerve  stretching  has  been  recommended  and  practiced  for  the  relief  of  the  painful 
complications  and  trophic  disturbances  of  nerve  leprosy. 

Prophylaxis. — The  only  means  of  limiting  leprosy  is  by  isolation.  While  absolute 
segregation  is  the  ideal  and  proper  measure,  it  meets  with  so  much  opposition, 
and  so  many  cases  are  concealed,  that  in  the  long  run  better  purpose  is  served  by 
adopting  a  reasonable  compromise  sunilar  to  that  followed  in  Norway.  This 
includes  caring  for  indigent  lepers  in  an  asylum  and  allowing  those  whose  people 
are  able  to  take  care  of  them  to  do  so  at  their  homes  under  proper  restrictions. 
The  Russian  laws  isolate  only  the  tuberculous  and  mixed  cases.  Although  it  is 
true  that  the  nerve  cases  are  much  less  contagious,  this  regulation  must  be  regarded 
as  a  mistake. 

FEBRICULA. 

Definition. — Febricula,  sometimes  called  ephemeral  fever,  is  a  condition  usually 
met  with  in  children,  and  is  undoubtedly  a  disturbance  of  the  heat  mechanism 
of  the  body  produced  by  the  action  not  of  one  but  of  several  agents;  that  is  to  say, 
many  different  causes  are  responsible  for  it  rather  than  one  specific  cause. 

Etiology. — The  causes  of  febricula  are  very  numerous.  In  some  instances  it  is 
probably  the  result  of  some  infection  which  is  overcome  by  the  protective  process 
of  the  body  before  it  can  develop  into  a  full-fledged  disease,  such,  for  example,  as 
an  aborted  influenza,  or  even  one  of  the  specific  eruptive  fevers,  or  some  infection 
entering  by  the  tonsils.  Some  years  ago  phj'sicians  believed  that  infectious  diseases 
could  be  aborted  in  their  early  stages  by  proper  measures  designed  to  aid  nature. 
This  view  fell  into  disrepute,  but  our  knowledge  of  protective  processes  and  of 
antitoxic  bodies  makes  it  probably  true.  In  children  an  ephemeral  fever  is  often 
due  to  gastro-intestinal  catarrh.    Sometimes  it  is  due  to  gastro-intestinal  irritation. 

Symptoms. — The  patient  after  a  feeling  of  wretchedness,  rarely  lasting  more 
than  a  few  hours,  is  found  to  be  mildly  febrile,  the  temperature  being  about  102° 
to  103°  at  the  most.  There  may  heflv^shing  of  the  face  and  even  delirium  in  young 
neurotic  children.  The  -puhe  and  respirations  are  cfdckened.  The  iever  usually, 
but  not  always,  ends  by  lysis  in  about  three  days  to  a  week. 

Diagnosis. — The  diagnosis  of  febricula  is  made  in  most  instances  after  the  patient 
is  well,  for  until  then  no  one  can  tell  that  the  symptoms  are  not  the  early  signs 
of  one  of  the  acute  infectious  fevers.  The  important  point  is,  not  to  be  content 
with  a  diagnosis  of  febricula,  which  is  but  another  way  of  saying  that  the  condition 
is  uncertain,  but  to  search  carefully  for  the  real  cause. 

Treatment. — This  consists  in  rest  in  bed,  the  use  of  a  little  calomel  followed  by  a 
saline,  and  the  employment  of  a  mixture  of  citrate  of  potassium  and  sweet  spirit 
of  nitre  to  keep  the  kidneys  active. 

MILK  SICKNESS. 

Definition. — Milk  sickness  is  a  very  rare  disease  which  is  usually  communicated 
to  man  by  milk,  or  by  the  butter  or  cheese  made  from  the  milk  of  cows  ill  of  a 
malady  called,  when  it  affects  cattle,  "trembles,"  or  "slows."  When  man  is 
infected  it  is  given  this  name  and  the  additional  one  of  "puking  fever."  This 
disease  has  been  known  to  exist  in  the  central  western  states  of  the  United  States, 
for  a  century.  It  is  met  with  occasionally  in  North  and  South  Carolina,  Kentucky, 
Tennessee,  Ohio,  Illinois  and  in  Michigan.     It  is  said  that  the  flesh  of  aft'ected 


29G  niSEASKS  DUE  TO  A   HI'l'.CIFIC  iXFECTIOX 

animals,  if  not  cooked,  may  convey  the  infection.  It  is  important  to  know  that 
the  infection  may  be  transmitted  from  a  seemingly  healthy  cow  some  time  before 
it  develops  symptoms  of  the  disease.  Jordan  and  Haines  have  isolated  from 
infected  animals  an  aerobic  spore-bearing  Vjacillus  {Bacillus  lactamorbi).  They 
also  found  it  in  the  milk  of  infected  cows  and  in  the  soil  of  regions  where  animals 
were  so  infected.  Whether  this  is  the  specific  factor  in  the  disease  is  not  as  yet 
determined. 

The  disease  is  now  almost  never  met  with,  even  in  animals,  and  it  never  occurs 
east  of  the  Allegheny  Mountains  and  rarely,  if  ever,  west  of  the  INIississippi  River. 

Symptoms. — The  symptoms  in  the  cow  consist  in  refusal  to  eat,  redness  of  the 
conjunctiva,  staggering  gait,  and  muscular  tremors,  whence  the  name  "trembles." 
In  man,  after  a  day  or  two  of  ill-health,  the  patient  is  seized  with  epigastric  diMress, 
followed  by  violent  mmiting  and  obstinate  constipation,  fever,  and  thirst.  Miiscular 
tremors  also  appear.  The  breath  is  peculiarly  siveei  and  offensive  and  the  tongue 
swollen.  If  the  disease  is  severe  the  patient  may  develop  typhoid  symptoms,  and 
even  become  delirious,  comatose,  or  convulsed  but  there  is  no  fever.  In  fatal  cases 
death  may  come  as  early  as  the  fourth  day,  or  be  deferred  for  two  or  three  weeks. 
The  more  severe  the  cerebral  sjTnptoms,  the  more  grave  the  prognosis.  The 
mortalit.y  is  about  25  per  cent. 

Treatment. — The  treatment  is  purely  symptomatic  and  consists  in  the  use  of 
stimulants  or  sedatives  as  they  may  be  needed. 

WEK-'S  DISEASE. 

Weil's  disease,  or  Infectious  Jaundice,  is  a  very  rare  infectious  malady,  first 
described  by  Weil  in  1886.  It  is  characterized  by  the  development  of  fever  and 
acute  jaundice,  and  appears  usually  in  the  warm  months  of  the  year.  The  victims 
of  its  onset  are  usually  young  and  middle-aged  adults,  and  the  symptoms  are  severe 
headache,  lumbar  pain,  and  cramp-like  sensations  in  the  legs  and  arms.  The  mas- 
seter  muscles  also  suffer  from  severe  pains.  Jaundice  develops  as  an  early  symptom, 
and  the  liver  and  spleen  are  found  swollen  and  tender  on  deep  palpation.  The 
stools  may  be  putty-colored,  as  if  from  obstruction  of  the  gall-ducts.  The  fever 
may  last  two  w'eeks,  often  rises  to  103°  to  104°,  and  is  characterized  by  sharp  remis- 
sion, as  in  sepsis.  Albuminuria  may  occur,  and  even  coma  may  develop.  A  general 
hemorrhagic  tendency  may  be  present.  Recovery  usually  takes  place,  but  con- 
valescence is  slow. 

Weil's  disease  must  be  separated  from  bilious  remittent  fever,  catarrhal  jaui\dice, 
and  phosphorus  poisoning.  This  separation  is  readily  accomplished  if  the  char- 
acteristic symptoms  just  described  are  compared  to  those  presented  in  the  course 
of  these  conditions.  Remittent  fever,  which  is  the  malady  most  closely  resembling 
Weil's  disease,  is  differentiated  by  finding  the  estivo-autumnal  parasite  in  the  blood, 
and  phosphorus  poisoning  by  the  history  of  the  case  and  the  phosphorescent  char- 
acter of  the  vomit,  which  can  be  noted  if  it  is  examined  in  the  dark.  Treatment 
is  entirely  symptomatic. 

GLANDULAR  FEVER. 

Definition. — Glandular  fever  is  an  acute  infectious  disease  characterized  by  a 
moderate  febrile  movement  and  a  painful  enlargement  of  the  cer\-ical  l\-mphatic 
glands. 

History. — The  first  accurate  account  of  this  disease  was  published  in  18S9  by 
Pfeiffer,  although  it  is  probable  that  the  condition  described  some  years  before 
by  Filatow,  of  Moscow,  under  the  name  of  idiopathic  inflammation  of  the  cervical 
glands,  was  in  reality  glandular  fever. 

Cases  have  been  reported  from  dift'erent  coimtries  on  the  Continent,  and  from 


SPOTTED  OR  TICK  FEVER  297 

England  and  the  United  States.  J.  Park  West,  of  Bellaire,  Ohio,  has  reported 
an  epidemic  in  which  ninety-six  children  were  attacked,  this  being  the  most  extensive ' 
epidemic  on  record. 

Etiology. — The  specific  micro-organism  of  this  disease,  if  there  be  one,  has  not 
been  discovered,  but  that  the  disease  is  infectious  in  nature  is  shown  by  the  fact 
of  its  occurrence,  as  a  rule,  in  small  epidemics  involving  several  members  of  a 
family.  The  disease  generally  occurs  before  puberty,  although  Galvagni  and  A.  E. 
Roussel  have  observed  it  in  adults. 

Symptoms. — ^The  onset  is  sudden  and  is  characterized  by  moderately  high  fever, 
restlessness,  headache,  fain  in  the  limbs,  and  soreness  and  pain  in  the  neck,  which  is 
increased  by  turning  the  head  or  by  swallowing.  The  temperature  ranges  from 
101°  to  103°  and  may  even  go  as  high  as  104°.  The  bowels  are  usually  constipated, 
although  in  some  of  the  severe  cases  observed  by  West  copious  discharges  of  thin, 
green  feces  mixed  with  mucus  took  place  shortly  before  the  beginning  of  conval- 
escence. Abdominal  pain  is  a  common  symptom,  and  pressure  over  the  lower 
part  of  the  abdomen,  particularly  in  the  midline  between  the  lunbilicus  and  the 
symphysis  pubis,  often  elicits  pronounced  tenderness.  The  swelling  of  the  anterior 
cervical  glands,  which  usually  begins  on  the  left  side  and  then  extends  to  the  right, 
attains  its  maximutm  beween  the  second  and  fourth  days.  The  glands  are  hard, 
easily  distinguishable  from  one  another  by  palpation,  and  are  very  sensitive  to 
pressure.  Suppuration  rarely  occurs.  Examination  of  the  pharynx  reveals  either 
a  normal  condition  or  a  slight  hyperemia.  The  liver  is  always  enlarged,  and  not 
uncommonly  there  is  considerable  swelling  of  the  spleen.  Acute  nephritis  is  the 
most  frequent  and  most  serious  complication.  The  duration  of  glandular  fever 
is  variable.  European  physicians  have  described  a  mild  or  abortive  form  in  which 
the  temperature  falls  to  normal  on  the  second  or  third  day,  although  the  cervical 
glands  remain  swollen  several  days  longer.  The  average  febrile  period,  however, 
is  from  seven  to  ten  days.  In  West's  ninety-six  cases  the  average  duration  of  the 
disease  from  its  onset  until  the  complete  disappearance  of  glandular  swelling  was 
sixteen  days. 

Diagnosis. — The  occurrence  of  a  sudden  febrile  attack  accompanied  by  an  early, 
painful  enlargement  of  the  anterior  cervical  lymph  glands,  without  any  inflam- 
matory involvement  of  the  pharynx,  makes  recognition  of  the  disease  easy. 

Prognosis. — Prognosis  is  always  favorable.  Convalescence  is  rapid,  as  a  rule, 
although  in  some  instances  it  is  retarded  by  a  considerable  degree  of  depression  and 
anemia. 

Treatment. — Experience  has  demonstrated  that  there  is  no  drug  which  will 
influence  the  duration  or  course  of  this  disease.  The  patient  should  be  confined 
to  bed  and  a  mild  aperient  given  to  overcome  constipation. 

MOUNTAIN  FEVER. 

So-called  mountain  fever  really  does  not  exist  as  a  separate  entity.  It  has 
been  proved  to  be  an  aberrant  form  of  typhoid  fever  infection  in  a  number  of 
instances,  particularly  by  the  United  States  Army  surgeons  or  those  attached  to 
the  United  States  Health  and  Marine  Hospital  Service.  In  some  cases  the  infection 
may  be  paratyphoid.  (See  Paratyphoid  Fever.)  In  still  other  instances  the  fever 
may  be  due  to  an  anemia  depending  upon  intestinal  parasites  such  as  the  Anchylos- 
tomum  duodenale.    Some  cases  may  be  "tick  fever."     (See  below.) 

SPOTTED  OR  TICK  FEVER. 

Definition. — Rocky  Mountain  Spotted  Fever,  or  Tick  Fever,  is  a  febrile  malady 
chiefly  prevalent  in  the  eastern  foot-hills  of  the  Bitter  Root  Mountains  in  Montana, 


298  DISEASES  DIE  TO  A   SPECIFir  ISFRCTIOS 

in  an  area  four  to  ten  miles  wide  and  fifty  miles  long,  but  it  also  oceurs  in  all  the 
States  in  the  Rocky  Mountain  area,  such  as  California,  Colorado,  Iflaho,  Nevada, 
Oregon,  Utah,  AYashington  and  Wyoming.  It  has  also  been  seen  in  Alaska.  Its 
period  of  occurrence  is  from  the  middle  of  March  until  the  end  of  July.  Herders 
and  ranchmen  are  chiefly  infected. 

This  form  of  so-called  spotted  fever  is  not  to  he  confused  with  cerebrospinal 
meningitis. 

Etiology. — This  disease  is  due  to  a  parasite  which  is  probably  conveyed  to  man 
by  the  bite  of  some  insect.  It  has  Ijeen  thought  that  the  insect  was  always  the  tick, 
male  or  female  { Deniiaccntor  occidental  is),  but  this  is  by  no  means  certain, 
although  the  tick  is  undoubtedly  one  of  the  transmitting  agents. 

In  the  second  phase  of  its  development  the  organism  in  the  red  blood  corjiuscle 
appears  to  be  solitary  and  distinctly  larger  than  in  the  first  phase. 

Wilson  and  Chowning  thought  they  had  discovered  the  cause  of  this  disease 
in  the  blood  but  Stiles  and  Craig  claim  to  have  proved  the  non-existence  of  these 
so-called  parasites,  the  former  asserting  his  inability  to  discover  any  structures 
which  lead  him  to  a  belief  in  the  presence  of  a  protozoon  as  a  cause  of  the  malady. 
Craig  believes  that  the  changes  seen  by  Anderson  in  the  red  lilood  cells  are  not 
due  to  a  parasite,  but  dependent  upon  certain  alterations  chiefly  taking  place  in 
the  hemoglobin,  such  as  are  often  seen  during  the  course  of  epidemic  influenza, 
typhoid  fever,  measles,  variola,  and  other  acute  infections.  The  cause  of  tliis 
disease,  is,  therefore,  at  present  of  uncertain  character.  Rickets  has  been  able 
to  transmit  the  disease  to  the  guinea-pig  and  monkey  by  the  use  of  defibrinated 
blood.     The  organism  of  Texas  cattle  fever  is  incapable  of  infecting  man. 

Morbid  Anatomy. — This  is  not  peculiar  to  the  disease.  The  postmortem  con- 
dition is  as  follows:  early  rigor,  icterus  and  petechial  lesions  in  the  skin,  epicardial 
hemorrhages,  a  soft,  flabby  heart  muscle,  greatly  enlarged  spleen  and  li\er  and 
enlargement  of  the  external  and  internal  lymph  nodes. 

Symptoms. — The  disease  makes  its  appearance  in  from  three  to  ten  days  after 
the  bite,  with  chilly  sensations,  malaise,  tiausea,  headache,  and  nniscular  soreness. 
The  bowels  are  constipated,  the  conjunctiva  congested,  the  urine  scanty  and  albuminous, 
and  slight  bronchitis  occurs.  Epistaxis  is  a  constant  symptom.  The  fewr  rises 
sharply  after  the  chill,  but  has  morning  remissions  like  typhoid  fe\'er.  The  rapidity 
of  the  pulse  is  out  of  proportion  to  the  fever,  often  amounting  to  110  or  140  per 
minute,  and  there  is  a  very  moderate  leukocytosis.     Respiration  is  rapid. 

Its  acme  is  reached  by  the  twelfth  day,  when  it  gradually  falls  by  lysis  for  four 
days  more,  and  so  convalescence  begins.  In  fatal  cases  the  fever  remains  high, 
about  104°  or  105°,  or  even  106°.  The  pulse  is  usually  very  rapid  and  thready, 
and  the  blood  rapidly  becomes  anemic. 

The  rash  usually  develops  about  the  third  day  on  the  wrists,  arms,  legs,  and 
forehead,  and  later  on  the  back,  chest,  and  abdomen,  and  consists  at  first  in  a 
macular  roseola  which  becomes  papular  and  passes  into  profuse  petechial  or  purpuric 
eruption.     Desquamation  may  follow. 

Sometimes  in  the  later  stage  of  the  eruption  it  appears  like  the  marks  on  a 
turkey's  egg.  Anderson  states  that  slight  gangrene  of  the  fingers,  toes,  and  scrotum 
may  occur.     Albuminuria  is  a  constant  symptom. 

One  attack  develops  partial  immunity  from  a  second  attack. 

When  death  ensues  it  occurs  as  a  rule  on  the  sixth  to  the  tenth  day. 

Diagnosis. — The  section  of  the  country  in  which  the  disease  occurs,  the  history 
of  tick  ])itcs,  and  the  finding  of  the  changes  in  the  blood  are  the  factors  which  make 
the  diagnosis  positive.  From  ordinary  purpura  the  disease  is  .separated  by  the 
lack  of  sore  throat  and  the  absence  of  arthritis.  From  typhoid  fever  the  diagnosis 
may  be  quite  difficult.  In  that  di.sease,  however,  the  rose  rash  appears  first  on 
the  belly  on  the  ninth  to  the  twelfth  day,  whereas  in  tick  fever  it  appears  as  early 


MILIARY  FEVER  299 

as  the  third  day,  and  on  the  wrists.  The  (Hscovery  of  a  positive  Widal  test  in 
the  blood  will  settle  the  diagnosis.  Typhus  fever  breaks  out  in  groups  of  i)ersons. 
Tick  fe\-er  always  appears  sporadically. 

Prognosis. — The  disease  varies  greatl\-  in  se\'erit\-  in  diHerent  regions.  The 
disease  in  Montana  is  a  very  grave  one,  having  a  mortality  of  about  70  per  cent., 
whereas  in  Idaho  it  is  as  low  as  4  per  cent.  Sometimes  the  mortality  is  as  high  as 
90  per  cent. 

Prophylaxis. — Prophylaxis  consists  in  dipping  domesticated  animals  which  have 
the  tick  in  solutions  which  destroy  it,  as  crude  oil  or  tobacco  infusion.  Regions 
known  to  be  infected  should  be  burnt  off.  Persons  exposed  should  wear  tick- 
proof  clothing.  If  the  tick  has  attached  itself  co\'er  it  with  oil,  gently  remove  it, 
and  cauterize  the  spot  with  carbolic  acid.  If  Ricketts'  protective  serum  can  be 
had  it  should  be  employed. 

Treatment. — So  far  as  is  known  quinine  seems  to  act  as  a  specific  in  this  disease. 
Anderson  thinks  it  should  be  given  in  the  dose  of  15  grains  every  six  hours,  h^-po- 
dermically,  and  its  use  continued  into  convalescence.  The  heart  must  be  supported 
by  stimulants  if  it  is  feeble,  and  the  kidneys  flushed  by  copious  draughts  of  water. 


FOOT-AND-MOUTH  DISEASE. 

Definition. — This  is  an  acute  infectious  disease  of  herbivorous  animals,  which 
sometimes  attacks  omnivora  and  which  spreads  in  epidemic  form  over  large  terri- 
tories, causing  great  mortality  in  the  animals  affected.  When  the  disease  attacks 
the  cow  the  animal  becomes  feverish,  suffers  from  swelling  of  the  mucous  mem- 
branes of  the  mouth,  and  develops  blisters  on  the  edges  of  the  tongue  and  on  the 
lips.  These  blisters  become  discolored  and  ruptiu-e,  leaving  ulcers.  At  times 
similar  lesions  appear  on  the  teats.  The  milk  of  such  animals  is  discolored  and 
seems  to  be  thickened  as  if  by  mucus. 

The  disease  is  rarely  met  with  in  England  and  America,  but  at  this  time  a 
widespread  epidemic  among  cattle  is  present.  It  possesses  interest  to  us  only 
because  it  is  capable  of  being  conveyed  to  man.  This  conveyance  occurs  in  the 
case  of  children  by  the  use  of  the  milk  of  the  diseased  cows,  and  in  adults,  as  a 
rule,  by  this  means  or  by  cheese  or  butter. 

The  symptoms  in  man  are  like  those  of  severe  stomatitis,  associated  with  fever. 
Recovery  in  man  usually  occurs,  but  a  mortality  of  about  10  per  cent,  is  recorded. 

The  cause  of  the  disease  has  not  been  isolated.  Even  a  porcelain  filter  does  not 
arrest  the  organism,  if  organism  it  be,  that  causes  the  malady. 

MILIARY  FEVER. 

Definition. — Miliary  fever,  sometimes  called  "the  sweating  sickness,"  is  an 
acute  epidemic  disease  characterized  by  fever,  profuse  sweating,  an  eruption, 
and  a  peculiar  sense  of  constriction  in  the  epigastrium. 

History. — The  disease  was  far  more  prevalent  in  the  seventeenth  century  than 
it  has  been  since  that  time,  but  it  still  appears  in  certain  parts  of  the  world.  Almost 
every  country  in  Europe,  including  England,  has  suffered  from  its  presence,  but 
it  has  not,  so  far  as  I  have  been  able  to  discover,  ever  appeared  in  the  United 
States. 

Etiology. — The  cause  of  the  disease  is  unknown,  but  it  is  an  acute  infection, 
apparently  resembling  influenza  in  the  manner  of  its  spread,  although  it  does  not, 
as  a  rule,  attack  large  numbers  of  people  throughout  a  wide  area,  as  does  that 
disease.  On  the  contrary,  it  is  very  often  limited  to  the  population  of  a  single 
town  or  district. 


300  DISEASES  DUE  TO  A  SPECIFIC  IXFECriOX 

Symptoms. — The  symptoms  of  miliary  fever  are  ushered  in,  as  they  are  in  all 
the  infections  diseases,  by  lassitude,  headache,  and  anorexia.  This  prodromal  stage 
may  last  a  day  or  two,  or  be  so  brief  as  not  to  be  recognized.  The  patients  go  to 
bed  well,  and  wake  in  the  morning  to  find  themselves  ill  and  suffering  from  a  drench- 
ing stiwat,  which  persists  throughout  the  illness.  The  bowels  arc  usually  confined, 
the  tongue  coated,  and  the  pube  but  little  altered  in  character  for  the  first  few  days 
of  the  illness.  A  symptom  complained  of  by  the  patient  is  one  of  oppression, 
as  if  the  air  of  the  room  were  hot  and  vitiated.  The  fever  is  usually  high,  rising 
to  104°  to  105°,  and  in  fatal  cases  to  107°.  On  the  third  day  there  appears  on  the 
skin  an  outbreak  of  red  miliary  pajmles,  which  often  de\'elop  a  white  tip  before  they 
disappear,  and  between  these  are  scattered  large  numbers  of  pearly  vesicles,  like 
sudamina,  which  seem  filled  with  clear  fluid.  Prior  to  the  appearance  of  this 
eruption  a  pecidiar  pricking  or  tingling  sensation  is  felt  in  the  skin.  When  the 
eruption  has  faded,  desquamation  sometimes  occurs.  The  entire  progress  of  the 
malady  is  usually  completed  in  nine  or  ten  days. 

The  following  facts  are  also  noteworthy,  viz.:  The  sweating  is  constant,  but  is 
characterized  by  paroxysms,  in  which  it  becomes  still  more  profuse.  The  rash 
appears  on  the  mucous  membrane  of  the  palate  and  cheeks.  The  sridainina, 
or  pearly  miliary  vesicles,  although  they  give  the  name  to  the  disease,  are  not  a 
constajit  symptom  in  all  cases. 

Abortion  nearly  always  occurs  if  a  pregnant  woman  is  attacked. 

Miliary  fever  causes  rapid  emaciation. 

It  is  very  prone  to  be  followed  by  a  relapse,  but  the  relapse  is  rarely  fatal. 

Prognosis. — Recovery  usually  occurs.  In  severe  cases,  in  which  the  onset  is 
fulminating,  death  may  occur  as  early  as  the  eighth  hour  after  the  attack  begins. 
These  cases  have  marked  nervous  symptoms,  consisting  of  convulsions,  delirium, 
and  coma.  Evidently  the  patient  is  overwhelmed  by  toxemia.  The  mortality 
rate  in  various  epidemics  has  varied  from  5  to  25  per  cent.  The  outlook  in  children 
is  usually  good. 

Treatment. — This  consists  of  cold  sponging  to  control  excessive  fever,  the  use 
of  copious  draughts  of  water  to  compensate  for  the  loss  of  water  by  the  skin,  and 
for  the  purpose  of  flushing  the  kidneys,  and  in  the  administration  of  stimulants, 
if  they  are  needed,  to  support  the  heart. 

VERRUGA  (VERRUGA  PERUVIANA). 

Definition. — Verruga  (a  wart)  is  a  chronic,  infectious,  and  inoculable  disease, 
characterized  by  initial  fever,  rheumatic  pains,  anemia,  and  the  development  of 
granulomatous  lesions  (warts)  on  the  skin,  mucous  membranes,  and  internal  organs. 

Distribution. — Verruga  is  limited  to  certain  high  valleys  of  Peru,  on  the  Pacific 
slopes  of  the  Andes.  At  present  it  is  principally  observed  in  the  valleys  of  Huaro- 
chiri,  Tanj'os,  Rimac,  and  Canta,  at  elevations  varying  from  3000  to  SOOO  feet  above 
the  sea.  It  is  not  observed  at  lower  levels.  Cases  are  also  reported  from  the  moun- 
tain districts  of  Ecuador,  Bolivia,  and  Chile.  The  disease  has  existed  since  remote 
times  in  Peru,  possibly  in  wider  extension  than  at  present.  It  occurred  among  the 
soldiers  of  Pizzaro's  expedition,  and  is  first  mentioned  by  Zarate  in  his  History 
of  Peru  (1543). 

Etiology. — Verruga  occurs  in  small  epidemics,  but  is  not  contagious.  Carrion, 
a  medical  student,  in  1885,  proved  its  inoculability  on  himself  and  died  of  the 
infection.  As  a  rule,  one  attack  of  the  disease  confers  inununity.  The  specific 
cause  of  verruga  has  not  been  established.  Nicolle  and  Letulle  regard  it  as  due 
to  a  bacillus  which  in  its  morphology  and  staining  reaction  is  identical  with  the 
tubercle  bacillus.  The  belief  is  prevalent  among  the  population  that  the  waters 
of  certain  springs  are  the  cause  of  the  disease.     ^Moisture,  heat,  and  elevation 


VERRUGA  301 

above  the  sea  seem  to  be  necessary  factors.  Malaria  is  apparently  closely  associated 
with  the  development  of  verruga;  a  particularly  pernicious  type,  locally  known  as 
"Oroya  Fever,"  being  commonly  observed  with  it.  All  ages  and  both  sexes  are 
equally  liable.  Natives  of  the  verruga  zone  seem  to  suffer  less  severely  than 
strangers  coming  to  the  valley.  For  a  time  this  disease  was  believed  to  be  a  form 
of  yaws,  or  frambesia,  and,  like  it,  was  interpreted  as  a  form  of  syphilis.  Yaws, 
however,  is  not  observed  in  the  internal  organs.  Furthermore,  verruga  is  observed 
in  the  domestic  animals,  including  fowls,  an  observation  contrary  to  any  known 
manifestation  of  syphilis. 

The  incubation  period  is  given  as  ten  days  to  a  year.  Fifteen  to  forty  days 
(according  to  Odriozola)  seems  a  more  reasonable  figure.  In  the  inoculation 
case  of  Carrion  the  incubation  was  twenty-three  days.  Strong  and'Tizzer  inocu- 
lated a  volunteer  and  the  primary  lesions  developed  at  the  site  of  inoculation  on 
the  sixteenth  day  and  increased  slowly  until  the  thirty-fifth.  Townsend  seems 
to  have  transferred  the  disease  by  means  of  a  biting  gnat  of  the  Peruvian  Andes. 

Symptoms. — Clinically,  two  stages  present  themselves,  the  stage  of  in\'asion 
and  the  stage  of  eruption.  The  stage  of  invasion  begins  with  prodromal  sjTuptoms. 
Lassitude,  restlessness,  and  weariness  of  the  legs,  lasting  for  a  few  days,  are  followed 
by  an  evening  fever. 

The  fever  gradually  increases  in  severity,  with  marl-ed  rigors,  and  may  be  remit- 
tent or  intermittent.  In  a  few  days  joint  pains  develop.  The  joints  in\'aded 
are  the  smaller  articulations  of  the  hands  and  feet,  the  knees,  and  the  spine.  The 
pain  is  severe,  is  worse  at  night,  and  is  fugitive,  passing  rapidlj'  from  one  joint  to 
another.  Painful  contractions  of  particular  muscle  groups  occur,  most  frequently 
in  the  calf-muscles  and  sternomastoids.  Sometimes  large  muscle  groups  are 
affected,  so  that  in  extreme  cases  opisthotonos  may  develop.  As  the  disease 
progresses,  anemia  and  emaciation  occur.  The  sliin  becomes  yale  and  icteric; 
the  liver  and  spleen  become  enlarged.  Soft  bruits  are  heard  over  the  precordium. 
The  fever  persists  from  three  to  five  weeks,  when  it  gradually  declines,  and,  with 
its  disappearance,  begins  the  stage  of  eruption.  The  eruption  usually  develops 
after  twenty  days,  or  it  may  be  delayed  as  long  as  six  or  eight  weeks.  In  rare 
instances  it  is  observed  at  the  very  beginning  of  the  disease. 

With  the  breaking  out  of  the  eruption,  all  the  general  symptoms  are  remarkably 
ameliorated.  Beginning  first  as  small,  pinkish  papules,  the  lesions  become  dark 
blue  in  color,  and  finally  develop  into  ivarty  excrescences.  They  appear  on  the  face, 
particularly  around  the  eyelids  and  nose,  on  the  limbs,  about  the  joints,  and  rarely 
on  the  trunk.  The  palms,  soles,  and  hairy  parts  of  the  body  are  also  attacked. 
In  size  the  lesions  vary  from  a  millet-seed  to  growths  as  large  as  an  apple.  They 
may  be  few  or  many  hundreds  in  number.  These  warty  growths  are  exceedingly 
vascular  and  bleed  freely,  thus  increasing  the  anemia  of  the  patient.  When  they 
develop  on  the  mucous  membranes  and  internal  organs,  dysphagia  becomes  a 
very  common  symptom,  and  hemorrhages  occur  from  the  various  organs  that  are 
the  seat  of  the  lesions;  hematemesis,  hemoptysis,  hematuria,  metrorrhagia,  etc. 
After  persisting  from  four  to  six  months,  perhaps  passing  through  various  recru- 
descences, the  lesions  subside  by  involution  and  desiccation  or  desquamation,  or 
they  may  ulcerate,  or  the  larger  lesions  may  suppurate. 

Prognosis. — The  prognosis  is  always  grave,  particularly  so  in  white  people,  in 
whom  60  to  70  per  cent,  of  all  cases  die.  In  natives  the  mortality  is  about  10 
to  15  per  cent.  The  early  and  complete  establishment  of  the  eruption  is  a  very 
favorable  sign.  In  delayed  or  partial  eruptions  the  prognosis  is  grave.  Excessive 
anemia  is  also  an  unfavorable  sign. 

Treatment. — Treatment  is  symptomatic.  On  account  of  the  very  general  associa- 
tion of  this  disease  with  malaria,  quinine  should  always  be  freely  administered. 
Sudorifics  and  hot  drinks  are  usually  employed  with  the  idea  of  hastening  or  coni- 


302  DJSKASES  DUE  TO  A   SPECIFIC  INFECTION 

])lctiiif;  tlic  eruption.  Descent  to  lower  altitudes  not  onh'  diminishes  the  pain  and 
ahhreviates  the  disease,  but  also  lessens  the  tendency  to  hemorrhages  from  the 
lesions.     Odriozoia  recommends  the  rcmo\'al  of  all  ulcerated  \errngas. 

GANGOSA. 

Gangosa  is  sometimes  called  Ogo  or  RhinophdrijngHi.s-  vnttilan.s-  and  is  an  infectious 
disease  characterized  hy  destructive  ulceration  of  the  soft  i)alate,  uvula,  hard 
palate  and  larynx  with  slight  constitutional  disturbance  and  low  mortality.  It 
occurs  in  the  West  Indies  and  Polynesia  and  has  been  best  described  l)y  Leys  of  the 
United  States  Navy  and  ]\lhik  and  McLean  of  the  United  States  Army.  Kinder- 
berger,  of  the  United  States  Na^•y  belie\'es  it  to  be  a  tertiary  stage,  or  sequel,  of 
yaws,  combined  with  an  element  of  hereditary  syphilis. 

SYPHILIS. 

Definition. — Syphilis  is  a  contagious  disease,  due  to  a  spiral  organism,  the  Tirjxi- 
nema  pallidum.  It  is  sometimes  called  "Lues,"  " Fo.v,"  or  "Lues  J'enerca."  It 
occurs  in  two  forms,  the  acquired  and  the  hereditary,  and  is  characterized  in  the 
different  stages  of  its  progress  by  a  greater  nimiber  of  pathological  changes  in  the 
tissues  of  the  body  than  any  other  known  malady.  It  has  been  said  that  he  who 
knows  the  whole  pathology  of  syphilis  and  tuberculosis  knows  all  pathology.  This 
is,  of  course,  an  exaggerated  statement,  but  it  emphasizes  the  fact  that  the  disease 
presents  lesions  in  many  different  tissues. 

The  acciuired  form  is  usually  divided  into  three  stages,  called  the  primary, 
secondary,  and  tertiary. 

The  primary  stage  is  characterized  by  the  development  of  a  chancre  or  hard 
sore,  also  called  the  "initial  lesion;"  the  secondary  stage  by  the  appearance  of 
eruptions  and  lymphatic  swellings,  and  by  ulceration  of  the  mucous  membranes. 
The  third  stage  consists  in  the  growth  of  tumor-like  masses,  called  gummata,  and 
])athological  changes  in  the  bones  and  in  the  nervous  and  vascular  systems. 

History. — The  history  of  syphilis  is  not  definite.  Certain  investigators  believe 
that  it  is  one  of  the  most  ancient  maladies,  but  it  was  not  clearly  recognized  as  a 
separate  affection  in  Europe  until  1494.  Those  who  wish  to  look  into  this  cjuestion 
should  consult  Sj/philis  in  ^\ncient  and  Prchisioric  Times,  by  Buret,  translated  by 
Ohmanii-I  Jumcsnil. 

Distribution. — Syphilis  is  founil  all  over  the  world,  and  in  its  frequency  and 
virulciU'C  is  not  modified  materially  by  climate  or  geographical  conditions,  but  it  is 
worthy  of  note  that  the  disease  is  unknown  among  savage  peoples  who  have  not 
(■onie  in  contact  with  civilized  communities. 

Etiology. — A  distinct  advance  in  the  investigation  of  the  disease  was  made  in 
IDIK),  when  ^Nletschnikoff  and  Roux  succeeded  in  producing  characteristic  lesions 
in  the  higher  apes  by  inoculating  syphilitic  virus  from  human  beings;  this  has  since 
been  many  times  repeated.  Early  in  1905  Schaudiim  and  Hoffmann  described  a 
small  sjiiral  organism  which  they  found  constantly  in  i)rimary  and  secondary 
syphilitic  lesions  and  which,  because  of  its  indifferent  staining  qualities,  they  termed 
the  Spiroclu'ta  pallida.  Later  they  gave  it  the  name  Trejioneina  pallidum.  Their 
findings  have  since  been  confirmed  by  hundreds  of  observers  in  all  parts  of  the 
world.  This  organism  is  found  in  the  lesions  of  primary  and  secondary  syphilis 
and  less  freciuently  in  tertiary  manifestations.  Xoguchi  and  others  ha\e  found 
it  in  the  brain  in  cases  of  paresis  and  in  the  cord  in  cases  of  tabes,  thus  still  further 
im])licating  syphilis  as  the  cause  of  these  affections.  The  findings  of  some  observers 
indicate  that  with  proper  technique  the  treponema  can  be  demonstrated  in  every 
case  of  paresis.     It  is  found  in  the  artificially  produced  lesions  in  apes,  and  highly 


SY  Fin  LIS  3(« 

important  is  its  presence  in  the  blood  and  tissues  of  infants  dead  from  Iiereditary 
sypliiiis.  LeAaditi  has  made  extensive  studies  of  these  cases  and  finds  the  organism 
in  greatest  numbers  in  the  liver,  lung,  and  suprarenal  glands  resiJecti\'ely.  It 
exhibits  a  preference  for  the  perivascular  tissues  rather  than  for  the  blood  stream 
and  is  found  in  and  without  the  vessel  walls  in  enormous  numbers.  Many  are 
intracellular,  especially  in  epithelial  cells.  The  organism  is  4^  to  15m  long,  does  not 
exceed  0.5^  in  thickness,  and  possesses  numerous  pronounced  spirals.  It  is  actively 
motile  and  has  flagella. 

It  is  important  to  remember  that  the  spirochete  of  syphilis  must  be  carefully 
separated  from  other  spirochete  in  no  way  connected  with  syphilis.  This  differen- 
tiation requires  the  skill  of  one  constantly  examining  spirocheta?  and  some  persons 
go  so  far  as  to  assert  that  a  diagnosis  of  syphilis  is  not  justified  unless  two  separate 
observers  report  that  the  organism  present  is  the  Spirocheta  palUda.  It  is  not 
difficult  to  recognize  a  spirochete  on  a  dark  field  but  it  is  difficult  to  differentiate 
it  as  the  specific  spirochete  of  syphilis.  It  can  be  grown  in  pure  culture.  In  films 
it  may  be  stained  by  Giemsa's  and  other  methods. 

The  rapid  method  by  Giemsa  is  as  follows:  (1)  FLx  a  thin  film  for  30  minutes 
in  absolute  alcohol;  (2)  Stain  for  1  hour  in  this  solution  (prepared  at  the  time  of 
using);  Giemsa's  solution  (Grubler),  10  drops;  1  per  cent,  aqueous  sodium  carbonate, 
10  drops;  distilled  water,  10  c.c;  (3)  Wash  with  distilled  water.  Dry  with  filter 
paper  and  examine,  with  or  without  mounting  in  balsam,  by  the  one-twelfth  oil- 
immersion  objective.  The  slower  method  with  Giemsa's  stain  is  preferable: 
(1)  Dry  films  in  air,  then  fix  in  absolute  alcohol  for  30  minutes.  (2)  Stain  for  20 
hours  in  Giemsa's  solution,  35  drops  (1.2  c.c);  distilled  water,  20  c.c.  (3)  Same 
as  in  the  rapid  method.     By  these  methods  the  treponema  stains  a  reddish-violet. 

Burri's  method  of  making  the  containing  material  opaque  is  fairly  satisfactory. 
A  drop  of  fluid  from  a  chancre  or  obtained  from  a  lymph  node  or  other  lesion  is 
mixed  with  an  equal  amount  of  India  ink  and  quickly  smeared  in  a  thin  fihn  on 
a  slide;  when  dry  examine  with  an  oil-immersion  objective.  The  treponema 
appears  as  a  white  spiral  in  a  black  field. 

In  sections  of  tissue,  methods  of  using  the  silver  salts,  as  Levaditi's,  give  the 
best  results.     These  require  a  week  or  ten  days. 

In  the  vast  majority  of  cases  syphilis  is  accjuired  by  sexual  intercourse,  although 
a  large  number  of  cases  of  acquired  s^■philis,  due  to  non-sexual  contact  with  syphilitic 
persons  or  their  garments  when  infected  by  discharges,  have  been  recorded.  (See 
Bulkley  on  Syphilis  Tn^oniium.)  Obstetricians,  midwives,  and  nurses  haA'e  often 
contracted  the  disease  through  a  break  in  the  skin  of  the  finger.  Wet-nurses 
have  been  infected  though  the  nipples  by  syphilitic  infants,  and  drinking  utensils, 
knives,  forks,  spoons,  pipes,  and  dental  instruments  have  conveyed  the  poison  to 
the  mouths  of  innocent  persons.  The  disease  can  be  transmitted  by  kissing  and 
by  the  drinking  cup.  Primary  lesions  of  sj"philis  have  also  been  produced  in  the 
mouth  by  perverted  sexual  practices. 

The  A'irus  of  the  disease  is  active  in  the  transmission  of  the  malady  throughout 
the  primary  and  secondary  stages,  and  during  this  time  all  secretions  from  the 
lesions  of  these  stages  are  capable  of  producing  the  disease  in  another  person, 
provided  that  they  be  brought  in  contact  with  a  solution  of  continuity  in  the  skin 
or  mucous  membrane.  Infection  does  not  take  place  through  healthy  skin  or 
mucous  membrane,  but  the  break  in  the  surface  may  be  so  slight  as  to  be  overlooked. 
The  blood  of  the  patient  during  the  secondary  stage  is  capable  of  spreading  the 
disease  by  inoculation,  but  notwithstanding  this  fact  it  is  noteworthy  that  the 
secretions  of  the  various  glands  do  not  contain  the  poison  unless  they  are  contami- 
nated by  discharges  from  local  syphilitic  lesions. 

The  acquired  disease  is  not  conveyed  by  the  discharges  from  syphilitic  sores,  or 
by  the  blood  of  a  syphilitic,  if  five  years  have  elapsed  since  the  date  of  primary 


304  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

infection;  indeed,  in  most  cases  tlie  virus  ceases  to  he  capable  of  inociilatini;  another 
I)crson  at  tlie  end  of  two  years  after  infection.  This  rule  holds  true,  even  altljough 
the  patient  may  be  suffering  from  syphilitic  sores  or  other  active  lesions  at  the  time 
of  contact.  On  the  other  hand,  the  spermatozoids  may  indirectly  transfer  the 
poison  from  the  man  to  woman  by  the  fcetus. 

A  person  who  is  suffering,  or  has  suffered,  from  acquired  syphilis  is  ])rotected 
against  a  second  infection  in  the  vast  majority  of  instances,  although  a  few  cases 
have  been  recorded  \\hich  seem  to  throw  doubt  upon  the  statement  of  some  syphilog- 
raphers  that  the  protection  is  absolute.  This  immunity  is  developed  at  once 
after  primary  infection,  as  early  as  the  development  of  the  primary  lesion  or  chancre, 
and  in  some  cases  even  earlier  than  this.  In  the  case  of  a  person  who  has  inherited 
syphilis  from  one  or  both  parents  the  protection  against  acquired  infection  is 
absolute,  even  if  no  signs  of  the  hereditary  disease  be  present. 

Plereditary  syjDhilis  may  come  to  a  child  through  one  or  both  parents.  When 
the  father  only  is  syphilitic,  the  term  "sperm  inheritance"  is  employed,  and  when 
the  mother  only  is  syphilitic  it  is  called  "germ  inheritance."  A  sj-philitic  male 
may  transmit  sj^jhilis  to  his  offspring  without  manifesting  at  the  time  of  intercourse 
any  symptoms  of  sj^philis  and  without  producing  in  the  mother  any  signs  of  the 
disease.  It  is  also  possible  for  him  to  have  a  healthy  child;  that  is,  he  may  fail 
to  transmit  the  infection.  This  depends  largely  upon  the  stage  of  the  malady, 
its  virulence  and  activity,  and  the  value  of  any  antisjqjhilitic  treatment  that  may 
have  been  instituted  for  the  father's  benefit  before  conception,  and  for  the  benefit 
of  the  mother  and  child  after  conception. 

A  woman  suffering  from  syphilis  may  or  may  not  bear  a  sj'jDhilitic  child,  and  if 
active  antisyphilitic  treatment  during  pregnancy  is  maintained,  the  child  is  likely 
to  escape.  It  is  also  possible  for  a  mother  who  contracts  s.^•]>hilis  during  her  preg- 
nancy to  give  birth  to  a  non-syphilitic  child,  but  it  is  also  possible  for  the  child  to 
contract  primary  syphilis  from  a  mucous  patch  as  it  passes  through  the  birth  canal. 
It  is  interesting  to  note,  howe^'er,  that  \\hile  the  syphilitic  mother  is  not  always 
able  to  confer  immunity  to  primary  infection  upon  her  child,  so  that  it  cannot  be 
infected  by  the  disease  before  or  after  birth,  it  is  possible  for  the  syphilitic  foetus 
in  idcro  to  confer  immunity  upon  its  mother,  or,  to  express  it  differently,  given  a 
child  in  vfcro  by  a  sj'philitic  father,  that  child  may  be  sjT^hilitic  at  birth,  but  its 
mother  may  not  have  been  infected  during  pregnancy,  and  is  protected  against 
.syphilitic  infection  subsequently.  TJiis  is  known  as  Colles'  law.  That  immunity 
to  sjiihilis  can  be  so  acquired  is  proved  by  the  fact  that  if  a  syphilitic  liaby  nurses 
at  its  mother's  breast  she  A\-ilI  not  contract  syphilis,  even  if  its  moutli  be  filled  with 
mucous  patches,  but  if  that  infant  is  nursed  by  an  innocent  wet-nurse  it  can  produce 
syphilis  in  that  nurse. 

From  what  has  been  said  .so  far  it  is  evident  that  a  s^-jihilitic  father  or  s\-iihilitic 
mother  may  be  the  parent  of  a  syphilitic  or  non-syphilitic  child.  If  both  parents 
are  syphilitic,  the  probability  of  the  child  being  infected  is  twice  as  great  as  if 
one  parent  is  aiTected. 

Prevention. — The  prevention  of  syphilis  is  one  of  the  great  social  questions  of 
tiic  age  that  has  not  been  solved.  In  many  cities  prostitution  has  been  licensed 
in  order  that,  l)y  governmental  and  medical  control,  prostitutes  suffering  from 
syphilis  might  be  treated  and  prevented  from  plying  their  vocation  while  capable 
of  transmitting  the  disease.  This  plan  when  instituted  has  not  checked  the  dissemi- 
nation of  svphilis,  since  it  continues  to  spread  through  illicit  intercourse  carried 
out  Mith  unlicensed  women  who  will  not  be  classed  as  registered  prostitutes. 

Sjphilis  may  also  be  pre\ented  by  forbidding  intercourse  on  the  part  of  persons 
suffering  from  the  disease,  and  by  instructing  the  non-syphilitic  to  avoid  intercourse 
while  any  break  exists  in  the  mucous  membrane  or  skin  of  the  external  genitals. 
Careful  regard  to  cleanliness  after  intercourse  is  of  some  protective  value. 


SYPHILIS  305 

A  practically  sure  prophylaxis  against  infection  is  the  use  of  35  per  cent,  calomel 
ointment.  The  sooner  this  is  used  after  intercourse  the  greater  the  pre\-enti\-e 
power.  It  fails  if  used  twenty  hours  after  exposure  but  rarely  if  used  within  six 
hours.  The  ointment  should  be  well  rubbed  into  tiie  penis  Ijehind  the  foreskin 
with  special  attention  to  any  abrasions,  and  left  on  the  part  for  several  hours. 
Several  countries  now  provide  soldiers  and  sailors  with  prophylactic  packages  of 
this  ointment  and  insist  that  it  is  used. 

Frequency. — It  is  almost  impossible  to  determine  the  prevalence  of  syphilis, 
since  the  living  keep  its  presence  secret  and  the  physician  rarely  returns  a  death 
as  due  to  it,  but  to  some  indirect  result  of  it. 

In  1874  Dr.  F.  R.  Sturgis  estimated  that,  out  of  a  population  of  942,292  in  New 
York  City,  50,450  were  suffering  from  syphilis. 

In  an  appendix  to  Sanger's  History  of  Prostitution,  1892,  it  was  estimated  that 
100,000  persons  out  of  a  population  of  1,800,000  had  sj-philis. 

Kober  believes  that  there  are  2,000,000  syphilitics  in  the  United  States.  And 
Edsall  found  that  in  1696  cases  admitted  to  the  Massachusetts  General  Hospital 
between  8  and  10  per  cent,  gave  a  positive  Wassermann  reaction.  As  the  blood 
is  often  negative  in  old  cases  the  proportion  of  syphilis  in  these  patients  was  prob- 
ably higher  than  the  percentage  given. 

At  the  present  time  the  population  of  Greater  New  York  is  about  3,560,000, 
and  assuming  that  the  rate  of  increase  of  the  disease  has  kept  pace  with  the  increase 
in  population  there  would  be  nearly  200,000  syphilitics  in  that  city.  These  esti- 
mates are  not  made,  however,  on  a  statistical  basis. 

A  committee  appointed  by  the  Medical  Society  of  the  County  of  New  York 
for  the  study  of  measures  for  preventing  venereal  diseases,  addressed  a  circular 
letter  to  all  the  physicians  in  Greater  New  York  asking  them  to  report  the  number 
of  cases  of  gonorrhea  and  syphilis  which  they  had  treated  from  I\Iay  1,  1900,  to 
May  1,  1901.  Of  the  4750  physicians  to  whom  the  letter  was  sent,  678  forwarded 
statistics  of  their  cases.  The  total  number  of  cases  of  syphilis  reported  was  7200. 
Assuming  that  as  many  cases  occurred  in  the  practice  of  the  physicians  who  sent 
no  reports  as  in  the  practice  of  those  who  forwarded  statistics,  calculations  would 
show  that  50,400  cases  of  syphilis  were  under  treatment  in  pri^'ate  practice  during 
the  period  of  time  which  the  investigation  covered.  As  many  patients  go  from  one 
physician  to  another,  it  is  not  improbable  that  some  of  the  reported  cases  may 
have  figured  twice  in  the  statistics;  but  the  committee  believed  that  the  number 
which  did  so  was  more  than  offset  by  the  large  class  of  patients  who  take  treatment 
from  advertising  quacks. 

Of  forty-five  dispensaries  and  charitable  institutions  visited  by  the  committee 
nine  refused  to  give  any  information.  An  inspection  of  the  records  of  the 
remaining  thirty-six  showed  that  7607  cases  of  syphilis  had  been  treated  during 
the  year. 

Burre  shows  by  statistics  that  the  morbidity  of  syphilis  among  the  inmates 
of  the  licensed  houses  of  prostitution  in  Paris  fell  from  30  per  cent,  in  1873 
to  0.25  in  1902.  On  January  1,  1873,  1126  public  women  were  registered,  and 
during  the  j^ear  338  cases  of  sj'philis  were  recorded  from  among  the  number. 
On  January  1,  1902,  429  public  women  were  registered,  and  only  1  case  of 
sjqjhilis  was  observed  among  them  during  the  year.  Burre  attributes  this 
decrease  in  syphilis  to  the  more  general  dissemination  of  knowledge  concerning 
the  infectious  nature  of  the  disease  and  to  the  adoption  of  hygienic  measures  for 
its  prevention,  which  at  present  are  largely  practised  by  all  the  licensed  prostitutes. 
He  also  lays  some  stress  upon  the  matter  of  obligatory  elementary  education, 
believing  that  it  may  have  served  to  make  the  prostitutes  more  intelligent  as  a 
class  than  they  were  thirty  years  ago.  His  statistics  illustrate  very  well  the  fallacy 
of  collecting  cases  and  drawing  conclusions  from  them  without  due  care.  Surely 
20 


306  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

no  one  supposes  that  the  numlnT  of  prostitutes  in  Paris  has  diminished  in  the 
proportion  of  nearly  75  per  cent. 

R.  W.  Taylor  stated  that  most  of  the  eases  of  sjT^hilis  u-hich  he  saw  in  hospitals 
were  from  tenement  houses  and  had  not  contracted  the  disease  from  regular  pros- 
titutes, which  illustrates  the  difficulty  of  preventing  its  spread  by  licensing  women 
of  the  town. 

Pathology  and  Morbid  Anatomy. — As  already  stated,  syphilis  may  in  its  various 
stages  of  development  affect  almost  every  tissue  of  the  body.  Some  of  these 
manifestations  are  not  distinguishable  from  lesions  resulting  from  other  causes, 
and  hence  their  syphilitic  character  can  only  be  established,  if  at  all,  by  the  exclusion 
of  other  factors  and  the  associated  presence  of  recognizable  luetic  phenomena. 

The  primary  lesion  of  syphilis,  called  the  chancre,  develops  at  the  point  of  infec- 
tion, and  is  usually  characterized  by  thrombotic  or  proliferative  changes  in  the 
vessels  with  round-cell  infiltration  of  the  surrounding  connective  tissue,  and  by  the 
formation  of  connective-tissue  cells  which  are  particularly  nimierous  about  the 
bloodvessels.  As  a  result  of  the  vascular  changes  and  associated  lessened  nutrition 
and  possibly  the  action  of  the  syphilitic  poison,  with  or  without  added  infection, 
superficial  and  usually  central  necrosis  occurs  and  an  ulcer  results. 

Soon  after  the  formation  of  the  chancre,  just  described,  commonly  in  about  sLx 
weeks,  the  secondary  stage  develops.  The  lymph  nodes  all  over  the  body,  but 
notably  those  adjacent  to  the  initial  lesion,  become  enlarged  and  inflamed,  and 
inflammatory  and  degenerative  or  necrotic  processes  develop  in  the  skin,  in  the 
mucous  membranes,  and  in  the  bones  and  viscera. 

Following  this  so-called  secondary  period  of  the  disease  there  develops  the 
tertiary  stage,  in  which  the  periosteum  and  the  internal  viscera  suffer  from  peculiar 
growths  of  newly  formed  tissue.  A  most  constant  lesion  is  characterized  by  the 
formation  of  a  new  tissue  consisting  of  spheroidal  and  polyhedral  cells  and  scattered 
giant  cells,  poorly  supplied  with  bloodvessels,  and  having  a  marked  tendency  to 
necrosis,  especially  coagulation  necrosis,  and  hyaline  degeneration  in  their  earlier 
stages,  and  later  caseation  closely  resembling  that  seen  in  tuberculosis.  The 
growth  of  this  new  tissue  is  usually  in  circumscribed  nodes,  and  it  is  in  these  masses 
that  the  necrotic  and  degenerative  processes  just  named  occur  most  markefily 
or  are  most  evident.  These  "gummata"  may  grow  to  considerable  size.  They 
appear  as  dirty-white,  firm  masses  which,  on  section,  often  are  found  to  be  caseous 
at  the  centre,  where  the  new  tissue  has  imdergone  necrotic  change. 

Syphilis  produces  gra\'e  changes  in  the  bloodvessels,  and  no  other  pathological 
process  impairs  the  general  vascular  system  so  markedly,  except  it  be  renal  disease. 
A  syphilitic  arteritis  develops  with  diffuse  overgrowth  of  fibrous  tissue  in  the 
adventitia,  and  even  gummata  may  form  along  the  -vessels.  The  arteritis  also 
involves  the  middle  coat  and  even  the  endothelial  lining  of  the  vessels,  and  so 
narrows  or  occludes  them.  This  of  course  diminishes  the  blood  supply  to  the 
various  organs  and  increases  the  labor  of  the  heart.  The  heart  muscle  also  suffers 
from  a  myocarditis  characterized  by  o\ergrowth  of  its  connective  tissues,  and  the 
pericardium  and  endocardium  may  be  thickened  for  a  like  reason,  but  gumma  of 
the  heart  is  very  rarely  produced.  The  changes  in  the  heart  are,  therefore,  almost 
entirely  due  to  the  effects  of  the  disease  on  the  vessels  which  supply  it,  and  upon 
the  changes  which  occur  in  the  aorta  and  the  peripheral  ^•essels.  In  other  words, 
while  arteritis  may  result  in  myomalacia  cordis  the  conspicuous  change  is  a  fibrosis 
of  the  heart  muscle.  The  aortitis  and  general  arteritis  result  in  increased  cardiac 
and  vascular  stress.  Brooks,  from  a  study  of  50  cases,  found  the  myocardium 
diseased  in  44  and  the  aorta  in  a  like  number.  lie  emphasizes  the  point  that 
these  changes  may  begin  early  in  the  disease  instead  of  being  a  late  manifestation. 

In  the  secondary  stage  of  syphilis  an  acute  syphilitic  nephritis  has  been  described. 
Later  on  a  destructive  overgrowth  of  connective  tissue  develops  in  association 


SYPHILIS 


307 


with  the  vascular  changes  just  described,  and  gummatous  growths  occur  in  the 
kidneys. 

The  liver  is  very  commonly  affected  by  the  formation  of  gummata  or  by  con- 
nective-tissue proliferation,  which  produce  grave  interference  with  its  function. 
These  changes  take  place  in  both  the  acquired  and  in  the  hereditary  form  of  the 
disease.  This  overgrowth  of  connective  tissue  occurs  in  two  types.  It  is  developed 
between  the  lobules,  constituting  an  interlobular  or  perilobular  cirrhosis,  and  between 
the  cellular  columns  forming  an  intralobular  cirrhosis.  In  some  instances  these 
connective-tissue  formations  consist  in  large,  firm  bands  which  run  in  various 
directions  through  the  liver  and,  in  contracting,  draw  in  the  capsule  of  Glisson  and 


Nodular  syphilis  of  the  liver.     (Kast  and  Rumpler.) 


SO  cause  great  distortion  of  its  surface.  (See  Fig.  60.)  Not  rarely  gummata  are 
enclosed  by  these  bands.  In  the  earlier  stages  and  milder  forms  of  sjqDhilitic 
hepatic  cirrhosis  the  changes  cannot  be  considered  pathognomonic,  but  in  the 
exaggerated  form,  just  described,  typical  syphilitic  changes  occur.  As  secondary 
lesions  of  the  liver,  amyloid  disease  and  atrophy  of  its  parenchyma  are  occasionally 
observed.     (See  Cirrhosis  of  the  Liver.) 

The  lesions  in  the  lungs  consist  in  gummata  which  are  often  surrounded  by 
exudative  material,  as  in  pneumonia.  These  gummata  may  contain  a  cheesy 
area  as  in  tuberculosis  and,  by  pressure,  may  cause  secondary  alterations.  A 
second  change  is  overgrowth  of  fibrous  tissue  around  the  bronchi  which,  associated 
with  catarrhal  processes  involving  their  mucosa,  distorts  these  tubes,  causing 


308  DISEASES  DUE  TO  A  SPECIFIC  LXFECTIOX 

narrowing  at  some  points  and  at  others  bronchiectases.  Infarctions  may  occur 
because  of  the  obliterative  changes  in  the  bloodvessels. 

A  true  syphihtic  phthisis  presenting  symptoms  resembling  tuberculous  pulmonary 
phthisis,  but  in  which  tubercle  bacilli  are  not  present,  may  occur,  but  it  is  exceed- 
ingly rare.  It  is  true  that  cases  have  been  reported  in  which  gunnnata  in  the  lungs 
have,  like  tubercles,  undergone  softening  of  a  caseous  type,  and  Wilks  has  recorded 
an  instance  in  which  this  process  had  gone  on  to  the  de\'elopinent  of  a  ca\ity. 
^'irchow  and  Fowler  have  recorded  similar  cases.  These  cases,  howe\er,  although 
they  may  j)roduce  physical  signs  of  ca\ity  do  not  present  the  characteristics  of 
pulmonary  phthisis  in  the  sense  of  pulmonary  tuberculosis,  nor  do  those  instances 
in  which  bronchiectatic  cavities  develop  as  the  result  of  syphilitic  fibroid  changes 
in  the  lungs  do  so,  even  though  the  physical  signs  may  be  similar.  The  main 
pathological  difference  in  the  two  states  is  this — viz.,  that  in  tuberculosis  there  is 
not  only  a  destruction  of  the  tubercle  by  softening,  but  the  intervening  tissue  is 
infiltrated  with  exudate  which  soon  becomes  tuberculous  and  jiroceeds  to  necrosis. 
This  does  not  occur  in  syphilis.  In  rare  cases  syphilis  of  the  lung  and  tuberculosis 
may  be  coincident. 

In  the  hereditary  syphilis  of  infancy  a  lobar  or  bronchopneumonia  in  which 
the  pulmonary  tissues  show  red,  gray,  and  white  exudates,  according  to  the  stage 
of  the  local  disease,  is  sometimes  met. 

The  iiimph  nodes  in  cases  of  syphilis  are  always  affected  by  an  overgrowth  of 
connecti\e  tissue  after  the  primary  infection.  In  the  third  stage  gummatous 
masses  may  develop  in  them. 

Next  to  changes  produced  in  the  organs  of  circulation  syphilis  manifests  its 
gra^-est  changes  in  the  central  nervous  system.  It  has  been  shown  that  in  late 
syphilis  of  the  brain  as  in  paresis  the  perivascular  spaces,  and  the  cortical  and 
subcortical  tissues  are  loaded  with  spirochete  and  this  has  completely  changed 
our  \'iews  as  to  the  so-called  late  nervous  lesions  hitherto  thought  to  be  due  to  the 
fact  that  infection  had  once  been  present.  The  meninges  may  be  the  seat  of 
gummata  with  or  without  the  presence  of  chronic,  indurati\"e  overgrowth  of  con- 
nective tissue.  In  the  brain  it  causes  gummata  manifesting  the  symptoms  of 
brain  tumor;  it  also  produces  a  sj'philitic  inflammation  which  is  associated  with 
the  formation  of  a  gelatinous  tissue,  this  gi\-es  rise  to  serious  degenerative  changes 
in  the  arteries  which  interfere  with  the  nutrition,  and  later  by  rupturing  bring 
about  cerebral  hemorrhage.  It  also  causes  gumma  of  the  cord  and  its  membranes, 
which  usually  have  their  origin  in  the  tissues  of  a  bloodvessel  or  in  the  pia  arachnoid. 
Rarely  it  affects  the  peripheral  ner\-es,  tlu-ough  pressure,  as  they  emerge  from  the 
cerebrospinal  sheaths.  In  the  spinal  cord  it  causes  degenerative  changes  of  cells 
and  fibres  and  overgrowth  of  the  sustentacular  tissue. 

Paresis,  meningo-encephalitis,  locomotor  ataxia,  etc.,  will  be  discussed  with  dis- 
eases of  the  nerA-ous  system,  althougJi  our  present  knowledge  indicates  that  they 
might  well  l)e  considered  in  this  article. 

Symptoms. — The  symptoms  of  acquired  syphilis  are  best  described  as  they 
appear  in  the  three  stages  of  the  disease. 

First  St.\ge. — In  from  twehe  to  twenty-one  days  after  exposure  and  infection 
the  patient  develops  at  the  site  of  original  contact  with  the  virus  a  small  papule 
or  pimple  which  has  an  area  of  indinated  tissue  about  its  base,  the  so-called  primary 
lesion  or  hard  chancre.  Further  examination  of  the  patient  will  reveal  the  fact 
that  the  inguinal  glands  arc  slightly  enlarged. 

This  period  of  primary  syphilis  lasts  from  three  to  ten  days  or  two  weeks,  and 
is  followed  by  the  development  of  the  secondary  sinqe. 

Sec(ixd  Stage. — In  the  secondary  stage  we  find  jerer  as  an  early  symptom, 
which  varies  in  its  degree  very  greatly  in  different  patients.  In  some  instances 
it  is  so  mild  as  to  be  o\-erlooked;  in  others  it  may  rise  to  a  point  as  high  as  104° 


SYPHILIS  309 

or  even  105°.  The  more  common  febrile  movement  is  one  in  which  the  temperature 
for  some  days  stays  in  the  neighborhoofi  of  101°.  When  the  fever  intermits, 
being  fairly  high  at  one  period  and  then  breaking  sharply,  it  may  mislead  the 
physician  into  a  diagnosis  of  malarial  infection  or  acute  sepsis.  I  have  seen  .several 
cases  in  which  a  diagnosis  of  typhoid  fever,  malarial  fever,  or  tuberculosis  was 
made  when  in  reality  the  disease  was  early  secondary  syphilis. 

The  skin  eruptions  of  the  secondary  stage  consist  chiefly  of  the  roseola,  the 
development  of  which  often  marks  the  onset  of  the  secondary  stage.  This  roseolom 
rash  may  occur  in  limited  areas  or  be  widely  distributed  over  the  body  anrl  even 
involve  the  face.  On  one  occasion  a  woman  with  a  well-developed  syi)hilitic  roseola 
presented  so  scarlet  a  visage  that,  although  she  was  \-eiled,  she  caused  the  other 
patients  to  leave  my  waiting-room  in  alarm,  they  thinking  that  she  had  scarlet 
fever.     As  a  rule,  however,  the  rash  is  not  so  marked  on  the  face. 

In  other  cases,  in  place  of  roseola  there  develops  a  macular  syphilide,  character- 
ized by  the  appearance  of  reddish-brown  or  copper-like  macules  scattered  over 
the  trunk. 

As  the  secondary  stage  advances  the  eruption  may  be  papular  and  finally  pusiiilar, 
and  at  this  time  it  may  closely  resemble  that  of  true  variola.  In  still  other  cases 
a  squamous  or  scaly  eruption  appears  which  differs  from  psoriasis  in  that  it  is  not 
chiefly  on  the  extensor  surfaces  as  is  ordinary  psoriasis,  and  in  addition  it  is  fre- 
quently copper-colored. 

At  the  point  of  junction  between  the  mucous  membrane  and  the  skin,  as  at 
the  anus  or  at  the  angles  of  the  mouth,  "mucous  patches,"  or  ulcers,  develop,  and 
upon  the  skin  in  the  neighborhood  of  these  lesions  warty  growths  of  a  flat  character, 
the  so-called  syphilitic  condylomata,  appear.  Mucous  patches  on  the  buccal 
mucous  membrane  and  tongue  also  appear. 

There  is  nearly  always  some  falling  of  the  hair  in  secondary  syphilis.  Sometimes 
this  falling  is  well  distributed;  in  other  cases  it  is  in  patches — syphilitic  alopecia. 

A  serious,  oftentimes  painful  complication  at  this  stage  is  syphilitic  iritis.  If 
the  treatment  is  not  active  sight  may  be  lost. 

A  rapid  development  of  anemia,  which  often  becomes  quite  marked,  not  as  to 
hemoglobin,  but  as  to  the  number  of  the  red  cells  present,  is  often  obser\-ed. 

The  secondary  stage  lasts  from  twelve  to  eighteen  months,  and  is  usually  followed 
by  a  period  during  which  the  symptoms  are  modified  or  entirely  disappear,  the 
virulence  of  the  disease  seeming  to  have  spent  itself,  but  even  if  no  sjiDhilitic  symp- 
toms are  present  a  child  begotten  at  this  time  will  usually  suffer  from  hereditary 
syphilis. 

Third  Stage. — In  the  great  majority  of  untreated  cases  the  malady  proceeds 
to  the  so-called  tertiary  stage.  This  is  characterized  by  the  presence  of  skin  lesions, 
which  are  more  severe  than  those  of  the  secondary  period,  such  as  tuhercuhus  and 
ulcerous  formations  of  a  subacute  or  chronic  character.  There  is  an  overgrowth 
of  connective  tissue  in  different  parts  of  the  body,  as  in  the  secondary  period, 
and  multiple  gummata  are  often  present  in  numbers,  developing  in  the  skin,  in 
the  subcutaneous  tissues,  in  the  muscles,  and  in  the  internal  viscera,  particularly 
in  the  liver.  When  in  the  skin  they  often  slough  and  produce  ulcers,  and  in  the 
internal  organs  they  become  filled  with  fibrous  tissue  and  undergo  contraction 
in  the  manner  already  described. 

Last,  but  by  no  means  least,  of  the  changes  due  to  syphilis  in  its  tertiary  stage, 
we  meet  with  lesions  of  the  nervous  system.  These  changes,  as  a  rule,  are  late 
manifestations  of  the  disease;  occurring  some  years  after  the  infection.  Rarely 
they  may  appear  as  early  as  within  the  first  six  months,  usually  within  the  first 
ten  years,  sometimes  as  late  as  twenty  years.     (See  Paresis  and  Ataxia.) 

Syphilis  in  certain  cases  may  seem  to  possess  great  virulence  and  become  destruc- 
tive in  its  course,  almost  from  the  onset.     The  chancre  may  rapidly  ulcerate  and 


310  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

spread,  the  fever  may  be  marked,  and  the  anemia  severe.  The  skin  lesions  become 
pustular,  even  in  the  secondary  stafje,  and  form  deep  ulcers,  which,  in  turn,  cause 
scars  as  they  heal.  Destructive  chanf^es  rajjidly  develop  in  the  bones  and  viscera. 
The  patient  may  die  within  a  few  months  of  the  infection.  In  these  cases  there  is 
usually  a  lowered  vital  resistance  which  permits  the  disease  to  progress  imopposed. 

In  other  cases  the  symptoms  are  remarkably  mild.  The  chancre  is  so  small 
that  it  is  o^'erlooked,  the  patient  truthfully  stating  years  afterward  that  he  has 
never  had  a  primary  lesion.  The  rose  rash  may  not  occur,  or  be  so  faint  and 
fleeting  as  not  to  attract  notice,  and  the  primary  anemia  may  be  entirely  absent. 
Syphilis  may  end  in  complete  recoAcry  at  the  close  of  the  secondary  stage,  but  such 
a  fortunate  result  is  rare,  unless  active  treatment  has  been  instituted. 

It  is  a  fact  worthy  of  note  that  nervous  lesions  seem  to  occur  more  frequently 
in  cases  which  have  presented  mild  secondary  sjTnptoms  than  in  those  who  have 
had  severe  secondary  and  tertiary  lesions. 

Three  intracranial  conditions  due  to  sj^jhilis  may  produce  violent  headache, 
namely,  arteritis,  meningitis,  and  gumma.  When  arteritis  is  the  cause,  giddiness, 
weakness  of  groups  of  muscles,  difficulty  of  speech,  and,  it  may  be,  signs  of  general 
paresis  develop.  On  the  other  hand,  when  the  ocular  muscles  are  affected  and  an 
optic  neuritis  is  present,  meningitis  is  the  more  likely  condition,  particularly  if 
there  is  spasmodic  contraction  of  certain  cranial  muscles  and  fever.  Neuroretinitis 
is  present  in  meningitis  and  in  gumma,  but  is  not  commonly  present  in  arteritis. 
(See  Meningitis.) 

The  symptoms  of  syphilis  of  the  brain  depend  very  largely  upon  the  site  of  the 
lesion,  for,  as  already  stated  in  the  section  on  the  Morbid  Anatomy  of  Syphilis, 
these  lesions  may  be  at  the  base,  on  the  convexity,  or  in  the  membranes.  By  far 
the  most  common  symptom  of  cerebral  syphilis  is  headache,  which  is  usually  diffuse 
and  constant,  but  if  the  meninges  are  involved,  or  a  gumma  is  causing  pressure, 
it  may  be  exceedingly  severe  and  characterized  by  what  are  known  as  "crashing 
pains."  Patients  with  cerebral  syphilis  are  often  unduly  somnolent.  (See  Diagnosis.) 

When  gummatous  growths  form  at  the  base  of  the  brain  the  symptoms  are 
those  due  to  interference  with  the  cranial  nerves,  such  as  squint,  optic  atrophy, 
and  facial  paraJysis.  When  the  convexity  of  the  brain  is  affected  the  symptoms 
are  those  of  localized  or  Jacksonian  epilepsy,  or  of  jjc^f?  mal.  Sometimes  the 
epileptic  seizure  is  general.  Fournier  laid  down  as  a  law  that  epilepsy  beginning 
in  adult  years  is,  nine  times  out  of  ten,  syphilitic.  A  third  form  of  cerebral  syphilis 
is  that  in  which  there  are  psychical  disorders,  such  as  melancholia  or  delusions  of 
grandeur.     (See  Paresis.) 

Spinal  syphilis  manifests  itself  as  the  result  of  the  presence  of  gummata  or  of 
connective-tissue  changes  in  the  cord.  When  the  lesion  is  a  gumma  the  symptoms 
are  those  of  pressure  on  the  cortl.  When  connecti\'e-tissue  changes  occur  the  signs 
are  those  of  spastic  paralysis  of  the  lower  limbs,  with  markedly  exaggerated  reflexes, 
low  muscle  tension,  and  vesical  disturbances.  Often  the  disorder  of  the  functions 
of  the  bladder  is  the  first  sign  of  spinal  difficulty.  The  bladder  may  lose  its  expulsive 
power  or  incontinence  may  occur.  As  a  late  syphilitic  affection  locomotor  ataxia 
is  the  most  common  nervous  disease.     (See  Locomotor  Ataxia.) 

Diagnosis. — The  diagnosis  of  accjuired  syphilis  is  readily  made  if  the  patient 
lircscnts  the  well-developed  symptoms.  In  many  cases,  however,  these  are  not 
manifested.  The  indurated  base  of  the  chancre  is  an  invaluable  sign  if  the  chancre 
has  not  been  cauterized,  and  the  presence  of  enlargement  of  the  lymph  nodes  in 
the  groin  and  in  the  great  chain  of  nodes  in  the  neck  is  also  a  useful  d' agnostic 
point.  The  presence  of  secondary  syphilitic  roseola,  and  fe\er  with  sore  throat, 
and  mucous  patches,  and  abo\-e  all  the  presence  of  the  specific  spirochete  in  these 
lesions  are  diagnostic.  In  some  cases,  however,  the  secondary  symptoms  never 
develop  or  are  so  mild  as  to  be  o^•e^looked,  yet  well-marked  tertiary  signs  develop 


SYPHILIS  311 

later.  The  employment  of  mercury  Or  iodide  of  potassium,  followed  by  the  dis- 
appearance of  the  symptoms,  is  a  therapeutic  test,  but  such  a  result  is  not  a  path- 
ognomonic sign  of  syphilis. 

There  are  two  tests  for  syphilitic  infection  which  can  be  definitely  relied  ujjoii 
if  positive,  namely,  the  Wassermann  serum  complement  reaction  test  or  Noguchi's 
modification  of  it,  and  the  so-called  luetin  test  for  which  we  are  also  indebted  to 
Noguchi.  The  Wassermann  test  should  be  made  by  an  expert  and  if  negative 
should  be  repeated  at  least  once  in  a  suspected  case  before  it  is  finally  accepted. 
This  test  is  positive  only  after  the  infection  has  existed  long  enough  to  have  resulted 
in  general  systemic  infection.  Within  twenty-one  days  after  infection  it  is  present 
in  75  per  cent,  of  cases  and  when  secondary  symptoms  are  well  de\eloped  in  about 
100  per  cent.  As  time  goes  by  it  is  found  less  frequently,  so  that  in  cases  of  se^'eral 
years'  standing  and  which  present  no  symptoms  it  may  be  positive  in  only  30  per 
cent.  It  is  noteworthy  that  in  late  nervous  syphilis  the  Wassermann  test  of  the 
blood  may  be  negative  but  that  of  the  cerebrospinal  fluid  is  positive.  Such  cerebro- 
spinal fluid  contains  a  very  great  excess  of  small  lymphocytes.  Occasionally  cases 
of  suspected  or  suppressed  syphilis  which  give  a  negative  Wassermann  reaction 
will  on  active  treatment  develop  a  positive  reaction.  Finally,  all  persons  who 
have  skin  lesions  and  who  give  a  positive  Wassermann  test  are  not  necessarily 
suffering  from  the  skin  lesions  of  syphilis,  for  it  may  be  that  they  have  two  diseases. 
A  diagnosis  of  syphilis  should  not  rest  solely  on  a  positi^'e  Wassermann  test  because 
an  error  in  technique  may  give  a  positive  reaction  when  it  should  be  negative. 
A  number  of  distressing  incidents  have  followed  such  an  error  causing  suicide, 
divorce  or  vows  of  life-long  celibacy.  Furthermore,  a  positive  Wassermann  reac- 
tion occurs  in  scarlet  fever,  which  in  turn  is  sometimes  taken  with  its  roseolous 
rash  and  sore  throat  for  syphilis,  if  it  occurs  in  an  adult  who  has  been  exposed. 
It  also  is  positive  in  some  cases  of  tuberculosis  and  of  carcinoma  and  in  yaws, 
trypanosomiasis  and  leprosy.  In  scarlet  fever  it  disappears  with  convalescence, 
in  syphilis  it  persists  Finally  it  would  appear  that  some  healthy  persons  give  a 
positive  Wassermann  reaction.  Thus  in  5946  non-syphilitics  the  test  was  positive 
in  1.1  per  cent. 

The  luetin  test  or  reaction  of  Noguchi  is  positive  in  about  50  per  cent,  of  late 
cases.  It  has  the  great  advantage  that  it  is  present  in  late  cases  of  syphilis  when 
the  Wassermann  is  negative,  as  in  tertiary  syphilis  and  in  cases  in  which  active 
treatment  has  prevented  a  positive  Wassermann  reaction.  It  fails  to  appear  if 
syphilis  is  really  cured.  The  test  consists  of  injecting  between  the  layers  of  the 
skin  a  drop  of  the  suspension  of  the  killed  spirochetse  in  the  medium  in  which  they 
are  grown,  preserved  by  adding  trikresol.  If  syphilis  is  present  a  small  inflammatory 
nodule  develops  about  the  fifth  day,  but  may  be  as  early  as  the  second  or  as  late 
as  the  thirtieth  day,  at  the  point  of  injection.  This  nodule  may  slough  but  it  does 
not  occur  in  non-sj^philitic  cases,  and  begins  to  fade  away  after  the  second  day. 
It  is  not  accompanied  by  systemic  symptoms. 

Prognosis. — The  outlook  in  acquired  syphilis  as  to  severity  of  attack  and  ultimate 
recovery  depends  largely  upon  the  state  of  the  general  health,  and  the  promptness 
with  which  specific  treatment  is  instituted.  Much  depends  also  upon  the  faitMul- 
ness  of  the  patient  in  carrying  out  the  treatment  for  a  sufficient  length  of  time. 
In  the  great  majority  of  cases  active  and  skilful  treatment  permits  a  favorable 
prognosis  as  to  absence  of  symptoms,  and  even  as  to  the  safety  of  future  marriage. 
In  the  malignant  cases,  or  those  in  which  tertiary  lesions  have  already  formed,  we 
can  only  hope  to  modify  the  progress  of  the  malady,  or  perhaps  arrest  it  without 
being  able  to  remove  all  signs  of  its  invasion.  That  a  syphilitic  may  be  told  with 
perfect  assurance  that  he  is  "curable  or  cured,"  in  the  sense  that  this  may  be 
said  after  an  attack  of  pneumonia  or  typhoid  fever,  is  questionable.  He  may 
have  no  late  symptoms,  and  after  a  time,  treated  or  not  treated,  he  will  be  no 


312  DISEASES  DUE  TO  A  SPECIEIC  INFECTION 

longer  a  disseminator  of  the  maliuly,  l)iit  it  is  yet  to  be  proved  that  by  any  means 
now  known  is  he  completely  and  permanently  rendered  as  free  and  wholesome  as 
before  he  was  infected.  (Jummatous  growths  nia\',  however,  be  removed  by  treat- 
ment, even  in  tlie  tertiary  stage. 

Hereditary  Syphilis. — The  symptoms  of  hereditary  syphiliis  may  be  present  at 
birth,  the  skin  being  already  the  site  of  sypliilific  eruptions,  of  which  pemphigus 
neonatorum — that  is,  a  bleb-like  eruption  about  the  wrists  and  ankles — is  typical. 
The  liver  and  spleen  are  usually  enlarged,  and  the  child  may  be  wasted  and  poorly 
nourished.  In  other  instances  the  child  manifests  no  lesions  at  birth,  but  within 
its  first  six  months  of  life  develops  syphilitic  rhinitis,  or,  as  it  is  called,  "snuffles." 
This  is  accompanied  or  folloAved  by  cutaneous  lesions,  of  which  the  most  frequent 
is  mucous  patches  about  the  anus  and  in  the  mouth.  It  may  waste  away  from 
so-called  syphilitic  marasmus,  developing  a  syphilitic  rosary  at  its  costocartilaginous 
junctures,  as  in  rickets.  The  ends  of  the  long  bones  are  the  sites  of  syphilitic 
epiphysitis.  If  the  child  lives  to  reach  the  period  of  second  flentition  its  teetii  may 
be  notched — the  so-called  "Hutchinson"  or  "peg"  teeth.  This  malformation 
does  not  appear  in  the  milk  teeth.  In  many  cases  of  hereditary  syphilis,  in  infancy 
the  child  looks  like  an  old  man,  wdiereas  in  hereditary  syphilis  of  early  adult  life 
the  patient  often  looks  very  immature — "syphilitic  infantilism."  Children  having 
hereditary  syphilis  are  prone  to  suffer  from  syphilitic  keratitis,  from  deafness,  and 
from  hone  lesions  Avhich  de\-elop  after  several  years  of  life.  The  periosteum  is 
thickened  and  even  nodular  in  its  appearance,  particularly  on  the  tibia. 

Another  lesion  is  deformity  of  the  fingers,  in  which  they  become  thickened  at 
the  base  and  taper  rapidly  to  the  tip,  being  somewhat  pear-shaped  or  top-shaped — 
the  so-called  syphilitic  dactylitis. 

Children  suffering  from  hereditary  syphilis  give  a  positive  Wassermann  reaction 
nearly  always. 

Treatment. — The  treatment  of  syphilis  is  divisible  into  two  parts,  /.  e.,  that  by 
salvarsan  or  neosalvarsan  and  the  older  plan  by  mercury  and  iodides.  But  before 
any  treatment  is  instituted  it  is  of  course  essential  that  an  absolutely  correct 
diagnosis  be  made.  If  a  smear  from  a  suspected  chancre  can  be  submitted  to 
one  or  two  competent  microscopists  and  they  report  the  Spirochefa  pallida  present, 
there  can  be  no  doubt  that  salvarsan  or  neosaharsan  should  be  gi\-en  at  once  to 
destroy  the  parasite  in  the  chancre  and  anJ^vhere  else  it  may  be  in  the  body. 
When  such  a  laboratory  test  is  impossible  some  practitioners  of  experience  have 
insisted  that  it  is  unwise  to  administer  mercury  to  a  patient  suffering  from  a  sus- 
picious primary  lesion  until,  by  the  development  of  secondary  symptoms,  the 
diagnosis  of  syphilis  is  absolutely  confirmed;  since  if  we  do  not  wait  for  these 
symptoms,  the  possibility  exists  that  a  patient  who  has  not  really  acquired 
syphilis  may  be  condemned  to  the  belief  that  he  has  been  inoculated,  yet  the 
malady  is  only  suppressed,  and  this  may  cause  him  great  mental  suifering  during 
the  rest  of  his  life. 

Another  group  of  practitioners  haAC  strongly  urged  a  view  directly  ojiposed 
to  this,  claiming  that  we  ha^e  no  right  to  permit  the  disease  to  become  thoroughly 
engrafted  upon  the  patient's  system  without  instituting  measures  for  its  relief, 
or  at  least  for  the  diminution  of  the  severity  of  the  infection.  The  leaders  in 
this  line  of  thought  haxc  achocated  the  excision  of  the  chancre  in  the  belief  that 
by  so  doing  the  jjrimary  focus  of  infection  was  removed.  It  must  be  remembered, 
however,  that  the  primary  lesion  does  not  develop  until  two  or  three  weeks  after 
the  actual  inoculation,  and,  therefore,  although  it  ajipears  at  the  site  of  inoculation, 
there  is  good  reason  to  believe  that  it  is  not  a  source  from  which  still  further  infection 
takes  place,  but  rather  a  localized  manifestation  that  inoculation  has  been  accom- 
plished. Nearly  always  there  can  be  found  in  the  adjacent  lymphatics  evidence 
that  they  are  att'ected  as  earlj*  as  the  chancre  appears.     The  question  as  to  whether 


SYPHILIS  313 

the  chancre  should  be  excised  must,  therefore,  be  left  to  the  Judgment  of  the  indisid- 
ual  physician,  with  the  statement  that  it  is  possible,  but  not  probable,  for  the 
excision  to  have  some  influence  for  good. 

It  is  with  those  who  believe  in  the  immediate  administration  of  antisyphilitic 
treatment  as  soon  as  the  chancre  is  de\'eloped  that  I  agree.  It  does  not  seem 
to  me  rational  to  permit  the  disease  to  run  on  imcontrolled  until  he  who  runs  may 
read  that  infection  has  taken  place.  While  it  is  true  that  the  chancre  at  times 
is  not  sufficiently  characteristic  to  enable  us  to  make  a  positive  diagnosis  that  it 
is  true  syphilis,  we  are  justified  in  such  a  case  in  considering  that  it  is  such  and 
proceeding  at  once  to  the  relief  of  the  patient. 

The  production  of  salvarsan  and  neosalvarsan  has  provided  us  with  a  specific 
treatment  of  syphilis,  but  not  a  certain  cure  by  the  use  of  one  large  dose,  as  Ehrlich 
at  first  claimed,  because  very  large  doses  are  not  always  safe  and  because  the 
spirochete  is  often  in  tissues  which  are  not  permeable  to  the  drug  when  it  is  placed 
in  the  blood,  for  example,  in  the  brain  and  spinal  cord,  and  from  these  and  other 
sequestered  places  the  organisms  sally  out  and  reinfect  the  disinfected  tissues 
whereby  relapses  ensue.  It  is  also  to  be  recalled  that  these  new  agents  do  not 
directly  kill  the  spirochete  but  produce  some  change  in  the  body  whereby  they 
are  killed.     Spirochetse  placed  in  a  test-tube  with  salvarsan  are  not  destroyed. 

Salvarsan  should  be  given  as  soon  after  a  chancre  is  discovered  as  possible,  in  the 
hope  that  it  will  abort  the  disease.  Given  in  the  early  stages  salvarsan  acts  like 
magic  upon  the  parasites  in  open  lesions.  A  mucous  patch  teeming  with  the 
specific  organism  one  day  is  sterile  the  next,  which  is  not  only  valuable  to  the  patient, 
but  prevents  the  spread  of  the  disease  to  others.  It  may  be  said  that  early  second- 
ary manifestations  indicate  this  drug  above  all  others.  When  gummata  are 
present  it  is  probably  no  more  useful  than  mercury,  except  in  gummata  of  the  skin. 
Upon  cutaneous  eruptions  and  enlarged  glands  it  is  not  materially  more  active 
than  mercury,  unless  the  skin  lesions  are  breaking  down,  when  it  is  often  surprisingly 
effective. 

.Where  late  syphilis  of  the  nervous  system  is  present  salvarsan  has  limited  power, 
first,  because  destroyed  tissue  cannot  be  replaced  and,  second,  because  unless  the 
specific  substance,  induced  by  the  intravenous  injection  of  salvarsan,  in  the  blood 
serum  is  injected  into  the  subarachnoid  space  the  remedy  gets  to  the  micro- 
organisms in  too  small  an  amount  to  be  of  service. 

In  well  developed  syphilis  the  best  results  seem  to  be  obtained  by  giving  salvarsan, 
or  neosalvarsan,  in  ascending  doses  every  week  for  eight  weeks  and  then  giving  a 
course  of  mercury,  returning  later  to  the  newer  drug  if  any  acute  symptoms  develop. 

Concerning  the  effect  of  salvarsan,  or  neosalvarsan,  on  the  Wassermann  reaction, 
it  would  seem  that  except  when  used  very  early  it  has  no  more  effect  in  producing 
a  negative  reaction  than  properly  used  mercurials.  Occasionally  in  a  suspicious 
case'  giving  a  negative  test  a  dose  of  salvarsan  provokes  a  positive  reaction. 

Salvarsan  is  much  more  efficacious  when  used  intravenously  than  when  given 
intramuscularly,  but  it  never  causes  death  when  injected  into  a  muscle  and  has 
caused  death  when  given  into  a  vein,  although  very  rarely  in  thousands  of 
cases. 

When  given  intravenously  it  should  be  injected  as  is  normal  salt  solution,  by 
means  of  a  sharp  needle  pushed  into  a  vein  in  the  arm,  immediately  after  it  is 
prepared  for  use  as  follows: 

Place  in  a  glass  cylinder  of  500  c.c.  capacity,  provided  with  a  stopper  and  50 
glass  beads,  30  c.c.  of  normal  salt  solution  and  add  0.6  of  salvarsan.  Cork  and 
shake  thoroughly  until  dissolved  and  then  add  1.14  c.c.  of  15  per  cent,  solution 
sodium  hydroxide.  Dissolve  the  precipitate  by  shaking.  Add  enough  salt  solution 
to  make  300  c.c.  and  if  need  be  to  keep  in  solution  add  a  few  drops  more  of  the 
sodium  hydroxide  solution. 


314  DISEASES  DUE  TO  A  SPECIFIC  IXFECTIOX 

The  ijrc'paration  of  the  drug  in  oil  can  be  oVjtained  in  iicrineticallN-  scaled  glass 
ampoules  ready  for  intramuscular  use. 

Before  salvarsan  is  given  intravenously  the  patient  should  miss  a  meal  and  be 
well  purged.  Pie  should  be  in  the  recumbent  posture  when  treated  and  remain 
so  for  some  hours. 

Neosalvarsan  is  less  efficacious  than  salvarsan  even  if  given  in  doses  one-third 
larger  but  is  more  easily  preparetl  and  less  prone  to  produce  disagreeable  s\ni])toms. 
It  is  entirely  soluble  in  water  and  should  be  dissolved  in  250  c.c.  of  freshly  distilled 
(not  hot)  water  immediately  before  it  is  used.  The  solution  must  not  be  shaken 
or  heated  and  is  best  given  intravenously,  very  slowly,  under  strict  antisejjtic 
precautions  with  the  patient  recumbent  and  remaining  so  for  se\cral  hours  after. 

The  dose  of  neosalvarsan  varies  from  0.15  gm.  to  1.5  gm.,  and  it  comes  in 
ampoules  each  of  which  contains  a  single  dose.  The  first  dose  for  an  adult  is 
usually  0.9  gm.,  gradually  increased  until  the  fourth  dose  equals  1.5  gm.  In 
urgent  cases  it  may  be  given  every  other  day.  Women  usually  receive  one-third 
less  and  children  0.15  gm.  to  0.35  gm.     Infants  0.05  gm. 

Salvarsan  is  contra-indicated  in  acute  and  chronic  nephritis,  in  advanced  cardio- 
vascular lesions,  in  lymphatism,  and  in  those  with  an  idiosyncrasy  to  arsenic. 

Often  its  use  is  followed  by  an  increase  in  the  inflammation  and  redness  of  the 
lesions  for  a  time;  the  so-called  Her.xlieimer  reaction.  Sometimes  this  reaction 
is  sharper  after  the  second  than  after  the  first  dose.  In  nervous  syphilis  this 
reaction  about  vital  nervous  centres  may  temporarily  exaggerate  the  symptoms 
and  cause  a  dangerous  exacerbation,  and  if  the  symptoms  are  meningeal,  another 
dose  in  less  than  a  week  may  cause  death.  Mercurj'  should  be  used  in  such  cases 
until  every  evidence  of  meningeal  irritation  or  cerebral  disturbance  has  long  since 
passed  away. 

When  salvarsan  cannot  be  used  the  treatment  of  the  secondary  stage  of  syjihilis 
must  consist  in  the  administration  of  full  doses  of  the  protiodide  of  mercury,  which 
should  be  given  in  the  form  of  uncompressed  tablet  triturates  in  the  dose  of  |  of 
a  grain  three  times  a  day,  increased  by  one  or  two  quarters  each  day,  until  the 
patient  manifests  distinct  evidences  of  the  full  systemic  effect  of  the  drug,  as 
evidenced  by  some  looseness  of  the  bowels  or  by  the  development  of  tenderness  of 
the  teeth  and  slight  salivation.  It  is  important  when  this  drug  is  given  that  tablet 
triturates,  and  not  compressed  tablets,  are  employed,  as  the  compressed  tablets 
are  often  unabsorbed,  because  of  their  hardness,  and  frequently  cause  irritation 
of  the  stomach,  whereas,  the  properly  made  tablet  triturate  rarely  does. 

As  soon  as  the  patient  manifests  any  of  the  symptoms,  mentioned  as  indicative 
of  the  fact  that  he  is  using  all  of  this  drug  which  he  can  well  bear,  it  is  proper  to 
diminish  the  dose  one-half,  and  keep  it  at  this  point,  provided  that  this  dose  seems 
competent  to  prevent  the  development  of  further  syphilitic  manifestations.  If, 
however,  this  half-dose  is  not  sufficient  for  this  purpose,  the  drug  must  be  given  in 
ascending  doses  the  second  time,  and  if  the  syphilitic  manifestations  are  at  all 
malignant  it  may  be  necessary  to  continue  it,  even  if  opium  or  bismuth  have  to 
be  givxn  to  control  diarrhea. 

It  is  essential  in  the  use  of  the  protiodide  of  mercury  in  syphilis,  first,  that  the 
stomach  shall  not  be  disordered,  because  it  is  of  vital  importance  that  the  ])atient 
should  be  able  to  take  full  quantities  of  highly  nutritious  food,  in  order  that  by 
maintaining  his  vitality  his  own  vital  processes  may  aid  him  to  combat  the  infection. 

It  is  also  essential  that  great  care  be  taken  against  the  (le\elopment  of  mercurial 
stomatitis.  If  this  condition  once  develops,  it  is  often  difficult  to  cure  it  while 
the  mercury  is  continued,  and  it  frequently  will  prevent  the  patient  from  taking 
sufficient  doses  of  the  drug  to  favorably  influence  his  .syphilitic  infection.  If  the 
patient  is  directed  to  take  the  greatest  possible  care  as  to  cleanliness  of  his  mouth, 
to  use  a  tooth-brush  and  some  antiseptic  dentifrice  after  each  meal,  to  keep  particles 


SYPHILIS  315 

of  food  from  between  the  teeth  by  the  use  of  floss  silk,  and,  finally,  if  he  also  be 
given  a  prescription  calling  for  10  grains  of  chlorate  of  potassium  and  10  drops 
of  tincture  of  myrrh  in  an  ounce  of  elixir  of  calisaya,  which  is  to  be  dihitcd  one-half 
with  water,  and  used  as  a  mouth-wash  night  and  morning,  it  will  be  found  that  he 
will  be  able  to  take  much  larger  doses  of  mercury  than  if  these  measures  are  delayed 
until  some  evidences  of  mercurial  sore  mouth  present  themselves. 

Should  the  manifestations  of  syphilis  be  virulent,  then  it  is  necessary  to  give 
the  drug  to  the  patient  not  only  in  the  form  of  the  protiodide  by  the  moutli,  but 
to  use  blue  ointment  rubbed  into  the  skin  at  least  once  a  day,  in  tlie  dose  of  about 
1  drachm,  choosing  a  different  spot  each  time  for  the  rubbing,  and  exercising  great 
care  that  the  rubbing  is  continued  long  enough  to  actually  cause  the  absorption 
of  the  mercury.  Usually  a  hot  Turkish  bath  or,  if  this  is  impossible,  an  ordinary 
hot-water  bath  should  be  taken  before  the  mercurial  ointment  is  used,  in  order 
that  the  skin  may  be  rendered  pliable  and  put  in  such  a  state  that  the  mercury 
can  be  readily  taken  up  by  the  tissues  beneath  it.  The  entrance  of  mercurial 
ointment  into  the  body  may  also  be  aided  by  smearing  it  on  a  flannel  binder  and 
placing  this  about  the  patient's  waist. 

In  other  instances,  in  addition  to  the  internal  and  external  use  of  mercury,  or 
in  place  of  one  of  them,  hypodermic  injections  of  mercury  may  be  employed.  For 
this  purpose  one  of  the  best  preparations  is  corrosive  sublimate  dissolved  in  normal 
salt  solution  and  given  in  the  dose  of  |  of  a  grain,  injected  deeply,  but  gently,  into 
the  loose  cellular  tissues  of  the  buttocks  or  back,  or,  better  still,  into  the  body  of 
the  greater  muscles,  such  as  the  gluteus.  Great  care  must  be  exercised  that  anti- 
sepsis is  complete,,  since  otherwise  the  irritant  drug,  although  antiseptic  in  itself, 
may  cause  abscess.  This  injection  should  not  be  given  oftener  than  every  two  or 
three  days.  In  other  instances  gray  oil  may  be  used,  prepared  by  rubbing  2  drachms 
of  lanolin  with  a  sufficient  quantity  of  chloroform  to  form  an  ernulsion,  continuing 
the  rubbing  until  most  of  the  chloroform  is  evaporated,  then  adding  metallic 
mercury  to  the  extent  of  4  drachms,  and  rubbing  again  until  the  mixture  is  complete. 
This  strong  gray  ointment,  diluted  still  further  by  the  addition  of  equal  parts  of 
olive  oil,  may  be  injected  in  the  dose  of  1  or  2  minims  every  second  or  third  day  in 
the  same  manner  as  corrosive  sublimate. 

Still  another  way  of  getting  mercury  into  the  body  is  by  means  of  the  sublimation 
of  calomel.  The  patient,  being  stripped  of  all  clothing,  is  wrapped  in  a  blanket 
and  placed  upon  a  chair  with  a  wooden  seat.  Under  this  chair  is  place  an  alcohol 
lamp  and  over  it  a  disk  of  metal  upon  a  small  iron  stand,  on  which  20  grains  of 
calomel  is  laid.  Upon  this  stand  is  also  placed  a  tincupful  of  water.  The  heat  of 
the  lamp  vaporizes  the  water  and  sublimes  the  calomel,  and  the  mercury,  being 
desposited  upon  the  skin  of  the  patient,  is  absorbed.  This  method  of  treatment  is 
useful  for  the  relief  not  only  of  the  systemic  symptoms,  but  also  for  the  syphilitic 
eruption  of  the  skin.  A  similar  plan  of  sublimation  can  be  carried  out  with 
inhalations,  the  patient  holding  his  face  eighteen  inches  away  from  the  pan  and 
inhaling  the  fumes.  If  this  is  done  mucous  patches  in  the  mouth  are  -v^ery  frequently 
rapidly  healed,  but  after  each  employment  of  sublimation  and  inhalation,  the 
mouth  should  be  well  rinsed  with  water,  in  order  that  an  excess  of  mercury  may  not 
remain  there  and  produce  stomatitis.  In  many  cases  the  best  results  are  produced 
by  a  plan  of  treatment  in  which  both  the  iodide  of  potassium  and  protiodide  of 
mercury  are  given  together  or  alternately. 

The  treatment  of  the  tertiary  stage  of  syphilis  consists  chiefly  in  the  administration 
of  iodide  of  potassium  or  iodide  of  sodium  or  iodide  of  strontium,  in  as  full  .doses 
as  the  patient  can  well  bear,  but  should  evidences  of  gummatous  growth  in  the 
brain  present  themselves  the  iodide  is  not  sufficiently  active  in  its  action,  and 
mercury  should  be  given  with  it. 

The  dose  of  the  iodides  varies  greatly  with  the  susceptibility  of  different  Individ- 


316  DISEASES  DUE  TO  A  SPECIFIC  IXFECTIOX 

uals.  As  ;i  rule,  tertiary  syphilis  is  not  benefited  l)y  s'^'i^S  '^^^  tlian  IflO  grains  a 
day.  I  have  had  a  patient  under  my  eare  who  would  take  SOO  irpains  a  day  with 
great  benefit,  with  no  other  disagreeable  symi)toins  than  the  development  of  an 
intense  aene.  But  we  rarely  meet  with  instanees  where  thesi'  enormous  doses 
must  be  taken. 

The  proper  way  to  administer  the  drug  is  to  order  a  saturated  solution  of  iodide 
of  sodium  dissolved  in  the  strength  of  1  grain  to  the  minim  of  water,  and  direct 
that  10  minims  of  this  be  given  in  a  dessertspoonful  of  the  compound  syrup  of 
sarsaparilla  three  times  a  day  an  hour  after  meals,  })eing  increased  each  day  from 
1  to  5  minims  at  a  dose.  If  careful  attention  is  paid  to  the  diet  and  to  the  condition 
of  the  bowels,  patients  who  would  not  be  able  to  take  large  doses  at  first  soon  become 
fairly  immune  so  far  as  untoward  efi'eets  are  concerned,  and  can  take  effective 
quantities  within  a  brief  period  of  time. 

Hereditary  syphilis  is  to  be  treated  b>'  the  use  of  neosalvarsan  and  the  active 
employment  of  mercury.  In  babies  suffering  from  syphilis,  gray  powder  may  be 
given  in  the  dose  of  2  grains  two  or  three  times  a  day,  and  mercurial  ointment  may 
be  rubbed  into  the  abflomen  and  on  the  inside  of  the  thighs  and  smeared  upon  the 
abdominal  binder  of  the  child.  This  will  prove  a  most  advantageous  plan  of  treat- 
ment. The  change  in  the  nutrition  and  appearance  of  the  infant  under  these 
circumstances  is  little  less  than  marvellous. 

The  diet  should  be  carefully  regulated,  and,  if  the  digestion  will  stand  it,  cod- 
liver  oil  should  be  given  internally.  The  employment  of  the  mercurial  ointment 
produces  an  active  systemic  influence  without  disordering  digestion,  and  is,  there- 
fore, particularly  advantageous  when  hereditary  syphilis  is  being  treated  in  infants. 
(For  the  treatment  of  syphilis  of  the  nervous  system  see  Paresis  and  Locomotor 
Ataxia.) 

MALARIAL  INFECTION. 

Definition. — By  malarial  infection  we  refer  to  a  condition  produced  by  the  entrance 
into,  and  development  in,  the  blood  of  specific  micro-organisms  known  as  the 
Plasmodium  vialariw,  the  hematozoon  of  malarial  fe\'er,  or,  more  correctly  speaking, 
the  Hemameba  malaria. 

The  infection  is  manifested  by  four  different  types:  First,  the  so-called  intermit- 
tent type,  in  which  the  patient  has  recurring  attacks  which  are  characterized  by  a 
chill,  a  fever,  and  a  sweat.  These  recurrences  commonly  take  place  daily,  on 
alternate  days,  or  on  every  third  day,  and  are  called  cpiotidian,  tertian,  or  quartan. 
Second,  a  type  in  which  there  is  present  continued  fever  with  remissions  in  its 
course,  the  so-called  remittent  malarial  fever.  Third,  a  type  in  which  the  infection 
is  of  a  malignant  or  pernicious  form  with  profound  toxemia.  Fourth,  that  form 
in  which  more  or  less  subacute,  or  chronic,  and  profound  cachexia  is  present, 
associated  with  marked  anemia  and  enlargement  of  the  spleen,  and  often  of  the 
liver.  The  first  is  due  to  the  tertian  or  cpiartan  parasite,  the  second  and  third  to 
the  estivo-autumnal  parasite,  while  the  fourth  form  may  be  due  to  any  one  of  the 
three  parasites. 

History. — ]\Ialarial  fever  was  recognized  as  a  distinct  disease  as  long  ago  as 
five  hundred  years  before  Christ,  and  Hippocrates  divided  it  into  the  ciuotidian, 
tertian,  and  cpiartan  types  we  recognize  today.  Empedocles  (.")()!)  B.C.)  recognized 
the  relationship  of  the  disease  to  stagnant  water  and  stojjped  an  epidemic  by 
draining  stagnant  pools;  but  it  was  not  until  ISSU  that  La\eran,  a  French  army 
surgeon,  first  recognized  the  specific  organism,  and  in  ISSti  Marchiafava  and  Celli 
described  it  more  fully.  In  the  same  year  Golgi  showed  that  the  malarial  attack 
occurred  simultaneously  with  the  sporulation  of  the  parasite,  but  not  until  1898 
did  IManson  and  Ross,  of  England,  and  Grassi  and  Bignami,  of  Italy,  prove  that 
the  infection  is  sjjread  from  man  to  man  by  a  certain  species  of  mosquito  known  as 


MALARIAL  INFECTION  317 

the  Anopheles.  In  the  United  States  excellent  work  has  been  done  by  a  number 
of  investigators,  of  whom  the  most  noteworthy  are  Osier,  Thayer,  and  Ilewetson 
in  Baltimore,  James  in  New  York,  Craig  of  the  United  States  Army,  and  Dock  in 
Texas. 

Distribution. — Malarial  infection  is  more  widely  diffused  throughout  the  tropical 
and  temperate  zones  than  any  other  disease.  It  is,  as  a  rule,  prevalent  and  severe 
in  direct  proportion  to  the  proximity  to  the  equator  and  is  rare  in  far  northern 
latitudes.  Certain  parts  of  the  world,  which  at  one  time  suiTered  severely  from 
the  disease,  are  now  free  from  it.  Forty  or  fifty  years  ago,  for  example,  the  valleys 
of  the  Delaware  and  Schuylkill  Rivers  near  Philadelphia  suffered  greatly,  whereas 
at  present  cases  of  the  disease  are  rarely  met  with  in  these  localities.  On  the  other 
hand,  it  is  very  prevalent  on  the  shores  of  the  Chesapeake  Bay,  which  is  not  more 
than  one  hundred  miles  away.  At  present  the  disease  appears  in  its  mild  forms 
in  France,  Germany,  and  England,  and  in  the  Middle  Atlantic  and  Central  United 
States,  and  in  its  severe  forms  in  the  Southern  States,  particularly  in  certain  lower 
portions  of  the  Mississippi  Valley.  The  virulent  forms  are  chiefly  met  with  in 
Africa,  in  certain  parts  of  India,  and  in  the  tropics,  as  in  the  West  Indies  and  in  the 
Philippines,  and  in  the  tropical  parts  of  South  America.  On  the  Pacific  coast 
of  the  United  States  the  disease  is  rare.  So  far  as  season  is  concerned,  it  may  be 
said  that  the  greater  proportion  of  cases  occur  in  July,  August,  September,  October, 
and  November  in  semitropical  or  temperate  regions. 

The  frequency  of  malarial  fever  varies  greatly  and  depends  entirely  upon  the 
prevalence  of  the  AnoplieJes,  the  sources  for  its  infection,  and  the  climate  which 
permits  of  the  growth  of  the  mosquito.  In  the  United  States  the  greatest  prevalence 
of  this  disease  is  in  the  States  bordering  the  Gulf  of  Mexico  and  that  tier  lying 
immediately  north  of  them.  The  death  rate  from  malaria  in  this  area  is  about 
30  per  1000  deaths  from  known  causes. 

Etiology. — The  Mosquito. — There  is  but  one  direct  etiological  factor  in  the 
dissemination  of  malarial  fever  in  man,  namely,  that  form  of  mosquito  known  as 
Anopheles.  Many  species  of  the  genus  Anopheles  have  been  described,  but  only 
two  have  so  far  been  found  to  be  present  as  malaria-bearing  hosts  in  the  United 
States,  namely,  the  Anopheles  maculipennis,  which  is  the  most  common,  and  the 
Anopheles  crucians.  In  Europe  the  infection  is  always  borne  by  the  Anopheles 
clamger,  sometimes  called  Anopheles  maculipennis.  Fortunately,  the  anopheles  is 
not  universally  distributed,  the  culex  being  the  genus  which  is  most  commonly  met 
with,  at  least  in  the  temperate  zones,  and  this  mosquito  seems  to  be  incapable 
of  carrying  the  infection.  The  anopheles  can  be  readily  differentiated  from  the 
culex  by  the  fact  that  when  it  rests  upon  a  plane  surface  its  body  is  held  at  right 
angles,  or  at  an  angle  of  forty-five  degrees,  whereas  the  body  of  the  culex  lies  parallel 
to  the  plane.  Again,  the  wings  of  the  anopheles  show  very  distinct  mottling,  as 
its  names  punctipennis  or  maculipennis  indicate.  Most  of  the  culex  species  lay 
their  eggs  in  rafts  or  bottle-shaped  masses,  which  remain  intact  until  the  larvae  are 
discharged.  The  eggs  of  the  anopheles  are  laid  in  groups  that  are  readily  broken 
up  and  scattered.  Any  stagnant  or  semistagnant  accumulation  of  water  is  a 
suitable  breeding-ground. 

The  indirect  factors  in  the  causation  of  malarial  infection  are,  therefore,  stagnant 
or  semistagnant  water  in  which  this  mosquito  can  breed,  and  the  presence  of  a 
source  from  which  it  can  obtain  the  parasite  so  that  it  can  transmit  it  to  a  healthy 
individual;  for  even  if  the  Anopheles  be  present,  it  cannot  inoculate  a  human  being 
with  malarial  fever  unless  it  has  first  bitten  a  person  whose  blood  contains  the 
hemameba.  No  more  interesting  experiments  proving  these  facts  can  be  adduced 
than  those  made  by  Patrick  Manson  on  his  son,  who  had  never  had  malarial  infec- 
tion. Bignami  and  Bastianelli  sent  Manson  in  England  relays  of  mosquitoes  which 
in  Italy  had  been  fed  upon  the  blood  of  patients  suft'ering  from  pure  benign  tertian 


318  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

malaria.  These  mosquitoes  were  allowed  to  bite  the  younger  Manson,  and  as  a 
result  he  developed  the  same  form  of  malarial  fever  as  that  suffered  by  tiie  Italian 
patients,  and  the  same  parasite  was  found  in  his  blood. 

TiiK  Hemameba  Malarle  in  Man. — The  parasite  itself  passes  through  two 
cyeles  of  existence,  namely,  one  which  is  carried  out  in  the  body  of  man,  and  another 
in  the  body  of  the  mosquito.  It  appears  in  three  distinct  forms,  namely,  as  the 
tertian  parasite,  the  quartan  parasite,  and  the  estivo-autumnal  parasite.  Each 
of  these  lives  in  the  red  cells  of  the  blood  and  to  some  extent  exists  in  the  plasma 
as  well. 

Marchiafava,  Celli,  Bighami,  and  Grassi,  of  Italy,  have  endeavored  to  show 
that  several  species  of  the  estivo-autumnal  parasite  exist,  but  their  views  have 
not  been  generally  accepted,  and  recently  they  have  admitted  that  there  are  not 
sufficient  grounds  for  advocating  this  proposition.  Craig  believes  there  is  one 
distinct  separable  type — the  quotidian. 

In  certain  cases  the  patient  suffers  from  a  mixed  infection  in  which  the  tertian 
and  estivo-autumnal  parasite  are  both  present  at  the  same  time. 

The  young  tertian  parasite,  Pla.vnodiuvi  vivax,  is  a  small  colorless  and  hyaline 
body  which  occupies  a  small  space  in  the  corpuscle.  When  in  a  state  of  cjuiescence 
it  is  round,  but  if  the  specimen  under  the  microscope  is  fresh  and  the  temperature 
suitable  it  manifests  active  ameboid  movements.  As  the  parasite  grows,  reddish- 
brown  granules  develop  in  its  interior.  These  pigment  granules  move  rapidly, 
and  are  often  seen  in  the  ameboid  projections  of  the  parasite,  so  that  it  may  appear 
that  several  parasites  are  in  one  corpuscle.  As  the  growth  continues  the  infected 
red  cell  becomes  more  and  more  pallid  and  swells  up  or  expands,  the  ameboid 
movements  of  the  contained  parasite  diminish  in  activity,  and  the  pigment  granules 
arrange  themselves  about  the  periphery  of  the  parasite.  At  this  time  the  corpuscle 
is  nothing  more  than  a  shell  of  its  former  self.  Later  the  pigment  granules  accumu- 
late near  the  centre  of  the  body,  and  as  they  do  so  the  process  of  segmentation 
begins;  radial  lines  divide  the  parasite  into  twelve  to  twenty  segments  arranged 
around  the  central  mass  of  pigment.  Each  segment  has  a  nucleus,  and  as  soon 
as  the  process  of  segmentation  is  completed  these  segments  break  out  of  the  corpus- 
cular shell  and  float  freely  in  the  blood  plasma,  where  they  speedily  attack  and 
enter  fresh  red  cells.  The  evolution  and  segmentation  require  about  forty-eight 
hours,  and  the  chill  and  other  acute  manifestations  of  illness  in  the  patient  develop 
at  the  time  of  segmentation.  In  some  instances  the  parasite  becomes  unusually 
large,  the  pigment  bodies  become  stationary  without  aggregation  in  the  centre, 
vacuoles  develop  in  it,  and  the  parasite  seems  to  die.  Some  of  the  parasites  do 
not  undergo  segmentation.  These  are  the  sexually  differentiated  forms  (gameto- 
cytes)  and  contain  actively  moving  (dancing)  pigment  granules.     (See  Plate  V.) 

The  following  distinctions  serve  to  separate  the  tertian  from  the  estivo-autumnal 
parasite:  The  nuclear  body  and  chromatin  mass  of  the  young  tertian  parasite  are 
achromatic  to  methylene  blue,  whereas  the  nucleus  of  the  estivo-autumnal  parasite 
is  densely  stained  by  this  agent  (Ewing).  The  tertian  ring  is  coarse  and  granular, 
whereas  the  estivo-autumnal  ring  is  a  perfect  circle  and  more  delicate.  The  tertian 
ring  is  usually  pigmented  before  the  chromatin  becomes  subdivided,  while  in  the 
estivo-autumnal  parasite  the  chromatin  is  subdivided  before  pigmentation  appears. 
There  are,  however,  exceptions  to  this  rule.  Lastly,  the  infected  red  blood  cor- 
puscle is  usually  distended  or  swollen  as  soon  as  it  is  attacked  by  the  tertian  parasite, 
whereas  it  is  shrunken  in  appearance  when  the  cstiA'o-autiminal  parasite  enters  it. 

The  quartan  •parasite,  PJasmodimn  malaria — that  is,  the  organism  that  causes 
an  attack  every  third  day — resembles  the  tertian  organism  just  described,  but 
differs  from  it  in  the  following  respects:  In  the  early  stages  it  occurs  as  a  hyaline 
body  which  is  smaller  than  the  tertian  parasite.  It  speedily  develops  a  sharper 
outline,  it  is  more  refracti\'e,  and  the  ameboid  movements  are  slower.     The  pigment 


DESCRIPTION  OF  I'LATES  V  AND  \I.' 

The  drawings  were  made  with  great  care  and  skill  by  Mr.  Max  Broedel,  with  the 
assistance  of  the  camera  lucida,  from  specimens  of  fresh  blood.  A  Winkel  microscope, 
objective  1-14  (oil-immersion),  ocular  4,  was  used. 

Figs.  4,  13,  23,  24,  and  42  of  Plate  V  were  di-awn  from  fresh  blood,  without  the  camera 
lucida. 

PLATE   \. 

The  Parasite  of  Tertian  Fever. 

1. — Normal  red  corpuscle. 

2,  3,  4. — Young  hyahne  forms.    In  4  a  corpuscle  contains  three  distinct  parasites. 

5,  21. — Beginning  of  pigmentation.  The  parasite  was  observed  to  form  a  true  ring 
by  the  confluence  of  two  pseudopodia.  During  observation  the  body  burst  from  the  cor- 
puscle, which  became  decolorized  and  disappeared  from  view.  The  parasite  became, 
almost  immediately,  deformed  and  motionless,  as  shown  in  Fig.  21. 

6,  7,  8. — Partly  developed  pigmented  forms. 
9. — Full-grown  body. 

10-14. — Segmenting  bodies. 

15. — Degenerative  form  simulating  a  segmenting  bod}'. 

16,  17. — Precocious  segmentation. 

18,  19,  20. — Large  swollen  and  fragmenting  extracellular  bodies. 

22.— Flagellate  body. 

23,  24. — Degenerative  forms  showing  vacuolation. 

The  Para.site  of  Quartan  Feveb.- 

25. — Normal  red  corpuscle. 
26. — Young  hyaline  forn). 

27-34. — Gradual  development  of  the  intracorpuscular  bodies. 

35. — Full-grown  body.  The  substance  of  the  I'ed  corpuscle  is  not  visible  in  the  fresli 
specimen. 

36-39. — Segmenting  bodies. 

40. — Large  swollen  extracellular  form. 

41. — Flagellate  body. 

42. — Degenerative  form  showing  vacuolation. 

PLATE  VI. 

The  Parasite  of  Estivo-autumnal  Fever  (Plasmodivm  falciparum). 

1,  2. — Small  refractive  ring-Uke  bodies. 

3-6. — Larger  disk-like  and  ameboid  forms. 

7. — Ring-like  body  with  a  few  pigment  granules  in  a  brassy,  shrunken  corpuscle. 

8,  9,  10,  12. — Similar  pigmented  bodies. 

11. — Ameboid  body  with  pigment. 

13. — Body  with  a  central  clump  of  pigment  in  a  corpuscle  showing  a  retraction  of  the 
hemoglobin-containing  substance  about  the  parasite. 

14-20. — Bodies  with  central  pigment  clumps  or  blocks.    Presegmenting  forms. 

21-24. — Larger  bodies  with  central  pigment  blocks.  Presegmenting  bodies.  Seen  in 
the  peripheral  circulation  during  a  severe  paroxysm. 

25-28. — Segmenting  bodies  from  the  spleen.  Figs.  25-27  represent  one  body  where 
the  entire  process  of  segmentation  was  observed.  The  segments,  eighteen  in  number,  were 
accurately  counted  before  separation,  as  in  Fig.  27.  The  sudden  separation  of  the  seg- 
ments, occurring  as  though  some  retaining  membrane  were  ruptured,  was  observed. 

29-37. — Crescents  and  ovoid  bodies.  Figs.  34  and  35  represent  one  body  which  was 
seen  to  extrude  slowly,  and  later  to  withdraw,  two  rounded  protrusions. 

38,  39.— Round  bodies. 

40. — Pseudogemmation,  fragmentation . 

41. — Vacuolation  of  a  crescent. 
.   42-44. — Flagellation.     The  figures  represent   one  organism.     The  blood  was  taken 
from  the  ear  at  4.15  p.m.;    at  4.17  the  body  was  as  represented  in  Fig.  42.      At  4.27  the 
flagella  appeared ;  at  4.33  two  of  the  flagella  had  already  broken  away  from  the  mother  body. 

45-49. — Phagocytosis.    Traced  with  the  camera  lucida. 

1  These  plates  are  taken  by  permission  from  Thayer  and  Hewetson's  classical  report 
in  the  .Johns  Hopkins  Hospital  Reports,  1895,  vol.  v.  Four  figures— viz..  Figs.  21,  22,  23, 
and  24 — have  been  added  to  Plate  VI,  and  are  also  from  the  drawings  of  Mr.  Max  Broedel. 

-  The  color  of  the  pigment  in  these  figures  of  the  quartan  parasite  has  too  much  of  a 
reddish  tint. 


The  Parasite  of  Tertian  Pe 


m  m  & 


-\ 

'■- 

# 

% 


a't^':^ 


^■.'SJ-'- 


9       ^      ^ 


'if  ]  {   &  ■> 


'^-  "<"> 


■.','  *f 


The  Parasite  of  Aestivo-Aufunmal  fever. 


'(^:^ 


*f 


o       o 


%lf 


MALARIAL  INFECTION  319 

granules  are  larger  and  darker,  less  active,  and  lie  near  the  edge  of  the  parasite. 
Again,  it  is  noteworthy  that  the  red  cell  does  not  swell  as  do  those  containing  the 
tertian  parasite,  but  grows  smaller,  darker,  more  refractive  and  metallic  looking. 
The  quartan  parasite  reaches  its  growth  in  from  sixty-four  to  seventy-two  hours, 
and  then  appears  as  occupying  nearly  the  entire  red  blood  cell,  or  it  seems  to  float 
free  in  the  blood  serum.  As  the  time  for  the  paroxysm  approaches  the  pigment 
granules  at  the  periphery  flow  toward  the  centre  in  radial  lines,  so  that  it  becomes 
arranged  in  stellate  form  and  the  protoplasm  divides  into  from  sbc  to  twelve  pear- 
shaped  segments,  each  of  which  has  a  refractive  centre.  These  segments  escape 
and  infect  new  cells.  Some  of  the  parasites  do  not,  however,  go  on  to  this  develop- 
ment, but  fail  to  sporulate  and  become  sexual  bodies  or  gametocytes. 

The  third  form  of  parasite,  the  estivo-autumnal  form,  Plasmodium  falciparum,  is 
smaller  than  the  tertian  and  quartan  organisms,  and  presents  a  ringed  appearance. 
It  contains  much  less  pigment  and,  moreover,  it  soon  causes  the  corpuscle  into 
which  it  enters  to  become  shrivelled  and  brassy  looking.  After  a  time,  possibly 
a  week,  the  parasite  increases  in  size,  becomes  refractive,  crescentic,  or  round, 
or  ovoid  in  form,  and,  in  the  centre,  masses  of  dark  pigment  acciunulate.  It  is 
these  latter  bodies  which  are  indicative  of  infection  by  the  estivo-autumnal  type, 
and  it  is  to  be  remembered  that,  as  a  rule,  they  are  not  constantly  present  in  the 
peripheral  circulation,  but  only  in  the  blood  of  such  internal  organs  as  the  liver, 
spleen,  and  in  the  bone-marrow.  Because  of  their  small  size,  slow  development, 
and  the  difficulty  of  obtaining  blood  from  deeply  situated  organs,  they  are  less 
readily  discovered  than  the  two  other  types.  It  appears  established  that  the 
crescentic  and  ovoid  bodies  do  not  undergo  segmentation  or  sporulation,  but  corre- 
spond to  the  sexual  bodies  described  above,  the  gametocjles.  These  crescentic 
and  ovoid  bodies  do  not  continue  their  development  in  the  hiunan  being,  sporulation 
being  the  human  cycle.  The  fertilization  of  the  female  by  the  male  body  occurs 
in  the  extracorporeal  or  intermediate  cycle.     (See  Plate  ^T.) 

The  three  forms  of  malarial  parasite  as  they  appear  in  man  have  now  been 
described.     The  mosquito  cycle  of  its  existence  is  as  follows: 

The  Hemameba  Malaria  in  the  Mosquito. — A  mosquito  of  the  genus  Ano- 
pheles, when  it  sucks  blood  from  an  individual  in  whom  the  parasite  has  developed 
sexual  forms,  receives  into  its  stomach  bodies  ready  for  the  sexual  process;  in  other 
words,  gametocytes.  The  male  bodies,  or  microgametocj'tes,  develop  long,  actively 
moving  flagella,  called  microgametes,  which  break  loose  from  the  organism  and 
penetrate  and  fertilize  the  larger  female  bodies  or  macrogametes,  these  bodies 
being  simple  macrogametocytes  which  have  extruded  from  their  nuclear  substances. 
The  impregnated  female  now  penetrates  the  wall  of  the  mosquito's  stomach,  within 
which  further  development  occurs.  Within  forty-eight  hours  there  may  be  seen 
encapsulated  in  the  muscular  wall  of  the  mosquito's  stomach  small,  round,  refrac- 
tive, and  granular  bodies  which  have  in  them  pigment  granules  much  like  those 
present  in  the  parasite  existing  in  the  red  blood  corpuscles.  At  the  end  of  a  week 
the  parasite  has  grown  considerably,  and  it  is  found  to  be  marked  by  radial  striations 
forming  sporoblasts.  When  this  stage  is  completed  the  mother  body,  sometimes 
called  the  oocyst,  bursts,  and  so  sets  free  in  the  celomic  cavity  of  the  mosquito  a 
multitude  of  sporozoids.  These  sporozoids  gain  access  to  the  veneno-salivary 
glands  of  the  mosquito,  and  thence  to  the  veneno-salivary  ducts,  from  which  they 
are  ejected  into  the  human  being  bitten  by  that  mosquito.  No  sooner  are  the 
sporozoids  deposited  in  the  blood  of  man  than  they  speedily  become  parasites 
which  attack  blood  cells. 

Blood  cells  are  therefore  attacked  in  two  ways :  by  parasites  formed  during  the 
asexual  or  human  cycle,  and  by  parasites  produced  in  the  sexual  or  mosquito  cycle. 

Prevention. — The  prevention  of  malarial  fever  consists  in  (a)  protection  from 
the  bites  of  the  anopheles  by  the  use  of  mosquito  bars,  particularly  at  night;  (b)  in 


320  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

the  removal  of  all  marshes  by  filling  them  in  or  draining  them  so  that  the  breeding- 
place  of  the  mosquito  is  destroyed ;  (c)  in  the  destruction  of  tlic  larvie  of  tlie  mosquito 
by  diffusing  coal-oil  over  the  surface  of  pools  or  ponds,  and  (d)  by  not  permitting  a 
patient  who  has  the  parasite  in  his  blood  to  mingle  witli  his  fellows  wlien  the 
anopheles  are  present,  for  from  him  tlu\y  derive  their  supply  of  infection.  The 
latter  measure  can  often  only  be  carried  out  in  private  houses  and  barracks.  Such 
patients  should  always  sleep  under  a  mosquito-proof  canopy.  Finally,  it  is 
well  recognized  that  by  the  use  of  small  doses  of  ciuinine  taken  daily  (.5  grains)  it 
is  often  possible  to  prevent  infection.  (See  Latent  INIalarial  Infection  at  end  of 
this  article.) 

Pathology  and  Morbid  Anatomy. — The  changes  produccil  in  the  l)ody  by  the 
presence  of  the  malarial  parasite  are  much  less  pronounced  if  the  tertian  or  c(uartan 
parasite  is  present  than  if  the  estivo-autumnal  is  the  offending  body.  Indeed, 
in  many  cases  the  morbid  changes  are  so  slight  that  they  are  sijeedily  overcome 
by  the  natural  processes  of  repair,  and  hence  rarely  cause  death.  For  this  reason 
our  knowledge  of  the  acute  changes  produced  in  internal  organs  is  very  limited. 
These  changes  may,  however,  for  the  sake  of  study,  be  divided  into  two  forms,  the 
acute  and  chronic.  In  the  acute  type  the  parts  of  the  body  which  suffer  chiefly  are 
the  blood,  the  liver,  the  spleen,  the  kidneys,  and  the  alimentary  canal. 

The  changes  in  the  blood  consist  in  a  distinct  decrease  in  the  number  of  red  cells 
which  are  destroyed  primarily  by  the  growth  of  the  parasites,  and  possibly  second- 
arily by  poisons  produced  by  them.  That  some  such  agent  is  active  seems  to  be 
proved  by  the  granular  degeneration  of  the  red  cells  which  is  present  in  severe 
cases,  and  in  the  polychromatophilia  which  is  met  with  in  cells  into  which  the 
parasite  has  not  entered.  There  is  also  a  diminution  in  the  color-index;  that  is, 
of  the  individual  richness  of  the  cells  in  hemoglobin.  The  white  blood  cells  are 
usually  increased  in  the  proportion  of  mononuclear  leukocytes.  Pigmented  leuko- 
cytes are  also  found,  and,  if  the  infection  has  been  severe,  large  white  cells  (macro- 
phages) are  to  be  seen  heavily  loaded  with  pigment.  In  some  instances  particles 
of  pigment  are  seen  floating  in  the  blood  serum,  having  been  set  free  from  red  blood 
cells  destroyed  by  the  parasite. 

The  liver,  besides  showing  great  congestion,  may  present  areas  of  necrosis  and 
the  capillaries  may  be  found  filled  with  a  multitude  of  the  parasites  in  all  degrees 
of  growth.     The  capillaries  of  the  liver  may  also  contain  many  pigment  particles. 

The  kidneys  are  enlarged  and  congested.  They  may  contain  dotlets  of  deposited 
pigment,  and  their  capillaries  may  be  filled  by  leukocytes  laden  with  pigment. 
The  number  of  parasites  found  in  the  renal  vessels,  however,  as  compared  to  those 
found  in  the  hepatic  masses,  is  small.  Rarely  an  acute  diffuse  nephritis  may  be 
manifest. 

The  spleen  is  swollen,  soft,  and  its  pulp  is  very  dark.  ]\Iany  of  the  red  blood 
cells  which  it  contains  are  inhabited  by  the  parasites,  and  these  are  often  in  the 
stage  of  sporulation.  So  intense  may  be  the  swelling  and  congestion  of  the  spleen 
tjiat  it  may  be  ruptured  by  sudden  stress. 

The  mucous  membrane  of  the  stomach  and  bowels  is  engorged  and  its  capillaries 
often  contain  the  plasmodium. 

If  the  bone-marrow  is  examined  it  is  found  to  be  filled  with  segmenting  parasites 
and  with  pigment.  The  cresccntic  parasites  are  also  apt  to  be  numerous  in  these 
areas. 

The  chronic  changes  consist  in  profound  anemia,  manifested  by  a  diminution 
in  red  cells  and  in  hemoglobin  and  by  the  presence  of  nucleated  red  cells.  The 
liver  is  deeply  pigmented,  often  slaty  in  color,  the  granules  being  deposited  in  the 
endothelial  lining  of  the  capillaries  and  the  so-called  cells  of  Kupft'er,  that  is,  the 
perivascular  cells.  The  hepatic  epithelium  is  commonly  granular  and  a  certain 
degree  of  hepatic  cirrhosis  may  also  be  present. 


M.\LM!I.\L  I.SFIiCTION  '■'>2\ 

The  spleen  also  becomes  markedly  increased  in  size,  slate  colored  from  the  con- 
tained pigment  and  later,  due  to  increase  in  fibrous  tissues  it  becomes  very  firm, 
the  "ague  cake." 

The  kidneys  are  also  markedly  pigmented,  and  may  suffer  from  clironic  ililluse 
nephritis.  In  certain  cases  of  the  cerebral  type  the  parasites  may  be  found  in  the 
vessels  of  the  brain  and  a  malarial  neuritis  has  been  described.  As  in  the  acute 
form,  the  bone-marrow  is  deeply  pigmented  and  the  normal  marrow  may  be  replaced 
by  red  marrow  in  which  normoblasts  and  megaloblasts  are  present  in  the  majority 
of  cases.     All  these  changes  are  the  result  of  estivo-autumnal  infection. 

Symptoms. — The  symptoms  of  malarial  infection  may  be  divided  into  two  classes : 
those  due  to  the  tertian  or  quartan  parasites,  which  are  much  alike,  and  those  due 
to  the  estivo-autumnal  parasites,  which  are  very  different  from  those  produced  by 
the  more  benign  forms. 

The  Symptoms  of  Tertian  and  Quartan  Infection.  —  The  predominant 
symptoms  of  infection  by  these  parasites  are  the  development  at  regular  intervals 
of  a  chill  followed  by  a  fever,  and  this  in  turn  by  a  siveai. 

The  stage  of  onset  begins  with  a  feeling  of  malaise,  in  which  headache  and  a  general 
sensation  of  im-etchedness  are  present.  Patients  who  have  had  previous  attacks 
are  often  able  to  recognize  the  fact  that  they  will  ha^•e  a  paroxysm  in  a  few  hours. 

After  the  lapse  of  from  one  to  five  hours  the  chill  develops  and  is  often  in  the 
form  of  a  severe  rigor,  in  which  the  teeth  actually  chatter  and  the  patient  is  entirely 
unable  to  control  his  muscular  quivering.  At  this  time  the  skin  is  cold,  the  face 
is  pinched  and  often  anxious  in  expression;  but  while  the  patient  complains  of 
being  cold  and  presents  all  the  external  signs  of  a  lowering  of  body  temperature, 
his  actual  internal  temperature  is  raised  so  that  fever  is  really  well  developed  while 
the  so-called  cold  stage  is  still  manifest.  Thus,  it  is  not  uncommon  for  the  rectal 
temperature  to  be  as  high  as  105°  while  the  patient  is  shivering  and  trying  to  "get 
warm."  Associated  with  this  part  of  the  paroxysm  the  patient  is  usually  nauseated 
and  may  actually  vomit,  so  that  to  the  depression  of  the  chill  is  added  the  relaxation 
and  semicollapse  of  excessive  nausea.  Headache  of  the  congestive  type  is  also 
severe.  The  urine  is  copious  in  quantity  and  light  in  color,  and  the  pulse  small, 
rapid,  and  of  high  tension. 

This  stage  of  chill  lasts  from  a  few  minutes  to  an  hour  or  more,  and  is  followed 
by  the  true  febrile  stage,  in  which  the  surface  of  the  body  becomes  flushed  and  hot. 
In  place  of  the  cold,  pinched  expression  the  face  now  appears  hot  and  flushed,  the 
eyes  may  be  brightened  by  the  fever,  and  the  pulse,  which  has  hitherto  been  small 
and  tense,  becomes  full  and  bounding.  Headache,  however,  still  persists,  and 
active  delirium  may  develop,  but  the  actual  temperature  of  the  patient  is  rarely 
higher  than  during  the  stage  of  chill;  indeed,  it  may  be  a  little  lower.  The  so-called 
febrile  stage  is  not  therefore  any  more  febrile  than  the  stage  of  apparent  coldness, 
but  the  intense  sensation  of  heat  in  the  skin  at  this  time  when  the  physician  touches 
the  patient  is  noteworthy.  This  stage  lasts  from  thirty  minutes  to  several  hours 
and  comes  to  an  abrupt  ending  by  the  development  of  the  stage  of  sweat,  in  which 
the  temperature  drops  to  normal;  the  surface  of  the  patient  becomes  bedewed  with 
sweat,  which  may  be  so  profuse  that  it  is  truly  a  " dripping  sweat."  The  headache 
and  general  wretchedness  now  disappear  and  the  patient  drops  to  sleep  exhausted 
by  the  violence  of  his  attack,  but  otherwise  not  ill. 

The  accompanying  charts  (Figs.  61  and  62)  show  the  typical  temperature 
changes. 

As  in  all  diseases,  so  in  this  one,  it  must  be  recalled  that  all  cases  do  not  go  through 
these  stages  in  exactly  the  same  manner.  Some  individuals  suffer  from  a  very 
moderate  chill  and  an  equally  moderate  fever  and  sweat.  Some  suffer  the  paroxysm 
for  twelve  hours  and  some  for  a  much  shorter  space  of  time. 

There  are  three  important  physical  signs  which  may  be  demonstrable  in  many 
21 


322 


DISIjJASI'JS  due   to  a   SI'KCIFIC  IXFKCTIOX 


if  not  all  these  cases.  The  spleen  is  found  on  palpation  and  percussion  to  be  dis- 
tinctly enlarged,  extending  below  the  level  of  the  ribs;  some  hronchial  rales  are 
usually  to  be  heard  in  the  chest,  and  the  lips  are  apt  to  be  affected  by  herpes  at  the 
close  or  after  an  attack. 

Fio.  61 


Chart  showing  daily  paroxysm  due  to  double  tertian  infection.    One  set  of  parasites  segmented 
at  8  P.M.  and  the  second  set  at  4  p.m.    Paroxysm  stopped  by  quinine  on  fourth  day. 


Chart  showing  paroxysms  of  tertian  fever,  the  segmentation  of  the  organism  occurring  at 
about  12  o'clock  every  other  day. 


The  severity  of  all  the  signs  depends,  of  course,  upon  the  resistance  of  the  patient 
and  the  virulence  of  the  malarial  infection. 

There  yet  remains  to  be  considered  the  periodicity  of  these  attacks.  They 
may  occur  daily,  in  which  case  they  are  called  quotidian;  or  every  other  day,  when 
they  are  called  tertian;  or  every  third  day,  when  they  are  called  quartan.  The 
tertian  type  is  due  to  the  tertian  parasite,  which  sporulates  every  forty-eight  hours, 
so  that  the  next  paroxysm  develops  at  the  beginning  of  the  third  day;  hence  the 
term  tertian,  or  third.  When  the  attack  occurs  daily  it  is  due  to  the  fact  that  a 
double  infection  of  the  tertian  parasite  has  taken  place,  so  that  a  different  set  of 
organisms  mature  each  day;  in  other  words,  it  is  a  "double  tertian  infection." 
This  form  is  more  frequently  seen  in  the  United  States  than  any  other  type.  When 
the  attack  occurs  at  the  end  of  every  third  day — that  is,  after  the  lapse  of  seventy- 
two  hours,  which  is  really  therefore  on  the  beginning  of  the  fourth  day  of  actual 
time — it  is  due  to  the  quartan  parasite.  Sometimes,  however,  the  infection  with 
this  parasite  is  a  double  one,  the  sporulation  in  each  infection  taking  place  sepa- 
rately, in  which  case  the  attacks  occur  in  two  successive  days  with  a  free  day  follow- 
ing. In  still  other  cases  a  triple  quartan  infection  may  cause  a  daily  or  quotidian 
manifestation  of  the  disease.  A  daily  malarial  attack  may  therefore  be  due  to  a 
double  tertian  or  a  triple  quartan  infection. 


MALARIAL  INFECTION  323 

On  the  days  free  from  paroxysm  the  patient  is  entirely  free  from  ciiiils,  fever, 
or  sweats,  and  except  for  some  impairment  of  strength  may  be  almost  as  well  as 
ever.     It  is  for  this  reason  that  the  disease  is  called  "intermittent  fever." 

Diagnosis  of  Intermittent  Fever. — The  diagnosis  of  this  type  of  malarial  fe\-er 
is  easy  in  the  majority  of  cases,  but  the  physician  should  not  hurry  to  this  conclusion 
until  he  has  carefully  excluded  several  other  states  that  cause  a  similar  temperature 
curve.  These  states  are  tuberculosis  of  the  lungs  with  chills,  fever,  and  sweats; 
septicemia  and  ulcerative  endocarditis  with  the  same  train  of  symptoms,  and 
typhoid  fever  with  chills  of  a  sharp,  distinct  character.  The  number  of  poor 
human  beings  who  are  dosed  ad  nauseam  with  quinine  for  malaria  when  they  ha\-e 
tuberculosis  is  appalling.  The  history  of  the  case,  the  physical  signs  in  the  lungs, 
and  the  fact  that  the  attacks  of  chills  and  fever  do  not  cease  if  quinine  is  given, 
prove  that  malaria  is  not  the  cause  of  the  illness.  Careful  examination  of  the 
patient  ought  to  discover  sepsis  by  the  finding  of  a  definite  focus  of  pus,  and  in 
many  cases  ulcerative  endocarditis  can  be  discovered  by  the  changes  in  the  heart 
sounds.  TjTphoid  fever  can  be  discovered  by  the  state  of  the  tongue,  that  of  the 
bowels,  the  rose  rash,  and  the  Widal  test  of  the  blood.  Better  than  all  for  an 
absolute  diagnosis  is  the  discovery  of  the  malarial  parasite  in  the  blood  by  the  use 
of  the  microscope.  Unfortunately,  this  is  only  possible  to  the  expert.  (For 
examination  of  the  blood  for  the  parasite  see  Pathology.) 

Prognosis  of  Intermittent  Fever. — Intermittent  malarial  fe^'er  cannot  be  considered 
a  self-limited  disease.  It  is  true  that  individuals  affected  by  it  recover  without 
medication  if  they  are  otherwise  healthy  and  have  favorable  surroundings,  but  it 
is  notorious  that  they  are  very  liable  to  subsequent  outbreaks  of  the  disease  when 
for  various  reasons  their  vital  resistance  is  impaired  or  the  system  is  affected  by 
change  of  climate.  Thus  it  is  by  no  means  unusual  for  patients  seemingly  well 
of  the  infection  to  be  attacked  by  paroxysms  on  going  to  a  higher  altitude.  If 
quinine  is  used  with  skill,  and  further  infection  is  avoided,  complete  recovery  usually 
is  reached  if  no  complication  arises. 

Treatment  of  Intermittent  Fever. — In  the  treatment  of  intermittent  malarial  fever 
the  fact  is  always  to  be  borne  in  mind  that  in  quinine  we  have  a  true  specific  for 
the  disease  in  that  this  drug,  even  in  exceedingly  weak  solution,  is  capable  of  causing 
death  of  the  malarial  parasite.  So  complete  is  the  cure  produced  by  the  proper 
administration  of  this  drug  that  no  other  form  of  remedial  measure  can  be  considered 
until  after  it  has  been  given  full  opportunity  to  do  its  work.  But,  on  the  other 
hand,  it  must  not  be  forgotten  that  quinine  cannot  destroy  the  malarial  parasite 
until  it  (the  quinine)  has  entered  the  blood,  that  it  cannot  enter  the  blood  until 
it  is  absorbed,  and  that  it  is  impossible  for  it  to  be  absorbed  if  the  gastroduodenal 
and  hepatic  circulation  is  so  disturbed  that  catarrh  of  the  stomach  and  bowels 
is  present,  making  it  impossible  for  the  quinine  to  be  taken  up  by  the  circulation. 
It  is  therefore  essential,  in  almost  every  case  of  intermittent  fever,  that  the  bowels 
shall  be  thoroughly  unloaded,  preferably  by  full  doses  of  calomel  of  which  not 
less  than  5  nor  usually  more  than  20  grains  are  required,  this  in  turn  being  followed 
by  a  saline  purge.  If,  in  addition  to  these  measures,  it  is  insisted  upon  by  the 
physician  that  the  patient  shall  rest  in  bed  during  the  time  that  the  quinine  is 
being  given,  it  is  surprising  how  comparatively  little  quinine  is  needed  to  destroy 
the  parasites;  whereas,  if  these  precautions  are  not  taken,  enormous  doses  may  be 
given  with  no  curative  effect. 

Quinine  may  be  administered  at  two  periods  in  connection  with  the  paroxysm 
of  intermittent  malarial  fever.  One  method  is  to  administer  the  drug  several 
hours  before  an  expected  paroxysm,  with  the  hope  that  it  may  prevent  sporulation, 
or  at  least  destroy  the  spores  as  soon  as  they  escape.  This  plan  is  always  to  be 
resorted  to  when  the  physician  is  confident  that  an  attack  is  threatened  and  that 
a  sufficient  time  will  elapse  to  make  it  possible  for  the  quinine  to  be  absorbed.    The 


324  DISEASES  DUE  TO  A  SPECIFIC  IXFECTIOX 

other  methorl  consists  in  administering  the  drug  in  the  sweating  stage  of  a  paroxysm, 
for  the  i^urpose  of  destroying  the  young  parasites  which  have  just  escaped  from  the 
red  blood  corpuscles,  in  the  hope  that  they  may  he  destroyed  before  they  can 
attack  new  cells.  It  is  evident,  therefore,  that  neither  of  these  plans  is  contradic- 
tory, but  they  are  to  be  resorted  to  according  to  the  period  at  which  the  i)hysician 
sees  the  i)atient.  It  should  always  be  the  endea\'()r  of  the  physician  to  have  the 
quinine  in  the  blood  an  hour  or  two  l)efore  an  expected  paroxysm,  and  this  means 
that  it  should  be  given  sex'cral  hours  before,  when  taken  by  the  stomach. 

When  the  attack  is  quotidian  quinine  must  be  given  daily,  when  it  is  tertian 
it  must  be  given  every  other  day,  and  when  it  is  quartan  a  full  dose  of  quinine 
should  be  given  on  the  day  of  the  expected  attack  and  smaller  doses  on  the  off 
days.  If  it  is  a  double  quartan  infection  the  quinine  should  be  given  on  the  two 
consecutive  days  and  only  a  small  dose  on  the  third  day. 

The  cjuantity  of  quinine  which  is  required  varies  of  course  with  the  se\'erity 
of  the  infection  and  the  rapidity  of  the  absorption.  Ten  to  15  grains  are  usually 
sufficient  in  the  milder  types,  but  in  the  more  severe  types  30  to  (iO  grains  are  often 
required,  although  a  larger  quantity  is  usually  needless  if  attention  is  given  to 
the  processes  of  absorption.  The  quinine  should  be  given  in  powder  in  soft  ca])sules 
easily  dissolved. 

The  dose  of  quinine  should  be  generous  since  moderate  doses  may  seemingly 
cure  the  patient  by  arresting  sporulation  without  destroying  the  parasite  in  the 
spleen  and  bone-marrow  where  the  parasite  may  become  immune  to  quinine.  (See 
Relapse  and  Latent  Malarial  Infection.) 

There  is  some  evidence  to  prove  that  methylene  blue  has  a  destructix'c  influence 
upon  the  malarial  parasite.     It  may  be  given  in  the  dose  of  1  to  4  grains  in  capsules. 

So  far  as  the  attack  itself  is  concerned,  aside  from  the  use  of  C[uinine,  the  ])hysician 
may  modify  to  some  extent  the  effects  of  the  paroxysm  by  the  use  of  stimulants 
to  sui){)ort  the  circulation,  and  prevent  congestion  by  using  hot  compresses  or  hot 
foot-baths.  If  the  alimentary  canal  is  overloaded  with  food  or  fecal  matter,  the 
stomach  should  be  emptied  by  an  emetic  and  the  intestine  by  a  ]>urge  or  a  large 
enema.  Alcoholic  stimulants,  as  a-  rule,  are  not  advantageous.  If  the  attack 
is  exceedingly  severe,  a  dose  of  morphine  may  be  gi\'en  hypodermically,  or  deodor- 
ized tincture  of  opiiun  may  be  used.  During  the  fe\-er  the  patient  may  be  relieved 
by  a  tepid  sponging,  but  usually  antipyretic  measures  are  entirely  unncessary, 
and  coal-tar  products  ought  never  to  be  employed.  The  vomiting,  if  excessive, 
may  be  controlled  by  hourly  doses  of  1  grain  of  oxalate  of  cerium  with  5  grains  of 
bismuth,  and  by  counter-irritation  over  the  epigastrium. 

The  Symptoms  of  Estivo-autumnal  Infection  or  Remittent  Fever. — From  the  stand- 
point of  sc\crity  and  danger  to  the  in(li\-idual  attacked,  this  type  of  malarial  infec- 
tion is  by  far  the  most  important,  although  it  is  not  as  widely  distributed,  and 
therefore  not  as  commonly  met  with  as  the  tertian  and  quartan  forms,  except  in 
certain  localities  which  are  usually  tropical  or  semitropical.  The  term  "estivo- 
autumnal  fe\er,"  apjjlied  to  it  first  by  the  Italian  investigators,  Marchiafava  and 
Cclli,  indicates  that  it  occurs  most  commonly  in  the  summer  and  fall  months. 

The  symptoms  of  this  type  of  infection  ditt'er  markedly  from  the  intermittent 
ty])e  of  the  disease  in  a  number  of  particulars.  Thus,  it  is  not  characterized  by 
an  intcrmittence  of  the  fever  and  of  the  other  signs  of  illness,  but  instead  is  fypimlli/ 
remittent;  that  is  to  say,  the  fever  and  associated  symptoms  diminish  in  .severity 
at  times,  but  they  do  not  entirely  disappear.  On  the  contrary,  they  persist  in 
some  cases  to  such  a  degree  that  the  amount  of  remission  is  very  slight  indeed. 

As  the  gastro-intesthud dinturhance  due  to  this  infection  is  very  prone  to  be  marked, 
and  as  the  liver  is  usually  much  affected,  this  ty])e  of  the  disease  is  sometimes 
called  "bilious  remittent  fever"  or  "bilious  fever."  Vomitinq,  which  may  be 
very  persistent,  and  which  may  be  markedly  bilious,  is  a  common  symptom. 


MALARIAL  INFECTION  325 

The  remissions  just  spoken  of  may  occur  regularly,  but  in  the  majority  of  cases 
tliey  are  very  irregular,  both  as  to  the  time  of  tiieir  occurrence  and  to  the  flegree 
of  their  individual  severity.  In  some  instances  the  chilh  and  .iweat.i  are  distinct; 
in  others  they  are  so  ill-defined  as  to  be  scarcely  noticeable.  Further  than  this, 
the  febrile  viovement,  which  is  so  sudden  in  onset  and  which  ends  so  sharply  by 
crisis  in  the  intermittent  form,  is  usually  gradual  in  onset  and  equally  deliberate 
in  its  fall  in  the  remittent  type.  The  temperature  falls  by  lysis,  not  by  crisis,  in 
each  paroxysm.  This  lack  of  sharply  defined  waves  of  temperature  may  deprive 
the  physician  of  one  of  the  most  important  means  of  recognizing  that  the  illness 
is  really  due  to  the  estivo-autumnal  parasite,  and  may  mislead  him  into  the  diag- 
nosis of  typhoid  fever,  to  which  conclusion  he  is  aided  by  the  heavily  coated  tongue, 
the  somewhat  apathetic  face,  tlie  enlarged  spleen,  the  tympanitic  belly,  and  the 
state  of  the  bowels,  which  are  lax  in  some  instances  and  constipated  in  others,  just 
as  they  are  in  tN^jhoid  fever.  As  many  cases  of  typhoid  fe\'er  ha\-e  chills  and  sweats, 
the  confusion  is  all  the  more  readily  made,  particularly  as  a  subacute  bronchitis 
can  often  be  discovered  on  ausculting  the  chest,  just  as  it  can  be  foimd  in  typhoid 
fever. 

The  severity  of  the  symptoms  varies  over  a  wide  range.  In  some  instances  the 
patient  is  only  moderately  ill;  in  other  cases  he  is  manifestly  suffering  from  a  severe 
malady.  Delirium  may  be  marked,  and  the  mental  stupor  may  be  ^'ery  noticeable. 
The  2wi5e  varies  from  90  to  110,  as  it  does  in  typhoid  fe-\'er. 

There  still  remains  to  be  discussed  that  form  of  estivo-autumnal  infection  which 
is  so  violent  in  its  course  that  the  term  "pernicious  malarial  fever  '  has  been  applied 
to  it.  Pernicious  malarial  fever  is  very  rare,  except  in  the  tropics  and  in  a 
few  isolated  places  not  far  removed  from  these  areas.  It  manifests  itself  in 
two  forms. 

(a)  The  comaiose  form.,  in  which  a  patient  is  seized  with  symptoms  resembling 
intense  cerebral  congestion  or  apoplexy,  or  develops  acute  delirium  followed  by  semi- 
consciousness or  coma.  The  fever  is  usually  very  high  and  the  skin  intensely 
hot.  The  patient  may  die  in  twenty-four  hours  without  regaining  consciousness, 
but  if  he  survi^-e  so  long  a  remission  in  the  s\Tnptoms  sometimes  appears  and 
recoA'ery  takes  place;  or,  instead,  a  second  parox^'sm  comes  on  in  which  death  is 
likely  to  occur.  These  cerebral  symptoms  are  due  in  part  to  the  profound  systemic 
disturbance  caused  by  the  infection,  but  chiefly  to  the  formation  of  thrombosis 
of  the  cerebral  vessels  by  a  host  of  the  parasites. 

(b)  The  algid  or  cold  form,  in  which  the  febrile  movement  is  absent  or  very  mild, 
and  in  its  place  signs  of  collapse  and  exhaustion  appear,  with  great  coldness  of  the 
surface  of  the  body  and  a  complaint  of  feeling  cold  on  the  part  of  the  patient.  With 
these  symptoms  of  profound  depression  gastro-ititestinal  disturbances,  which  are 
choleraic  in  type,  may  develop.  There  may  be  violent  vomiting  and  active  serous 
diarrhea,  the  patient  being  at  death's  door  by  reason  of  the  exhaustion.  Here 
again  the  centralization  of  the  symptoms  about  the  intestines  is  due  apparently 
to  the  accumulation  of  vast  numbers  of  the  parasites  in  the  capillaries  of  the  intes- 
tinal mucosa.  These  pernicious  forms  usually  affect  persons  whose  resistance 
has  been  impaired  by  earlier  attacks  of  malarial  infection,  but  occasionally  develop 
in  previously  healthy  persons  with  great  suddenness  as  early  as  one  week  after 
exposure  to  infection.  Children  under  ten  years  are  more  susceptible  than  adults, 
as  are  also  the  aged. 

Complications  and  Sequelee  of  Estivo-autumnal  Infection. — The  most  serious  com- 
plication of  infection  by  the  estivo-autumnal  parasite  is  the  development  of  bloody 
urine,  which  is  of  two  forms,  namely,  a  true  hematuria  with  free  blood  cells  in  the 
urine,  and  a  true  hemoglobinuria  in  which  only  the  coloring  matter  of  the  blood  is 
present.  The  former  is  obviously  the  result  of  a  solution  of  continuity  in  the 
renal  vessels,  and  the  latter  is  equally  obviously  due  to  a  destruction  of  a  large 


326  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

number  of  red  cells  in  the  blood  itself.  This  "  black-water  fever,"  as  it  is  sometimes 
called,  is  practically  unknown  except  where  the  estivo-autumnal  parasite  is  found. 
It  occurs  cliicfly  in  certain  of  the  Southern  United  States  and  in  Africa  and  in 
Greece. 

The  symptoms  associated  with  the  development  of  the  bloody  urine  are  those 
which  are  often  manifested  by  ordinary  cases  of  severe  remittent  malarial  fever. 
If  the  blood  is  examined  before  the  urine  becomes  bloody,  a  large  number  of  estivo- 
autiuunal  parasites  are  usually  found.  On  the  other  hand,  after  the  bloody  urine 
has  appeared,  it  is  commonly  stated  that  an  examination  of  the  blood  does  not 
reveal  the  malarial  organism. 

The  statement  that  quinine  is  capable  of  producing  malarial  hematuria  is 
indorsed  by  so  many  practitioners  of  experience  that  it  cannot  be  ignored,  but 
I  cannot  help  feeling  that  coincidence  has  been  a  large  factor  in  the  development 
of  this  view. 

As  sequelse  of  malarial  fever  very  marked  anemia,  with  chronic  enlargement  of 
the  spleen,  sometimes  called  "ague  cake,"  develops;  the  patient  is  exceedingly  pallid, 
the  abdomen  may  be  distinctly  enlarged  because  of  the  swelling  and  congestion  of 
the  liver  and  spleen,  and  there  may  be  some  swelling  about  the  ankles.  There  is 
dyspnea  on  exertion.  Hemorrhages  in  the  retina  may  occur.  Fever  is  usually 
not  marked,  unless  there  be  attacks  of  malarial  infection  superimposed  upon  the 
chronic  state. 

It  is  quite  remarkable  that  in  young  children,  who  suffer  from  severe  malarial 
anemia  and  cachexia  with  associated  enlargement  of  the  spleen,  recovery  will  take 
place  under  the  administration  of  suitable  tonic  doses  of  arsenic,  the  avoidance 
of  fresh  malarial  infection,  and  resort  to  a  bracing  climate.  Even  the  spleen,  which 
seems  so  hard  and  enlarged  that  any  diminution  in  its  size  may  appear  impossible, 
undergoes  an  extraordinary  degree  of  shrinkage,  so  that  in  adult  life  any  evidences 
of  it  having  been  chronically  enlarged  may  have  disappeared.  Similar  improve- 
ment sometimes  takes  place  in  adults,  but  slight  enlargement  of  the  spleen  is  often 
a  persistent  evidence  of  earlier  malarial  infection,  even  after  the  disease  has  been 
apparently  absent  for  years. 

Among  the  rarer  complications  of  malaria  may  be  mentioned  neuritis, 
pleurisy,  ascites,  intestinal  heinorrhage,  splenic  abscess,  and  inflammation  of  the 
lymphatic  glands.  Cases  of  orchitis  have  been  reported  by  French  military 
surgeons,  and  a  rapidly  developing  and  very  painful  form  has  been  observed 
in  Sumatra,  by  Martin,  who  describes  it  as  a  fulminating  inflammation  of  the 
testicles. 

ChoiLX  has  collected  147  cases  of  rupture  of  the  spleen  due  to  malaria.  He 
recognizes  two  forms:  one  which  occiu-s  in  persons  who  have  not  suffered  very 
long  from  malaria,  and  whose  spleens  are  not  greatly  enlarged,  and  one  which 
affects  the  subjects  of  chronic  malaria  whose  spleens  are  enlarged  and  deformed 
by  splenitis.  In  the  later  class  rupture  is  usually  caused  by  traumatism.  Play- 
fair,  during  a  residence  of  two  and  a  half  years  in  East  Indies,  obser\-ed  twenty 
deaths  from  rupture  of  the  spleen. 

Ilemiplcyia,  either  with  or  without  aphasia,  is  the  most  common  of  localized 
cerebral  complications,  raraplegia  is  less  common,  and  monoiilcgia  is  of  still 
rarer  occurrence.  Amaurosis,  deafness,  and  perversions  of  ia.stc  and  smell  are 
occasionally  observed.  Symptoms  of  motor  irritation,  such  as  tremor  and  chorei- 
form movements,  have  also  been  reported  as  rare  complications,  and  a  case  of  post- 
hemiplegic malarial  chorea  has  been  described  by  Boinat  and  Salebert.  Paralysis 
of  the  lower  extremities,  due  to  lesions  in  the  cord,  occurs,  and  is  often  accompanied 
by  loss  of  control  over  the  rectum  and  bladder.  All  of  these  disturbances  may  be 
transitory.  Occasionally  some  of  the  paralyses  are  rapidly  fatal.  Multiple  .sclerosis 
is  a  relati\-ely  frequent  nervous  sequela,  and  tetany  and  paralysis  agitans  are  among 


MALARIAL  INFECTION  327 

the  less  frequent  complications.  Peripheral  disturbances,  such  as  hyperesthesia 
and  anesthesia  occur  in  a  few  cases,  and  supra-orbital,  trigeminal,  and  intercostal 
neuralgia  also  complicate  a  small  number  of  cases. 

'  Of  functional  nervous  complications  and  sequela?,  hysteria,  neurastfwnia,  and 
iiisomnia  may  be  mentioned.  The  various  -psychoses  are  of  rare  occurrence.  Pas- 
manik  in  an  analysis  of  5412  cases  of  malaria  found  106  cases  of  mental  derange- 
ment. None  of  these  patients  affected  were  known  to  have  an  hereditary  predis- 
position to  insanity,  and  only  4.8  per  cent,  of  the  number  were  alcoholics. 

Diagnosis  of  Estivo-autunmal  Fever. — Estivo-autiunnal  fever  must  be  carefully 
differentiated  from  typhoid  fever  and  from  the  so-called  continued  thermic  fever 
of  hot  climates.  Its  differentiation  from  typhoid  fever  is  possible  and  should 
always  be  achieved;  yet  diu-ing  the  recent  Spanish- American  war  the  number  of 
cases  reported  as  malarial  fever  which  were  tjqphoid  fever  and  the  number  called 
tj'phoid  fever  which  were  malarial  was  very  large. 

The  presence  of  estivo-autumnal  infection  is  determined  by  the  fact  that  the 
patient  is,  or  has  been,  living  in  a  region  in  which  this  disease  is  prevalent  or  at 
least  may  occur.  It  practically  never  occurs,  except  in  .imported  cases,  north  of 
the  State  of  Delaware  in  the  United  States,  or  in  any  of  the  northern  parts  of 
Europe.  Again,  its  presence  is  determined  by  the  discovery  of  the  estivo-autumnal 
parasite  in  the  blood.  This  is  not  an  easy  test  for  the  tjTo,  and  the  blood  is  not 
easy  to  obtain  from  the  deeply  seated  organs  in  which  the  parasite  is  found.  After 
the  first  week  of  the  illness  the  absence  of  rose  spots  and  the  Widal  reaction  will 
determine  the  case  not  to  be  one  of  typhoid  fever.  Finally,  good-sized  doses  of 
quinine  will  modify  the  fever  of  this  type  of  malaria,  but  will  not  affect  typhoid 
fever  at  all. 

IJrognosis. — ^The  prognosis  in  estivo-autumnal  infection  is  more  grave  than  in 
the  tertian  and  quartan  types.  In  the  pernicious  forms  the  mortality  is  about 
27.6  per  cent,  according  to  Deaderick,  who  bases  these  results  on  18,529  cases 
collected  from  various  writers. 

Treatment. — The  treatment  of  remittent  fever  is  much  more  difficult  than  that 
of  the  intermittent  form.  The  disease  is  more  dangerous  and  often  more  rapid 
in  its  course.  Further  than  this,  the  fever  is  so  much  more  prolonged  that  it  is 
of  itself  deleterious,  and,  as  the  patient  does  not  have  periods  of  intermittence  in 
which  he  can  make  a  partial  recovery,  strength  is  much  more  rapidly  lost.  The 
estivo-autumnal  parasite  seems  to  be  more  resistant  to  the  influence  of  quinine 
than  either  the  tertian  or  quartan  parasite,  and,  finally,  it  is  much  more  difficult 
to  cause  the  absorption  of  quinine  in  most  cases  of  bilious  remittent  fever,  both 
because  vomiting  is  frequently  a  persistent  sjTuptom  and  also  because  absorption 
seems  for  the  time  being  to  be  put  aside.  It  is  evident,  therefore,  that  where  vomit- 
ing is  too  persistent  to  permit  of  the  administration  of  quinine  by  the  stomach,  it 
must  be  given  hypodermically.  The  best  way  to  administer  it  is  intramuscularly 
in  the  form  of  the  bihydrochloride  of  quinine,  which  is  soluble  in  equal  parts  of  water. 
The  solution  should  not  be  concentrated  but  diluted,  for  concentrated  solutions 
are  prone  to  cause  abscess.  The  injection  is  best  given  by  means  of  an  antitoxin 
syringe,  and  which  may  be  injected  in  the  following  manner:  Dissolve  15  giains 
of  hydrochlorate  of  quinine  in  15  minims  of  alcohol  and  2|  drachms  of  distilled 
water.  .  Strict  asepsis  is  essential  to  avoid  abscess.  The  more  dilute  the  solution 
the  less  is  the  danger  of  abscess.  Just  before  using,  add  a  drop  or  two  of  dilute 
hydrochloric  acid.  The  difficulty  with  the  administration  of  quinine  by  the  rectum 
in  these  cases  is  that  absorption  is  too  slow.  But,  nevertheless,  the  drug  may  be 
given  in  this  manner  dissolved  in  starch-water  whenever  it  is  advisable  to  get  quinine 
into  the  blood  by  every  possible  avenue. 

Even  when  it  is  impossible  to  administer  quinine  by  the  stomach,  it  is  usually 
advisable  to  move  the  bowels  freely,  and  this  may  be  accomplished  by  the  use  of 


328  DISEASES   DIE   TO   .1    SI'FCIFIC  IXFKCTIOX 

Seidlitz  powder  i;i\-cn  in  (li\i(lcil  ddscs,  or  hy  tlic  fin])li)ymcnt  of  citrate  of  inafi- 
nesium. 

If  the  voinitini;  l)ecomes  so  exeessivo  as  to  l)e  a  daniferous  symptom  in  itself, 
it  may  l)e  eoutroiied  by  iiyixxlermic  doses  of  morphine,  or  i)y  5  to  20  minims  of 
spirit  of  ehloroforin  given  witli  the  same  amount  of  compound  spirit  of  lavender 
or  of  cherry-laurel  water.  Counter-irritation  may  also  be  applied  over  the  ei)igas- 
trium  in  the  shape  of  a  mustard  plaster.  Some  cases  arc  also  benefited  by  the 
application  of  hot  compresses  o\'er  the  li\er.  Tlie  value  of  large  doses  of  calomel, 
amounting  to  20  or  even  30  or  40  grains,  for  their  effect  in  overcoming  hepatic- 
torpor  cannot  be  denied.  All  practitioners  of  experience  in  intensely  lualarial 
districts  are  agreed  as  to  this  point. 

Should  hematuria  or  hemoglobinuria  complicate  a  case,  a  careful  consideration 
of  the  stage  of  the  disease  is  essential.  The  value  or  harmfulness  of  quinine  in 
malarial  hematuria  is  still  a  "bone  of  contention"  with  many  practitioners,  some 
claiming  that  the  quinine  is  capable  of  actually  producing  bloody  urine,  and  others 
asserting  equally  po'^itively  that  it  is  always  needed.  The  writer  has  expressed 
the  view  on  several  occasions  that  some  of  these  cases  of  bloody  urine,  comi)licating 
malarial  fever,  may  be  due  to  an  associated  parasite  upon  which  quinine  has  little 
influence.  Craig,  of  the  INIedical  Corps  of  the  United  States  Army,  believes  that 
all  causes  of  so-called  malarial  hemoglobinuria  are  due  to  an  associated  parasite 
not  identical  with  the  Plasmodium  malariw.  In  a  certain  number  of  cases  it  is 
probably  true  that  the  bloody  urine  is  a  sequel  rather  than  an  accompaniment 
of  the  development  of  the  parasite  in  the  blood.  Under  these  circumstances,  as 
enormous  doses  of  quinine  can  have  little  influence  upon  the  malarial  parasite 
and  also  may  irritate  the  kidneys,  it  is  conceivable  that  the  use  of  this  drug  at 
such  a  time  is  distinctly  contra-indicated;  whereas,  if  an  examination  of  the  blood 
reveals  the  presence  of  the  estivo-autumnal  parasite,  then  the  quinine  must  be 
given,  since  the  danger  of  producing  hematuria  by  its  administration  is  more  than 
counter-balanced  by  the  desirability  of  destroying  the  cause  of  the  illness.  In 
other  words,  to  give  quinine  in  some  cases  of  malarial  hematuria,  when  the  specific 
parasite  is  not  present,  is  like  locking  the  door  after  the  horse  is  stolen;  while  in 
others  its  administration  is  timely  and  appropriate. 

A  number  of  important  papers  on  this  subject,  notably  those  of  Craig  and  Brem, 
have  appeared  since  the  last  sentence  was  written  some  years  ago.  I  can  see  no 
reason  for  changing  this  opinion,  but  many  reasons  for  adhering  to  it. 

Many  physicians  of  large  experience  strongly  urge  the  use  of  hyposulphite  of 
sodium  in  doses  of  from  15  to  60  grains  every  four  hours  for  this  complication. 

The  use  of  normal  salt  solution  hx  hypodcrmoclysis  is  often  a  valuable  measure 
for  relief.     If  the  patient  is  moribund  it  should  be  given  intravenously. 

Latent  Malarial  Infection  and  Relapse. — Ijitrnt  malarial  infccfinn  is  probably 
much  more  common  than  pliysicians  believe,  although  the  laity  have  an  exag- 
gerated view  of  its  occurrence.  Craig  has  reported  the  result  of  examining  the 
blood  of  47  men  in  one  company  of  the  United  States  Army,  all  of  whom  had 
been  exposed  to  malarial  infection  in  the  Philipi)ine3,  but  all  of  whom  were  at  least 
well  enough  to  be  on  duty.  Twenty-seven  of  them  had  the  parasite  in  their  blood, 
and  25  were  infected  by  the  estivo-autumnal  parasite.  This  persistence  of  infection 
not  only  possesses  ordinary  interest,  but  shows  that  by  the  distribution  of  returning 
troops  to  various  parts  of  the  country  this  parasite  may  be  disseminated  in  areas 
hitherto  uninfected.  Similar  results  have  been  recorded  in  India  by  Ilehir 
and  Adiel  Aside  from  the  ultimate  cure  of  the  individual  it  is  imi)ortant  to 
control  such  sources  of  infection.  All  cases  in  which  definite  malarial  parasites 
have  been  found  should  receive  quinine  for  at  least  three  months  after  all  symptoms 
have  ceased.  Koch  advises  that  15  grains  of  quinine  be  given  on  the  consecutive 
days,  every  seven  days  for  this  purpose. 


RELAPSING  FEVER  329 

Relapse  in  malarial  fever  occurs  under  several  conditions  independent  of  a  new 
infection.  The  parasites  may  be  kept  in  ai)cyance  hv  good  liealtli  and  mofierate 
doses  of  cpiinine  only  to  become  active  when  the  heaitli  is  impaired  or  the  (|uinine 
is  stopped  on  a  return  to  a  non-malarial  district.  Sporulation  is  stopjjed  but  tiie 
parasite  is  not  destroyed.  Such  cases  reveal  no  jnirasites  in  the  Ijjood  until  tlie 
relapse  occurs  because  they  are  hidden  in  the  sperm  and  bone-marrow.  These 
cases  are  therefore  often  very  difficult  to  cure  because  of  the  hiding  place  of  the 
parasite  and  because  the  small  doses  of  quinine  have  been  sufficient  only  to  induce 
quinine  immunity  in  the  parasite.  Such  cases  often  can  be  cured  only  by  h\po- 
dermic  or  intravenous  use  of  large  doses  of  quinine  or  by  the  use  of  salvarsan.  As 
Craig  points  out,  the  development  of  a  masked  malarial  infection  may  greatly 
mislead  the  surgeon,  both  before  and  after  an  operation. 


RELAPSING  FEVER. 

Definition. — Relapsing  fever,  as  its  name  indicates,  is  characterized  by  an  attack 
of  fever  which  lasts  about  six  days,  this  in  turn  is  followed  by  a  period  in  which 
fever  is  absent,  and  this  again  by  a  recurrence  of  a  period  of  fever.  These  alternat- 
ing periods  may  be  repeated  three  or  four  times.  Sometimes  it  is  called  Fehris 
Recurrens,  "Seven  Days'  Fever,"  and  "Famine  Fever." 

History. — The  history  of  relapsing  fever  is,  when  compared  to  some  other  infec- 
tious diseases,  fairly  modern,  for  the  first  descriptions  of  it  occurred  in  medical 
literature  about  1729,  although  it  was  not  until  1739  that  Rutty  gave  a  clear 
description  of  its  course.  After  this  for  nearly  a  century  no  reports  of  its  existence 
are  to  be  found,  but  between  1S42  and  1852  it  appeared  over  a  wide  area,  occurring 
in  England,  Ireland,  Scotland,  Germany,  and  finally  in  America,  to  which  country 
it  was  brought  by  a  shipload  of  immigrants  who  came  from  Liverpool  and  landed 
in  Philadelphia  in  1844.  It  became  epidemic  in  the  United  States  in  the  decade 
from  1861  to  1870,  and  it  is  interesting  to  note  that  as  the  American,  Gerhard,  first 
aided  in  the  differentiation  of  typhoid  fever  from  typhus  in  Philadelphia,  so  Pepper, 
Rhoads,  and  Parry,  of  the  same  city,  have  contributed  to  medical  literature  the 
best  account  of  the  disease  as  it  has  appeared  in  this  country,  having  observed  a 
larger  number  of  cases  than  any  other  clinicians. 

Distribution. — Relapsing  fever  has  occurred  in  almost  all  parts  of  the  civilized 
world. 

Etiology. — It  has  been  claimed  that  filthy  surroundings  and  bad  food  are  active 
in  the  development  of  relapsing  fever,  but  they  probably  exercise  a  general  influence 
by  lowering  vitality  rather  than  by  directly  aiding  infection.  Sex,  age,  and  nation- 
ality exercise  no  influence,  and  it  is  doubtful  if  any  one  season  of  the  year  increases 
the  prevalence  of  the  disease.  The  actual  cause  of  relapsing  fever,  as  already  stated, 
is  a  spirillum  sometimes  called  the  spirillum  of  Obermeier,  now  known  as  Spirocheta 
recurrentis  in  the  European  type  and  Spirocheta  novyi  in  the  relapsing  fever  of 
America,  which  is  constantly  found  in  the  blood  of  patients  suffering  from  the 
disease  during  the  stage  of  fever.  It  is  absent  from  the  blood  in  the  intermissions, 
although  .small,  glistening  bodies,  said  to  be  spores,  can  be  seen.  The  disease  is 
contagious,  that  is,  it  requires  contact  with  the  patient  or  with  his  garments  for 
the  infection  to  be  spread.  Patients  may  be  infected  by  insects,  for  example,  by 
bed-bugs  which  have  previously  bitten  patients  suffering  from  relapsing  fever. 
That  the  disease  is  ever  conveyed  by  the  air  is  doubtful.  Relapses  may  be  explained 
by  the  hiding  of  the  spirochetffi  in  tissues  which  cannot  destroy  them.  Darling 
has  shown  that  the  so-called  Relapsing  Fever  of  Panama  is  sometimes  distinct  from 
the  forms  commonly  found  in  the  eastern  hemisphere,  although  belonging  to  the 
same  general  class  in  that  the  specific  organism  is  the  S.  dviionia  or  the  S.  carteri. ' 


330 


DISEASES  DUE  TO  A  SPECIFIC  INFECTION 


Pathology  and  Morbid  Anatomy. — The  changes  jjroduced  in  the  body  by  relapsing 
fever  are  not  only  not  marked,  but  not  at  ail  characteristic.  The  spleen  and  liver 
are  swollen  and  engorged,  as  in  nearly  all  t'elirile  infectious  fliseases,  and  the  volun- 
tary muscles  may  undergo  granular  degeneration.  Similar  changes  may  be  found 
also  in  the  heart  mu.scle.  Sometimes  multiple  infarctions  and  hyi)erplasia  of  the 
bone-marrow  are  present  and  ecchymotic  spots,  which  are  found  antemortcm,  are 
seen  in  the  skin  and  subcutaneous  tissues.  All  the  organs  may  show  this  staining. 
Darling  has  shown  that  the  bod3''s  mechanism  of  defense  is  phagocytosis  carried 
on  chiefly  by  the  endothelial  cells  of  the  liver. 

\\   Symptoms. — As  a  rule  about  si.x  or  seven  days  after  exposure  to  the  disease  the 
infected  person  is  abruptly  seized  by  a  severe  chill,  or  more  rarely  by  headache  and 


Mayor 

1 

2 

3 

4 

5 

c 

7 

S 

9 

10 

11 

12 

13 

M 

15 

10 

17 

IS 

10 

20 

21 

22 

23 

24 

25 

20 

«U 

M  !  E 

Ml   C 

Mi  e 

mI  e 

M       E 

uk 

mIe 

M,  E 

"mT7 

mIe 

M^ 

M    '   E 

Mit 

mIe 

M    T^ 

^Jl    z 

M  '  £ 

TIe 

M  'C 

V  Ie 

M,  E 

uje 

MfT 

U     £ 

—  ~ 

"■- 

z 

--'  — 

_':z 

-\- 

107  - 



-J- 

— 

—J- 

— 1 



— 

— 



—IT 

— 



1 ' 

' 

— 

~r 

:: 

A 

A 

- 

"■"" 

r 

:+: 

105  - 
103- 

zyr 

./ 

V^\ 

V 

J\ 

j 

-\" 

A 

r 

r 

r^ 

-q- 

\  - 

\J  ": 

:r  V 

i- 

::;:: 

: ; : 

^1-- 

:: 

11 

3E 

-- 

-^ 

'-'r- 

[- 

== 

EE 

\\_ 

■/ 

1= 

9<j . 

/ 

A 

^ 

nr 

i 

"\' 

T- 

:;ir 

" 

|/'\ 

A 

l\ 

\ 

/ 

V^^ 

f 

/ 

vE 

\/ 

/ 

;V 

V 

/ 

W 

^ 

[ 

y 

q^ 

_~ 

I'lil.i-. 

TIT 

T^. 

:■.  ;^ 

i  = 

T~r 

U^ 

TT 

TIJ 

77777 

T^ 

TjF 

T^ 

w 

kJ 

krr 

7~r 

1j~r 

W 

T^ 

"TT 

'Tii' 

I[.'>|>lrn(luii 

2|i"i 

B  ?i 

^' =■!-> 

^'1^ 

,. 

.tio 

i'-i 

'-'  ■  f. 

s  -■ 

.7,  slst?. 

.!. 

;;|?; 

yls|!j,=  |;,j|;;  s 

'■'f. 

r,   ', 

-n  --.-.Ir-.  -.]-:.  -i 

-,y. 

f.  i 

.^ 

Typical  case  of  relapsing  fever  terminating  in  recovery.    One  relapse  vdth  slight  postcritical  rise  in 

temperature. 

vomiting.  The  face  becomes  flushed,  but  the  expression  is  not  dull  and  apathetic 
as  it  is  in  typhus  fever,  unless  the  infection  is  very  severe,  when  typhoid  .sym])toms 
may  soon  develop.  A  moderate  degree  of  javndire  also  is  present  in  many  cases. 
No  characteristic  eruption  appears  on  the  skin,  althougli  .small  pctcclii;c  or  ecchymo- 
tic spots  may  occur  in  severe  cases.  Many  observers  have  recorded  tlic  presence 
of  a  disagreeable,  vmsty  odor  about  the  patient. 

The  febrile  movement  is  the  most  notable  manifestation  of  tlie  disease.  The 
fever  begins  to  rise  while  the  stage  of  chill  is  still  young,  and  reaches  102°  or  103° 
in  the  first  twenty-four  hours  and  104°  or  106°  in  the  ne.xt  twenty-four  hours. 
During  the  fel)rilc  stage  of  about  six  days  this  level  of  temperature  is  fairly  con- 
stantly maintained,  although  irregular  remissions  of  1°  or  2°  may  occur.   Sometimes 


TRYPANOSOMIASIS  331 

the  fever  reaches  108°.  In  some  cases  the  primary  febrile  period  lasts  only  two 
days.  While  the  febrile  movement  just  described  is  characteristic,  its  ending  is 
more  so,  for  a  critical  fall  of  temperature  takes  place  with  a  suddenness  and  com- 
pleteness which  is  rarely  met  with  in  any  other  disease  unless  it  be  croupous  pneu- 
monia (Fig.  63).  Not  rarely  it  falls  6°  in  three  hours,  although  a  fall  of  1°  an  hour 
is  more  common.  The  rapid  fall  may  carry  the  temperature  a  little  below  normal. 
After  a  few  days  of  no  fever  the  relapse  takes  place  with  the  same  sudden  onset 
as  occurred  with  the  primary  attack.  It  runs  a  course  in  all  respects  like  the 
original  seizure,  but  it  more  commonly  ends  by  lysis  than  does  the  first  paroxysm. 
The  third  and  fourth  attacks,  if  they  occur,  are  usually  milder  than  the  first  two. 
The  duration  of  the  period  of  intermission  varies  from  one  to  ten  days,  although 
it  is  usually  six  days  or  a  week,  and  the  duration  of  the  entire  illness  may  vary 
from  eighteen  to  ninety  days,  according  to  the  number  of  relapses. 

The  pulse  during  the  early  attacks  is  rapid,  and  it  may  be  bounding,  but  if 
the  patient  be  enfeebled  by  prolongation  of  the  illness  it  may  be  small  and  compress- 
ible. Severe  frontal  and  occipital  headache  is  often  experienced  by  the  patient 
in  the  first  attack,  but  delirium  is  rare  except  it  be  due  to  serious  complications 
or  to  very  high  fever. 

Prognosis. — The  prognosis  as  to  ultimate  recovery  is  quite  good,  the  mortality 
of  the  disease  usually  being  about  4  per  cent. 

Treatment.' — The  introduction  of  salvarsan  has  provided  us  with  a  specific  treat- 
ment for  relapsing  fever  in  that  this  drug  destroys  the  spirillum.  (See  Syphilis.) 
Good  nursing,  careful  feeding,  and  the  use  of  stimulants,  if  the  patient  is  feeble, 
are  of  course  needful.  The  action  of  the  bowels  and  kidneys,  as  in  all  infectious 
diseases,  should  be  carefully  attended  to.  No  results  from  the  use  of  hj-drotherapy 
in  relapsing  fever  have  been  published,  so  far  as  the  writer  is  aware,  but  the  course 
of  the  febrile  movement  scarcely  indicates  this  plan  of  treatment. 

PSOROSPERMIASIS. 

This  term  is  applied  to  an  exceedingly  rare  condition  in  which  psorosperms 
become  parasites,  growing  in  cells  and  producing  nodules.  These  nodules  may 
be  large  enough  to  be  felt  through  the  abdominal  wall.  The  patient  presents 
symptoms  which  are  like  typhoid  fever  in  character.  There  is  diarrhea,  stupor, 
some  fever,  hepatic  and  splenic  tenderness,  and  feeble  circulation.  Autopsy  in 
such  cases  has  shown  the  presence  of  masses  closely  resembling  tubercles,  which 
are  scattered  over  the  liver,  the  spleen,  the  peritoneum,  and  in  the  kidneys. 

Another  form  of  infection  by  sporozoa  has  been  described  as  occurring  in  the 
skin,  but  Stelwagon  states  that  the  condition  called  psorospermiasis  by  Darier 
is  now  known  not  to  be  due  to  this  cause.  On  the  other  hand,  Rixford  and  Gilclirist, 
in  Baltimore,  have  recorded  two  cases  in  which  tuberculosis  of  the  skin  was  thought 
to  be  present  for  eight  years.  During  this  time  the  lymphatic  glands  were  enlarged, 
other  parts  of  the  body  became  affected,  and  finally  death  ensued.  Numerous 
nodules,  looking  like  those  of  tuberculosis,  were  found  scattered  very  widely  through 
the  body,  and  these  were  found  to  contain  large  numbers  of  sporozoa. 

TRYPANOSOMIASIS. 

Definition. — Two  phases  of  one  disease  are  recognized  in  man  as  due  to  infection 
by  trypanosomaia.  These  are,  first,  an  ill-defined  fever  resulting  from  invasion 
of  the  circulation  by  the  Trypanosoma  gamhiense,  and  second,  African  lethargy, 
or  sleeping  sickness,  due  to  the  presence  of  the  same  parasite  in  the  cerebrospinal 
fluid.  Other  trypanosomes,  as  the  lujandetise  and  rhodesiense,  have  been  described 
as  separate  species  in  the  countries  indicated  by  their  names.     It  now  appears 


332  DISEASES  DUE  TO  A   SPF.CIFir  JXFECTIOX 

quite  certain  that  the  first,  and  probably  the  second,  is  in  reality  the  finmhiense. 
The  statement  that  all  the  trypanosomes  found  in  man  are  identical  does  not, 
however,  at  present  appear  warranted. 

The  trypanosomata  are  fiaf;eilated  protozoa,  found  in  the  Idodd  oF  xcrtcbrates. 
They  were  first  discovered  l)y  Gruby  in  1848  in  frogs,  and  by  DoHein  in  lS4r)  in 
rats  and  hamsters.  Since  that  time  they  have  been  found  in  pra(ticall\'  all  verte- 
brates. These  organisms  were  first  supposed  to  be  sjjirilli  before  their  animal 
nature  was  understood.  In  the  large  majority  of  instances  they  are  not  ])atli()gcnic. 
As  far  as  our  present  knowledge  goes,  the  varieties  represent  distinct  types,  C(jnfined 
to  the  particular  animal  which  they  infect.  At  least  six  trypanosomata  that  are 
pathogenic  occur  in  mammals.  Thus,  the  Trypanosoma  evansl  and  the  Trypanosoma 
hrucei  are  the  causes  of  very  fatal  diseases,  known  as  surra  and  nagana  among 
horses,  mules,  camels,  buffaloes,  and  wild  animals.  Trypanosoma  cquiperdiim  is 
the  cause  of  an  exceedingly  fatal  disease  of  horses  in  Algiers  and  the  Mediterranean 
coast,  called  "dourine"  transmitted  only  by  coitus.  Trypanosoma  equiniim  is 
also  the  cause  of  a  fatal  disease  of  horses  in  South  America.  Trypanmoina  ilwileri, 
the  largest  of  the  known  trypanosomata,  is  the  cause  of  a  serious  cattle  disease  in 
South  Africa.  The  most  widely  distributed  is  Trypanosoma  lewisi,  the  parasite 
infecting  rats.  This  particular  variety  is  very  common  in  the  rats  of  the  I'nited 
States,  and  has  been  found  in  practically  every  city  where  search  has  been  made 
for  it. 

A  trypanosoma  consists  of  a  leech-shaped,  granular  body  from  KV  to  2.3/x  long 
and  from  2//  to  4^  wide.  This  body  contains  a  nucleus  and  a  rod-shaped  centre 
known  as  the  centrosome,  or  micronucleus.  Along  one  edge  of  the  parasite,  begin- 
ning at  the  eentrosome,  is  a  delicate,  fringe-like  membrane  known  as  the  undulating 
membrane,  upon  the  outer  edge  of  which  is  a  single  flagellum  extending  from  T/j. 
to  15/i  beyond  the  anterior  end  of  the  parasite.  In  freshly  drawn  peripheral  blood 
these  parasites  are  seen  to  be  in  most  active  motion,  progression  being  in  the  direc- 
tion of  the  flagellum.  In  hanging-drop  preparation  they  live  several  days,  and 
as  long  as  fifty  days  if  the  slide  be  kept  cold  and  moist.  IMcNeal  and  Novy  have 
succeeded  in  cultivating  Trypanosoma  Icwisi  and  Trypanosoma  hrucei  on  a  culture 
medium  of  agar  and  defibrinated  rabbit's  blood.  This  is  the  first  instance  in  which 
animal  parasites  have  been  obtained  in  pure  culture. 

Human  trypanosomiasis  is  disseminated  or  conveyed  and  inoculated  by  the  bites 
of  suctorial  flies  and  perhaps  bed-bugs.  The  \\e\x  that  one  species  of  fly  only 
can  act  as  host  for  a  particular  trypanosome  is  generally  held,  but  is  by  no  means 
established.  .Among  the  known  transmitters  of  trypanosomiasis,  of  which  our 
knowledge  appears  accurate,  are  the  tsetse  fly  or  Glosslna  palpalis  for  those  of 
trypanosoma  fever  and  sleeping  sickness,  and  the  Glossina  morsitan-s  for  nagana 
and  possibly  human  trypanosomiasis. 

The  transmission  is  direct,  or  purely  mechanical,  that  is,  it  is  a  direct  inoculation 
without  the  parasite  first  going  through  a  cycle  of  development  in  the  fly.  These 
flies  become  infective  about  tiiirty-four  days  after  they  feed  upon  an  infected 
animal  or  man  and  remain  so  for  about  seventy-five  days  or  longer.  The  fly 
which  bites  an  infected  individual,  if  it  bites  a  healtiiy  person  at  once,  also 
transmits  the  disease.  This  statement  of  Bruce  contradicts  seemingly  his  state- 
ment as  to  infectivity  only  after  thirty-four  days. 

Prevention. — It  having  been  proved  that  trypanosomiasis  is  due  to  a  parasite 
infecting  human  beings  and  that  the  disease  is  transmitted  by  insects,  it  follows 
that  cases  known  to  be  infected  should  if  possible  be  isolated  and  protected  from 
flies.  Healthy  persons  should  also  be  protected  from  flies,  not  only  l)y  the  use  of 
nettings,  but  by  living,  if  possilile,  where  flies  are  not  numerous;  on  hillsides  as  far 
as  possible  from  materials  that  aid  in  the  breeding  of  flies.  Wild  game  and  domestic 
animals  undoubtedly  harbor  the  parasite  and  the  latter  should  be  protected  from 


TR  YPA  XOSOMIASIS  ■''■i-'> 

flies.  Indeed  it  has  been  proposed  to  attempt  the  extermination  of  all  fi;ame  in 
those  parts  of  the  world  where  trypanosomiasis  is  prevalent. 

Human  Trypanosomiasis  (Trypanosoma  Fever). — The  first  reported  case  of 
trypanosonia  in  man  was  made  l)y  Nep\-eu,  and  iiis  paper  contains  a  fair  drawing 
of  the  parasite.  Forde,  in  19(J1,  descril)ed  the  parasite  in  the  case  of  a  European 
from  the  Gambia  River  Colony  suffering  from  an  atypical  fever.  Since  that  time 
Manson,  Button,  Todd,  and  others  have  reported  cases,  nearly  all  of  them  from 
the  Congo  and  Gambia  River  district.  Manson's  case  occurred  in  a  woman  aged 
forty  years.  The  temperature  ranged  from  97°  in  the  morning  to  100°  in  the 
evening.  The  pulse  was  always  rapid  and  feeble.  Erythema  was  a  constant 
feature  in  the  case,  and  was  first  observed  when  the  fe\-er  began.  I-ldema  was  also 
present,  and  was  most  pronounced  on  the  back  and  face.  There  was  marked 
enlargement  of  the  spleen. 

In  many  cases  the  history  of  an  inflamed  and  painful  insect  bite  can  be 
obtained. 

In  Button's  case  there  was  the  history  of  the  patient  being  bitten  by  a  rat. 

Tlie  parasites  are  found  free  in  the  peripheral  blood  and  never  in  the  corpuscles. 
They  are  not  numerous,  varying  from  one  to  twenty  in  a  cover  preparation. 
They  may  be  absent  for  days  at  a  time.  In  the  case  reported  by  Manson 
experimental  inoculation  on  animals  was  negati\-e,  showing  the  distinct  nature 
of  the  parasite. 

The  blood  condition  is  interesting.  There  is  a  moderate  degree  of  anemia  in 
all  cases  and  a  marked  increase  in  the  large  mononuclear  leidcocytes,  running  as 
high  as  22  per  cent.  The  increase  in  these  cells  seems  rather  constantly  associated 
with  sporozoal  infection,  just  as  metazoal  parasitism  is  accompanied  by  eosinophilia. 

The  clinical  phenomena  in  the  reported  cases  are  chiefly  these:  In  some  cases 
the  parasites  occur  in  the  blood  without  the  patient  manifesting  any  conspicuous 
sjTnptoms.  In  other  cases  there  is  an  irregular  fever  which  may  be  high,  continu- 
ous, or  remittent  in  type.  It  does  not  yield  to  quinine.  After  persisting  from  three 
days  to  two  or  tlu-ee  weeks,  it  is  followed  by  an  apyretic  interval.  During  the 
course  of  the  fever  large  erythematous  patches  occur  all  over  the  body,  associated 
with  irregularly  distributed  areas  of  cutaneous  edema.  The  edema  and  erythema 
may  or  may  not  coincide.  The  edema  is  most  marked  on  the  face,  especially  on 
the  lower  eyelids.  The  pulse  is  rapid  and  running,  a  peculiarity  also  observed  in 
sleeping  sickness. 

There  is  a  diminution  of  intelligence  followed  by  tremors,  increasing  mental 
hebetude  and  unsteady  gait.  Finally  comes  the  third  stage  of  subnormal  tempera- 
ture and  profound  lethargy.  The  mortality  is  100  per  cent,  unless  the  disease 
is  treated  fairly  early  by  salvarsan  or  by  atoxjl  or  sodium  cacodylate. 

African  Lethargy  (Sleeping  Sickness). — Sleeping  sickness  is  a  chronic  disease 
characterized  by  increasing  lethargy,  and,  after  an  exceedingly  chronic  course, 
death  occurs  from  coma  or  from  inanition — "a  patient  sleeping  himself  to  death." 

Sleeping  sickness  is  at  present  confined  to  tropical  Africa,  principally  along  the 
west  coast.  The  northern  limit  of  its  extension  is  the  Senegal  River;  the  southern 
limit  is  the  Portuguese  Colony.  It  is  common  in  Senegambia,  along  the  Gold 
Coast,  and  at  Old  Calabar.  It  has  existed  for  a  long  time  in  the  basin  of  the  Congo 
River  from  Stanley  Falls,  in  the  heart  of  equatorial  Africa,  to  the  lower  Congo. 
It  has  recently  extended  from  Mctoria  Xyanza  to  the  head-waters  of  the  Nile. 
In  the  last  few  years  the  disease  has  assumed  epidemic  proportions  in  Uganda 
and  many  thousands  of  the  natives  have  perished.  In  the  days  of  the  slave  traffic 
sleeping  sickness  was  frequently  carried  to  the  West  Indies,  Southern  United  States, 
Brazil,  and  the  Bahamas,  but  it  never  succeeded  in  establishing  a  foothold  in  any 
of  these  places. 

The  older  views  that  sleeping  sickness  is  due  to  poisoning,  intoxication,  and 


334  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

filiiria  have  been  superseded  by  the  demonstration  of  a  trypanosoma  in  the  cere- 
brospinal fluid  by  Castellani,  and  the  confirmation  of  this  observation  by  Bruce 
and  other  members  of  the  English  Sleeping  Sickness  Commission,  who  have  success- 
fully propagated  the  disease  in  monkeys.  The  trypanosoma  of  sleeping  sickness 
is  indistinguishable  from  that  of  trypanosoma  fever,  and,  like  the  latter,  is  also 
found  in  the  blood.  Apparently  the  advent  of  sleeping  sickness  in  a  patient  having 
trypanosoma  fever  is  determined  by  colonization  of  the  parasites  in  the  cerebro- 
spinal fluid.  The  e.xact  relation  of  the  hypnococcus,  described  by  Castellani  and 
other  members  of  the  Spanish  Commission,  as  the  cause  of  the  disease  is  not  as 
yet  perfectly  clear;  apparently  it  is  only  a  terminal  infection. 

Sleeping  sickness  attacks  persons  of  all  ages  and  of  every  race. 

Pathology. — Mott  has  shown  that  the  lesion  of  sleeping  sickness  is  an  extensive 
meningo-encephalomyelitis.  In  the  cord  and  brain  extensive  round-cell  infiltration 
is  found  about  the  capillary  vessels.  The  cerebrospinal  fluid  is  deeper  in  color 
than  normal  owing  to  the  presence  of  numbers  of  red  blood  cells.  Besides  these, 
numerous  leukocytes  and  the  specific  trypanosoma  are  found.  In  the  latter  stages 
of  the  disease  there  is  some  ground  for  believing  that  there  is  a  concomitant — in 
a  terminal  sense — streptococcus  (hypnococcus)  infection. 

Symptoms. — The  incubation  period  is  variable,  but  always  long.  The  natives 
believe  that  the  disease  may  develop  as  long  as  seven  years  after  exposure.  As  a 
matter  of  fact  numerous  instances  are  on  record  where  the  disease  has  appeared  in 
negroes  several  years  after  leaving  the  endemic  area  and  settling  in  other  countries. 
It  would  appear,  from  the  meagre  knowledge  of  the  parasite  now  available, 
that  it  may  be  found  in  the  peripheral  blood  without  producing  any  symptoms. 
The  causes  that  determine  colonization  of  the  parasites  in  the  cerebrospinal  system 
are  unknown. 

The  disease  sometimes  begins  with  marked  psychical  prodromata,  including 
epileptiform  seizures,  melancholia,  and  even  transitory  viaiiia.  In  the  larger  number 
of  eases  there  is  headache,  vertigo,  puffiness  of  the  face,  and  slight  fever.  At  this 
point  the  lethargy  begins.  The  patient  at  first  is  somnolent  or  stupid,  but  he  can 
easily  be  roused  for  nourishment  or  to  attend  to  the  calls  of  nature.  When  so 
awakened  his  gait  is  staggering  and  the  moment  he  is  released  he  sinks  into  a  deep 
sleep.  In  the  early  stages  there  are  no  evidences  of  paralysis,  tremor,  or  convulsion. 
The  patellar  reflexes  are  decreased,  sometimes  abolished.  Gradually  the  lethargy 
deepens  until  finally  the  patient  can  only  be  aroused  with  the  greatest  difficulty, 
if  at  all,  and  immediately  falls  again  into  a  deep  sleep.  Partly  from  the  disease 
itself,  but  largely  because  the  lethargy  prevents  regular  nourishment,  nutrition 
fails,  emaciation  becomes  progressively  more  marked,  and  bed-sores  develop. 
Toward  the  close  paralyses  of  various  muscle  groups  develop,  convulsio7is  occur, 
and  fatal  coma  supervenes. 

Diagnosis. — The  symptoms  are  fairly  characteristic,  but  a  positive  recognition  of 
the  disease  is  rendered  easy  by  puncture  of  a  gland,  in  the  juice  of  which  the  parasite 
may  he  found.  Glandular  enlargement  all  over  the  body  but  particularly  in  the 
posterior  cervical  group  is  a  very  constant  symptom,  and  persons  sufl'ering  from 
such  a  state  in  an  area  known  to  be  infected  by  sleeping  sickness  should  be  suspected 
and  the  contents  of  glands  examined.  In  other  instances  a  diagnosis  may  be 
reached  by  lumbar  puncture,  centrifugalization  of  the  cerebrospinal  fluid,  and 
demonstration  of  the  parasites  by  a  microscopic  examination  of  the  sediment. 

Prognosis. — ^The  course  of  the  disease  is  chronic.  Cases  may  last  from  three  to 
four  years,  but  rarely  more  than  eighteen  months.     The  prognosis  is  bad. 

Treatment. — ^The  treatment  of  trypanosomiasis  consists  chiefly  in  the  use  of 
salvarsan  or  neosalvarsan  (See  Syphilis)  or  an  arsenical  preparation,  called  "atoxyl" 
or  meta-arsenic-anilid.  This  drug  is  given  hj-podermically  in  10  per  cent,  strength 
in  normal  saline  solution.     The  first  dose  is  2  grains  and  this  is  increased  every 


KALA-AZAR  335 

second  day  by  half  a  grain,  until  as  much  as  15  grains  are  given  or  until  some  signs 
of  toxemia  from  its  use  are  produced.  The  signs  consist  in  pain  in  the  belly,  pectoral 
cramps,  slowness  of  the  pulse  and  cold  extremities.  Notwithstanding  its  name, 
atoxyl  also  causes  serious  changes  in  the  optic  nerve  and  may  cause  blindness. 
For  this  reason  and  because  it  is  more  active,  salvarsan  is  always  to  be  used  by 
preference  if  obtainable.  Purging  in  the  early  stages  does  good  and  in  some  cases 
temporarily  arrests  or  delays  the  disease.  Massive  doses  of  arsenic  are  of  some 
service  and  should  be  used  when  atoxyl  or  salvarsan  are  not  available. 

KALA-AZAR. 

Definition. — Kala-azar  or  Tropical  Splenomegaly,  sometimes  called  Dum  Dum 
Fever,  is  a  chronic  infectious  disease,  characterized  by  long-continued  remittent 
fever,  extreme  emaciation,  profound  anemia,  marked  enlargement  of  the  liver 
and  a  characteristic  pigmentation  of  the  skin.     It  is  almost  invariably  fatal. 

Much  uncertainty  has  existed  as  to  the  nature  of  kala-azar,  and  our  present 
knowledge  rests  largely  upon  the  investigation  of  Leisliman,  who  in  1903,  showed 
that  it  is  due  to  a  parasite,  the  exact  nature  of  which  is  yet  uncertain.  Some 
consider  it  a  form  of  Trypanosome,  others  place  it  in  the  genus  Herpiomona-s. 
The  Leishmani  donovani  occur  as  small  round  or  oval  bodies,  2/1  to  in  in  diam- 
eter, with  a  spherical  nucleus  and  a  rod-shaped  chromatin  body  at  right  angles 
to  it.  In  cultures  they  have  a  flagellated  stage.  The  bodies  are  numerous  in 
the  spleen,  liver,  and  bone-marrow  and  are  also  found  in  other  organs  and  intes- 
tinal ulcers.  They  are  occasionally  found  in  the  leukocj-tes  of  the  peripheral 
blood,  especially  in  advanced  stages  of  the  disease.  The  parasites  are  best  obtained 
by  puncture  of  the  spleen  or  liver,  spreads  of  the  fluid  being  stained  by  Giemsa's 
or  Leishman's  stain.  These  bodies  have  been  found  in  persons  suffering  from 
kala-azar  in  India,  the  Egyptian  Soudan,  Algiers,  and  elsewhere. 

There  are  at  least  two  other  types  of  Leishvia7ii,  the  infantum  and  the  tropica. 
Microscopically  all  three  are  identical.  The  injantuvi  causes  a  disease  similar 
to  kala-azar  but  only  in  children  under  six  years  and  especially  in  infants  of  one  to 
two  years,  hence  is  known  as  infantile  kala-azar.  It  has  been  found  in  Tunis  and  in 
Italy.  The  tropica  causes  a  granulomatous  lesion  known  as  Oriental  sore  or  Aleppo 
or  Delhi  boil.     Wright,  of  Boston,  discovered  the  parasite  in  this  type  of  lesion. 

Donovan  asserts  that  careful  examination  of  the  peripheral  blood  will  give 
results  in  93  per  cent,  of  cases. 

Manson  believes  that  the  intermediate  host  of  this  parasite  in  some  scavenger-fly 
which  derives  the  parasite  from  the  intestinal  or  other  discharges  of  the  patient 
and  then  infects  the  human  being  by  a  bite.  There  may  be  a  sexual  multiplication 
in  the  fly,  but  in  the  human  host  the  parasite  multiplies  by  fission,  and  Manson 
thinks  that  this  multiplication  is  asexual.  Rogers  states  that  the  bed-bug  {Civiex 
rotjtndatus)  is  the  disseminator  of  the  disease. 

Pathology  and  Morbid  Anatomy. — The  autopsy  in  a  case  of  kala-azar  shows  enor- 
mous enlargement  of  the  spleen,  which  is  firm  and  friable.  The  liver  is  also  greatly 
enlarged  and  toughened  in  texture.  The  bone-marrow  and  the  organs  just  named 
are  crowded  with  the  parasites.  Leishman  bodies  can  also  be  found  in  the 
lymphatic  glands,  the  suprarenal  capsules,  in  the  testicles,  and  in  the  inflam- 
matory exudates  in  the  pleura  and  peritoneum.  The  direct  cause  of  death  seems 
to  be  an  associated  dysentery  or  pneumonia. 

Mortality. — In  certain  parts  of  India  the  death  rate  is  very  high.  Thus  Rogers 
reports  one  district  in  which  54,179  deaths  due  to  this  malady  occurred  in  ten  years. 

Symptoms. — The  symptoms  in  onset  resemble  those  of  malarial  fever,  being 
characterized  by  daily  chills  and  fever,  followed  by  free  sweating,  these  symptoms 
recurring  about  the  same  time  every  afternoon.     After  a  period  of  ten  days  or 


33(5  l)JSI<:.\SI<:s  Dili  TO  A  SPECIFIC  ISFECTIOS 

two  weeks  tliesc  symptoms  diminish  and  a  period  of  remission  oeeurs,  followed  after 
another  period  of  ten  days  or  two  weeks  by  a  return  of  the  paroxysm.  This  may 
last  for  weeks  or  months.  Oecasionally  the  remissions  already  s])oken  of  fail  to 
occur,  and  profound  inanition  develops  after  some  months.  In  still  other  cases 
the  febrile  movements  are  exceedingly  irregular  and  varied.  Enlargement  of  the 
liver  and  si)leen  begin  early.  The  patient  comyjiains  of  languor,  dys|)nea,  and  the 
general  manifestations  of  profound  anemia.  The  constant  symptoms  are  fever, 
enlargement  of  the  liver  and  spleen,  the  progressive  emaciation,  anil  grave  anemia. 
Treatment. — This  consists  in  the  use  of  salvarsan,  neosalvarsan  or  atox\l.  (See 
Syjjhilis  iuid  Trypanosomiasis.) 

TROPICAL  SORE. 

Aleppo  Boil,  Bouton  d'Orient,  Oriental  Sore,  Bagdad  Sore  is  a  sore  or  ulcer  on 
the  skin  or  mucous  membrane  due  to  the  presence  of  the  same  parasite  as  kala- 
azar  {Leishmani  donovani).  The  sore  has  been  met  with  outside  of  the  Tropics, 
as- on  the  shores  of  the  Mediterranean  Sea  and  even  in  America  and  Brazil.  The 
sore  is  usually  on  an  exposed  part  of  the  body  and  is  supposed  to  be  induced  by  the 
bite  of  some  insect.  The  parasite  is  found  in  the  sore  with  great  ease.  The  lesion 
has  a  natural  but  slow  tendency  to  heal,  leaving  a  bad  scar.  Healing  may  be 
hurried  by  curetting,  excision  or  by  the  application  of  powdered  jjermanganate  of 
potash  followed  in  some  days  by  a  10  per  cent,  solution  of  methylene  blue. 

NEMATODES. 

Ascariasis. — Ascaris  lumhricoides,  or  round  worms,  are  found  in  the  small 
intestine  of  man  more  commonly  than  any  other  parasite. 

They  are  not  segmented  as  are  the  cestodes,  but  occur  as  smooth  worms,  not 
unlike  an  ordinary  earth-worm,  except  that  they  are  provided  with  small  papilliB 
or  hairs.  The  worm  also  possesses  longitudinal  strite  and  transverse  rings,  a  mouth, 
and  an  anus.  They  are  not  hermaphroditic,  but  occur  in  the  form  of  the  male  and 
female  worm. 

They  are  met  with  far  more  frequently  in  children  than  in  adults.  The  female 
worm  is  of  a  light  brown,  or  red,  color,  and  is  usually  about  10  to  20  cm.  long  and 
0..5  cm.  thick.     The  male  is  about  one-half  the  size  of  the  female. 

IIow  these  worms  gain  access  to  the  body  is  not  known,  although  it  may  be  by 
ingestion.  While  they  most  commonly  are  found  in  the  small  intestine,  they 
occasionally  find  their  way  from  the  intestine  into  the  stomach,  and  cases  are  on 
record  in  which  they  have  wandered  into  the  esophagus  and  mouth,  and  even  into 
the  nose  and  bronchial  tubes.  Cases  have  also  been  reported  in  which  the  migra- 
tion of  a  worm  into  the  gall  duct  has  produced  ol)struction,  and  still  other 
instances  are  recorded  in  which  they  have  found  their  way  through  an  ulcer,  or 
through  a  perforation  in  the  appendix  vermiformis,  into  the  peritoneal  cavity. 
As  a  rule  they  are  present  in  the  intestines  in  numbers  and  do  not  occur  singly. 
In  rare  cases  coiled,  mottled  masses  of  lunibricoids  ha\'e  caused  intestinal 
obstruction. 

A  I'orTn  of  round  worm,  somewhat  like  that  found  in  man,  is  found  in  the  intestine 
oF  cats  and  dogs,  but  it  is  considerably  smaller  in  size  and  does  not  infest  man. 

Symptoms. — The  symptoins  of  the  i)resence  of  this  worm  do  not  difl'er  materially 
from  those  produced  liy  the  taj)eworm  (which  see).  Occasionally,  however,  this 
worm  seems  to  have  the  power  of  producing  an  irritant  poison  which  not  only  causes 
intestinal  irritation,  but  when  absorbed  may  cause  great  ner\()us  irritation  and 
apparently  be  responsible  for  convulsions  in  young  children. 


NEMATODES  337 

Treatment. — ^The  treatment  of  a  patient  suffering  from  Ascaris  lumhricoidcH 
is  abstinence  from  food  for  twelve  or  eighteen  hours  and  the  administration  of 
1  drachm  of  the  fluid  extract  of  spigelia,  or  2  drachms  of  the  more  old-fashioned, 
but  efRcacious,  fluid  extract  of  spigelia  and  senna.  In  other  cases,  .5  to  1.")  minims 
of  the  oil  of  chenopodium  in  capsule  or  emulsion,  or  on  sugar,  may  be  administered. 
In  still  other  cases  from  1  to  2  grains  of  santonin  may  be  given  in  tablets  or  troches. 
All  of  these  drugs  should  be  followed  by  castor  oil  or  a  saline  purge  in  order  to 
sweep  out  the  worms  while  they  are  poisoned  by  the  drug. 

Oxyuris  Vermicularis. — Under  the  name  Oxyuris  vermicularis  or  thread-worm, 
sometimes  called  pin-worm,  a  very  small  nematode  worm  exists  in  the  rectum  of 
young  children  and  is  sometimes  found  in  adults.  Occasionally  it  infests  the  entire 
colon.  The  length  of  the  female  is  about  10  mm.,  and  of  the  male  about  4  mm. 
This  worm  may  be  present  in  great  numbers  without  producing  any  symptoms 
whatever.  Some  irritation  about  the  anus  may  be  the  only  disturbance  produced 
by  their  presence. 

Seat-worms  are  to  be  removed  by  the  injection  into  the  bowel  of  soap  and  water, 
which,  after  it  is  passed,  is  to  be  followed  by  a  pint  of  warm  water  which  has  been 
medicated  by  boiling  in  it  from  |  to  1  ounce  of  quassia  chips. 

Trichina  Spiralis.^A  patient  infected  by  the  parasite  known  as  the  Trichina 
spiralis  is  said  to  suffer  from  irichiniasis.  This  parasite  was  first  described  by 
Owen  in  1835.  It  was  found  in  the  flesh  of  the  hog  by  Leidy  in  1S47,  and  in  a 
human  being  by  Zenker  in  1860;  the  patient,  a  young  girl,  being  thought  to  be  a 
suiTerer  from  enteric  fever  until  at  autopsy  the  parasites  were  found  free  in  the 
bowel  and  encapsulated  in  the  muscles. 

Etiology. — In  practically  every  case  the  infection  of  a  human  being  comes  from 
eating  the  flesh  of  an  infected  hog.  It  is  scarcely  necessary  to  state  that  infection 
does  not  occur  if  the  pork  has  been  well  cooked. 

The  frequency  with  which  the  disease  occurs  is  not  known,  but  it  is  not  as  rare 
as  some  have  thought.  Williams  found  it  present  27  times  in  505  unselected 
autopsies  in  Buffalo,  New  York. 

If  the  muscle  of  a  man  infected  by  this  parasite  is  examined,  tiny  little  white 
or  gray  dots  will  be  found  upon  its  surface  and  through  its  texture;  later  the  parasites 
encapsulate  and  look  like  deposits  of  calcareous  material  of  about  the  size  of  miliary 
tubercles.  If  such  a  calcareous  deposit  be  opened  it  may  be  found  to  contain  the 
embryo  of  the  parasite,  or  if  the  worm  be  dead  a  granular  detritus  only  is  present. 

When  uncooked  meat  containing  this  parasite  is  swallowed,  the  digestive  juices 
dissolve  the  capsule  of  the  parasite,  and  in  this  way  the  embryos  are  set  free  in  the 
stomach.  Here  they  rapidly  develop  and  become  sexually  mature  in  about  seven 
days.  The  female  parasite  gives  off  an  immense  number  of  embryos,  so  that  it  is 
estimated  that  one  parasite  may  throw  off  from  one  to  two  thousand  young.  These 
parasites  soon  find  their  way  through  the  wall  of  the  intestine,  enter  the  lymph 
spaces,  and  so  reach  the  circulation,  by  which  they  pass  to  the  muscles.  Their 
favorite  position  for  settlement  is  the  striated  muscles.  They  enter  the  muscular 
connective  tissue  and  then  the  sarcolemma,  where  they  coil  themselves  and  cause 
a  disintegration  of  the  contractile  substance.  Here  they  become  encapsulated 
in  about  six  weeks,  partly  by  the  inflammatory  exudate  which  is  produced  by 
their  presence,  and  partly  by  the  calcareous  material  which  they  seem  to  have  the 
power  of  collecting.  In  these  capsules  the  parasite  remains  alive  for  a  very  long 
period  of  time,  possibly  for  twenty-five  years.  Occasionally,  however,  it  dies, 
and  the  entire  mass  undergoes  calcification. 

When  one  of  the  domestic  animals  swallows  meat  infected  in  this  way,  the  same 
process  takes  place  in  the  muscles  as  occurs  in  the  muscles  of  man.  In  the  muscles 
of  the  hog  the  parasite  may  escape  notice,  as  it  often  lacks  the  calcified  capsule. 

Moreover,  an  infected  hog  may  be  in  excellent  health, 
22 


338  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

Pathology  and  Morbid  Anatomy. — Tlie  lesions  of  trichiniasis  consist  in  gastro- 
intestinal irritation,  o\c'rgT()\vtli  of  the  lymph  nodes  in  the  abdominal  cavity,  occa- 
sionally l)roncliopneunionia  with  n;reat  swelling  of  the  bronchial  glands,  still  more 
rarely  fatty  degeneration  of  the  liver,  and  constantly  a  parasitic  myositis  due  to 
the  embryos  invading  the  muscles.  Almost  every  muscle  of  the  body  may  be 
found  infected;  but  where  the  number  of  trichina;  is  not  very  great,  the  muscles 
of  the  neck,  the  intercostal  muscles,  and  the  diaphragm  seem  to  be  the  parts  in 
which  the  greatest  aggregations  occur.  Furthermore,  the  greatest  number  of 
trichinae  are  usually  found  near  the  insertions  of  the  muscles. 

Sjrmptoms. — The  symptoms  consist  in  muscular  soreness  and  ixiin,  and  disinclina- 
tion to  move.  A  diagnosis  of  muscular  rheumatism  is  often  made  because  of  these 
symptoms.  Headache,  'puffiness  of  the  skin  about  the  eyes  and  nose,  and  moderate 
fever  are  also  present.  Not  rarely  the  symptoms  may  closely  resemble  those  of 
typhoid  fever,  with  great  prostratimi  and  emaciation.  For  some  unknown  reason 
a  marked  leukocytosis  develops,  which  is  peculiar  in  the  fact  that  the  eosinophUe 
corpuscles  are  chiefly  increased.  From  investigations  made  by  Opie  it  would 
appear  probable  that  this  eosinophilia  is  of  some  value  from  both  a  diagnostic 
and  prognostic  stand-point.  The  eosinophiles  are  not  greatly  increased,  if  the 
infection  by  trichinae  is  excessive,  and  their  greatest  development  seems  to  occur 
at  about  the  time  that  the  embryonal  trichins  are  passing  from  the  intestine  by 
way  of  the  lymphatics  and  blood  to  the  muscular  tissues — that  is,  during  the  third 
week  after  the  ingestion  of  the  trichinatous  meat. 

Diagnosis. — In  a  suspected  case  the  diagnosis  may  be  reached  by  taking  a  small 
piece  of  muscle  and  examining  it  with  a  microscope.  The  stools  of  the  patient 
should  be  flattened  to  a  thin  layer  between  two  sheets  of  glass  resting  upon  a  black 
background,  and  then  examined  by  means  of  a  hand  magnifying  glass,  when  the 
parasite  may  be  found  as  small,  short,  glistening,  tliread-like  bodies. 

Prognosis. — The  prognosis  depends  largely  upon  the  severity  of  the  infection. 
In  the  worst  outbreaks  the  mortality  may  be  as  high  as  70  per  cent.  Many  cases 
recover  by  the  end  of  a  fortnight.  Others  remain  ill  for  weeks  or  months  before 
recovery  takes  place. 

Treatment. — There  is  no  treatment  which  can  be  directed  to  the  removal  of  the 
parasite  after  it  has  entered  the  muscles.  The  only  thing  the  physician  can  do  is 
to  give  a  nutritious  diet,  and  relieve  pain  or  other  s.vmptoms  by  symptomatic 
remedies.  If  the  discovery  is  made  that  the  patient  has  swallowed  trichinatous 
pork  within  a  few  hours,  then  .5  grains  of  thymol  followed  by  a  dose  of  sulphate 
of  magnesium  should  be  ordered,  to  kill  the  parasite  and  sweep  it  out  of  the 
intestines  before  it  can  migrate  into  the  tissues. 

Uncinariasis  (Ankylostomiasis). —  Definition. — Uncinariasis  is  an  infection  by 
different  varieties  of  worm  of  the  imcinaria  species;  it  occurs  not  only  in  man,  but 
in  many  of  the  lower  animals.  The  parasite  is  often  called  the  Ankylostomum 
duodcnale,  or  hook-worm.  The  chief  symptoms  are  severe  anemia,  abdominal 
pains,  asthenia  without  emaciation,  and  edema.  The  parasite  was  described  as 
uncinaria  by  Froelich  in  1789;  Dubini,  in  1843,  gave  it  the  name  ankylostoma. 

The  condition  is  also  known  as  "  brickmakers'  anemia,"  "Eg\'ptian  chlorosis," 
"miners'  anemia,"  "miners'  cachexia,"  "miners'  disease,"  "Porto  Rican  anemia," 
"St.  Gothard's  tunnel  disease,"  "tunnel  disease,"  "tunnel  anemia,"  "tropical 
chlorosis,"  and  "hook-worm  disease,"  besides  a  host  of  local  names.  It  is  one  of 
the  most  ancient  diseases  known  to  man,  for  it  was  described  by  the  Egyptians 
3500  years  ago. 

Frequency. — Uncinariasis  occurs  in  all  the  tropical  and  practically  all  the  sub- 
tropical world.  According  to  Thornton  it  is  the  greatest  enemy  of  the  human 
race  in  the  tropics;  greater  even  than  plague  or  cholera.  In  portions  of  India  7.5 
per  cent,  of  the  population  are  said  to  be  affected.     In  Egypt  this  worm  is  found 


NEMATODES  SSO 

at  nearly  every  postmortem.  It  has  been  the  most  disabling  of  all  diseases  in  the 
Egyptian  army,  as  well  as  the  greatest  cause  for  the  rejection  of  recruits.  In 
Ceylon  its  ravages  are  said  to  be  more  serious  than  those  of  cholera.  Harris  has 
found  it  in  Georgia  and  Florida,  and  believes  it  is  the  common  cause  of  the  severe 
anemias  of  the  Southern  United  States  that  have  hitherto  been  regarded  as  malarial. 
Stiles  has  also  made  very  valuable  studies  of  its  characters  and  recurrence  in  the 
Southern  United  States.  In  Assam  it  is  almost  universal,  299  cases  having  been 
found  in  300  postmortems.  According  to  Alden,  22. .5  per  cent,  of  the  total  death 
rate  of  Porto  Rico  was  ascribed  to  tropical  anemia  due  to  uncinaria,  and  Igaravidez, 
King  and  Ashford  found  that  90  per  cent,  of  the  peasants  were  infected,  300,000 
persons  having  less  than  50  per  cent,  hemoglobin.  In  more  temperate  regions  it 
has  been  found  in  nearly  all  our  States  as  far  north  as  New  York.  In  the  Cornwall 
and  Westphalian  mines  the  disability  caused  by  this  parasite  has  become  so  great 
as  to  threaten  the  existence  of  these  industries. 

Etiology. — The  uncinaria  is  a  nematode  worm  of  the  family  Strongylidas .  It  is 
very  widely  distributed  in  the  animal  world,  in  distinct  species.  In  man  two 
species  are  recognized,  viz.,  Uncinaria  duodenale  (Dubini)  and  Necator  americanus 
(Stiles),  commonly  spoken  of  as  the  old-world  and  the  new-world  uncinaria,  or 
hook-worm.  The  two  sexes  are  distinct;  the  male  worm  is  from  S  to  10  mm.  long 
and  the  female  slightly  longer,  10  to  18  mm.  They  are  grayish-white  in  color, 
cylindrical  in  shape,  with  a  contracted  head,  and  in  the  female  a  broad  caudal 
bursa.  When  male  and  female  worms  are  present,  as  they  usually  are  in  the  propor- 
tion of  one  male  to  three  females,  the  female  produces  an  enormous  number  of  ova. 
When  deposited  in  favorable  surroundings  these  ova  develop  into  embryos  in 
twenty-four  hours.  The  embryo  grows  rapidly,  passing  through  two  ecdyses  in 
about  five  days.  The  second  ecdysis  is  the  termination  of  the  extra-corporeal 
phase,  and  the  embryo  is  now  infective  for  man.  When  taken  into  its  appropriate 
host  the  worm  goes  through  three  more  ecdyses,  making  five  in  all;  the  fourth  mark- 
ing the  formation  of  a  provisional  buccal  armature;  the  fifth,  the  appearance  of  the 
definite  armature.     It  then  reaches  an  adult  or  matiu-e  form  in  from  five  to  six  weeks. 

In  by  far  the  larger  proportion  of  cases  the  infection  takes  place  through 
the  skin  during  or  after  the  second  ecdysis  of  the  worm.  Even  exposure  to  infected 
mud  for  a  few  minutes  may  be  followed  by  itching,  redness,  swelling  and  the  develop- 
ment of  papules  which  become  vesicles  and  sometimes  pustules.  This  state  is 
called  "ground  itch."  Very  rarely  the  infection  depends  upon  the  ingestion  of 
infected  water  or  food  and  the  accidental  ingestion  of  infected  earth  from  soiled 
hands.  There  is  no  doubt  that  geophagy  in  infected  areas  is  a  common  manner 
of  taking  the  disease;  but  it  is  also  true  that  this  habit  does  not  show  itself,  in  many 
cases,  until  the  disease  is  fully  de\'eloped.  In  these  cases  it  seems  clear  that  the 
earthy  matter  is  eaten  in  obedience  to  an  instinctive  craving,  and  that  it  brings 
relief  by  mechanically  loosening  a  number  of  the  parasites. 

Prophylajds. — Prophylaxis  of  uncinariasis  demands  the  exclusion  of  all  infected 
persons  from  earth-workings.  Where  large  bands  of  laborers  are  collected  in 
districts  in  which  the  disease  is  prevalent,  in  mines,  in  tunnels,  and  in  excavations 
of  all  kinds,  systematic  examination  of  all  cases  of  anemia  should  be  made.  Defeca- 
tion in  the  workings  or  tunnels  should  be  rigorously  prohibited.  Water-tight 
latrines  should  be  provided,  and  the  contents  rendered  harmless  by  a  cheap  disin- 
fectant. In  the  Arlberg  tunnels  the  pail  system  was  used  with  good  effect. 
Personal  prophylaxis  should  include  careful  washing  of  the  hands  before  eating, 
and  the  wearing  of  sound  shoes  when  working  in  suspected  soils. 

Pathology  and  Morbid  Anatomy. — Postmortem  the  subcutaneous  fat,  the  pannic- 
ulus  adiposus,  and  the  mesenteric  fat  are  fairly  well  preserved.  The  parasites 
are  found  in  the  jejunum,  still  attached  to  the  bowel  wall  if  the  section  is  early,  or 
free  in  the  intestinal  contents  if  the  section  is  delayed.    They  vary  in  number 


340 


DISEASES  DUE  TO  A  SPECIFIC  INFECT  I  OX 


from  100  to  GOO  or  more.    The  jejunum  is  covered  with  old  r.nd  recent  pinhead, 
bloody  extravasations.     The  bowel  is  thickened  in  spots,  and  there  may  be  small 
cavities  in  the  bowel  wall  filled  with  blood  and  con- 
FiG.  64  taining  the  heads  of  one  or  two  parasites.     The  liver 

and  kidneys  commonly  show  some  degree  of  fatty 
degeneration.  The  cause  of  the  anemia  is  probably 
twofold — the  mechanical  abstraction  of  a  consider- 
able amount  of  blood  by  the  parasites,  and  a  hemo- 
lytic effect  from  a  toxin  elaboraterl  by  the  worm. 
That  hemolysis  occurs  is  indicated  by  increased 
iron  in  the  liver,  the  occurrence  of  hematoidin  in 
the  liver  and  kidneys,  as  well  as  free  iron  in  tiie 
stools.     The  spleen  is  shrunken. 

The  blood  shows  the  ordinary  changes  similar  to 
those  observed  in  pernicious  anemia.  In  early  cases 
the  color-index  may  be  low,  the  loss  of  hemoglobin 
being  more  rapid  at  first  than  the  red-cell  loss.  The 
actual  hemoglobin  is  often  remarkably  low,  reaching 
8  per  cent.,  15  per  cent,  being  commonly  found. 
As  the  case  advances,  however,  the  hemoglobin 
index  rises  and  may  be  plus.  ^legaloblasts  are  not 
seen  in  as  large  numbers  as  in  other  pernicious  ane- 
mias. There  is  no  marked  leukocytosis;  there  is, 
however,  a  fairly  constant  relative  increase  in  the 
eosinophiles,  ranging  from  3  to  30  per  cent.,  and 
Ashford  and  King  of  the  United  States  Army  have 
shown  that  a  rise  in  the  number  of  eosinophiles  is  of 
favorable  omen.  A  low  eosinophile  count  in  se\-ere 
cases  is  an  evil  sign. 

The  feces  contain  the  ova.  They  also  contain 
considerable  blood,  in  which  differential  staining 
will  demonstrate  a  great  many  eosinophiles,  showing 
that  there  is  not  only  a  general  increase  in  these 
cells  in  the  circulation,  but  that  there  is  an  active 
determination  of  them  to  the  intestinal  lesions. 
Charcot-Leyden  crystals  are  constantly  present. 

Symptoms. — The  symptoms  \"ary  with  the  nimiber 
of   parasites  in  the  intestines  and  with  the  general 
condition  of  the  patient.     Recent  observations  seem 
to  make  it  clear  that  the  new- 
world  hook-worm  is  not  nearly 
so  fatal  as  the  old-world  hook- 
worm.    If  there  be   but  a  few 
worms,    the   general    symptoms 
produced  are  very  mild.     If,  on 
the  other  hand,  the  worms  run 
up   into  the  hundreds  or  thou- 
sands, the    blood    destruction  is 
extensive.    In  conditions  of  great 
\t..i,.  „f  \,  i„.i    .         1    J      1         111         u  deterioration,  in  the  half-starved 

Male  of  AnUyloslonia  duodcnalc:     ri,  bead;  li,  esophagus:  ...  ....  ,  . 

c,  gut;  d,  anal  glands;  e,  cervical  glands;  /,  skin;  g,  muscular  Orill-nourished,macuteorchromc 

layer;  h,  excretory  pore;  i,  tri-lobeJ  bursa;  k,  ribs  of  bursa;  /,  dvscntcr\',  the  presence  of  onl\'  a 

seminal  duct;  wi,  vesicula  seminalis;  n,  ductus  ejaculatorius;  c'        Cl.^'  -^  / 

0.  its  groove;  p,  penis;   g.    penile   sheath.     Magnification,  '^W  ot  these  parasites  may  act  as 

20.    (After  Schuithess,  from  Ziegler.)  a  Very  dangerous  Complication. 


NEMATODES 


341 


In  well-developed  cases  the  symptoms  are  those  of  pemicumn  anemia.  The 
principal  phenomena  are  dysyeplic  sym'ptoms  with  colicky  pains  in  the  early  stages, 
followed  by  progressive  anemia  with  little  or  no  emaciation,  and  with  terminal 
edema.  The  pain  in  uncinariasis  is  colicky  in  character,  is  one  of  the  earliest  symp- 
toms, and  is  fairly  constant  throughout  the  disease.  In  cases  in  which  onl\-  a  few- 
parasites  are  present,  it  may  amount  only  to  uneasiness;  when  there  are  many,  it 
may  be  severe.  Like  all  abdominal  pains  due  to  intestinal  parasites  it  is  relieved 
by  food  for  the  time  being.  The  appetite  is  very  \-ariable;  it  may  be  voracious 
or  it  may  be  diminished,  and  curious  perversions  of  taste,  such  as  earth-eating, 

may  develop. 

Fig.  6.5 


,  '^h- 


I   I   I    I   I    I  I    I    I    I    I   I    '    I    I    I    I    I    M    I   I    I    I    I    !    I    I    I    I    I   I    I    I    I    I   I    I    I    I 


Ova  and  embryo  of  Uncinaria  americana:  a,  unicellular  ovum;  b,  c,  d,  e,  ova  showing  various  stages 
of  segmentation;  /,  g,  ova  containing  larval  uncinarise;  h,  peculiarly  shaped  o\-um;  i,  larval  worm  just 
emerged  from  shell:  ,7,  larva  extended  .ifter  emergence.     (Stiles.) 


Following  the  development  of  the  colic,  anemia  appears  and  rapidly  becomes 
profound.  There  is  very  little  wasting,  the  subcutaneous  fat  being  fairly  well 
preserved.  The  slcin  is  a  lemon-white  color;  the  conjunctivae  and  lips  are  exsan- 
guinated; the  sclerse  pearly  or  muddy-white.  All  the  subjective  phenomena  of 
profound  anemia  become  marked.  There  is  lassitude,  hreaihlessness  on  the  slightest 
exertion,  vertigo,  and  occasionally  dimness  of  vision  from  retinal  hemorrhages. 
Crises  of  fever  occur  that  may  last  for  days  or  weeks.  Auscultation  over  the  precor- 
dial area  reveals  soft  hemic  bruits,  propagated  to  a  remarkable  distance  into  the 
great  vessels.  The  face  and  ankles  become  puffy,  and  there  may  be  a  slight  general 
edema.  Harris  has  reported  a  case  of  uncinariasis  with  sjTnptoms  resembling 
pellagra.  When  the  disease  attacks  children  before  the  age  of  puberty,  bodily 
and  mental  growths  are  stunted.  The  pubic  hair,  the  axillary  hair,  and  the  hair 
on  the  face  is  scanty  or  absent,  the  limbs  are  thin  and  unde^'cloped,  and  the  children 
are  markedly  pot-bellied.  Stiles  describes  a  fish-like,  staring  expression  of  the 
eyes  in  these  cases. 

Diagnosis. — The  diagnosis  is  easy,  once  the  attention  is  directed  to  the  intestinal 
parasites.  The  occupation  of  the  patient,  if  it  be  one  that  predicates  working 
in  earth,  is  very  suggestive.  The  anemia  is  very  commonly  diagnosticated  as 
malarial.  There  really  is  no  diagnostic  difficulty  between  malarial  anemia  and 
the  parasitic  anemia.  This  very  common  error  has  been  made  because,  in  the 
intensely  malarial  regions,  the  existence  of  this  parasite  has  not  been  generally 


342 


DISEASES  DUE  TO  A  SPECIFIC  INFECTION 


known.  The  disease  has  also  been  mistaken  for  heril)eri,  l)nt  tliere  is  a  complete 
absence  of  paralytic  symptoms  in  uncinariasis. 

A  diagnostic  sign  is  the  occurrence  of  triangular  black  or  bluish  patches  on  the 
dorsum  of  the  tongue,  looking  as  thougli  a  pen  had  l)cen  wiped  on  it.  This 
appearance  is  quite  striking.  It  is  very  constant,  and  appears  early,  even  before 
the  advent  of  pronovmced  anemia,  and  persists  to  the  end  of  the  disease. 

The  diagnosis  is  definitely  made  by  the  demonstration  of  the  ova  or  parasites 
in  the  feces.  Search  should  be  made  in  as  fresh  specimens  as  possible,  to  avoid 
confusion  in  case  embryos  have  occurred  and  cjuitted  the  ova.  A  small  amount 
of  the  material  is  placed  on  a  large  glass  slide  diluted  with  distilled  water,  and 
pressed  down  with  a  thick  cover.  The  ova  of  uncinaria  are  very  striking  bodies. 
They  are  clear,  transparent,  light  gray  in  color;  they  have  a  delicate,  transparent 
capsule,  containing  in  its  centre  from  one  to  six  gray  yolk  segments  with  gramilar 
nuclei.  In  shape,  they  are  regularly  oval,  with  an  average  length  of  60  microns  and 
an  average  width  of  35  microns.  Leichtenstern  has  found  as  many  as  4,216,930  ova 
in  a  single  stool.  Care  must  be  taken  not  to  mistake  the  egg  of  the  Ascaris  lumbri- 
coides  for  the  egg  of  the  uncinaria.  The  former  have  a  thick,  gelatinous,  often 
mammillated  covering,  and  unsegmented  protoplasm.  So,  too,  the  egg  of  the 
Ox-yuris  vennicularis,  which  is  a  thin,  symmetrical  shell,  one  side  of  which  is  almost 
straight  and  which  contains  an  embryo,  may  be  mistaken  for  the  ova  of  the  uncin- 
aria. The  egg  of  the  whip-worm,  Trichocephalus  dispar,  possesses  a  smooth, 
thick  shell,  apparently  perforated  at  each  end,  with  unsegmented  protoplasm. 


DOSES  OF  THYMOL 
Boycott's  chart  showing  results  of  treatment  with  thyniol  in  ankylostomiasis. 


Stiles  has  well  described  a  rapid  and  effective  test,  where  microscopic  evidence 
cannot  be  obtained.  The  stool  is  placed  on  ordinary  white  blotting-paper,  and 
allowed  to  stand  for  one  hour.  A  rusty-red  discoloration  or  stain  develops  along 
the  edge  of  moisture,  resembling  somewhat  that  due  to  the  presence  of  blood,  and 
indicates  the  probable  presence  of  uncinaria.  Stiles  directs  that  if  uncinariasis  is 
suspected,  and  it  is  not  practicable  either  to  make  a  microscopic  examination  or  to 
delay  matters  until  a  specimen  can  be  sent  away  for  examination,  still  another 
method  of  diagnosis  is  possible.  Give  a  small  dose  of  thymol,  followed  by  Rochelle 
salts,  and  collect  all  of  the  stools  passed.   Wash  the  stools  thoroughly  several  times 


NEMATODES  :M3 

in  a  bucket,  and  examine  the  sediment  for  worms  about  half  an  inch  long,  about 
as  thick  as  a  hairpin  or  hatpin,  and  with  one  end  curved  back  to  form  a  hook. 

Treatment. — In  the  treatment  of  uncinariasis  there  are  two  drugs  of  value:  male 
fern  and  thymol.  Of  the  two  the  more  effective  is  thymol  or  its  derivative,  thymol 
urethane  (thymol  carbonic  ether).  Thymol  should  be  given  in  capsule,  or  in 
emulsion  with  acacia,  in  the  dose  of  30  grains  repeated  in  two  hours  to  a  strong  adult. 
In  these  doses  the  drug  occasionally  causes  vertigo,  excitement,  and  smoky  urine. 
For  one  or  two  days  prior  to  the  administration  of  the  remedy  patients  should  be 
put  on  liquid  diet  and  given  a  brisk  saline  purge  the  night  before.  It  is  best  to 
restrict  the  quantity  of  food.  In  administering  thymol,  it  is  essential  that  none  of 
the  solvents  of  the  drug  be  given  either  with  it  or  immediately  after.  Several 
cases  of  poisoning  have  occurred  when  alcohol  or  alcoholic  drinks  have  been  given 
with,  or  closely  after,  a  dose  of  thymol.  Similarly,  ether,  chloroform,  glycerin,  and 
most  oils  act  as  solvents,  and  may  cause  severe  toxic  symptoms  owing  to  the  absorp- 
tion of  the  drug  in  bulk.  In  order  to  prevent  poisoning,  therefore,  thymol  should 
be  followed  by  a  saline  purge,  and  castor  oil  should  not  be  used.  Weekly  examina- 
tions of  the  stools  should  be  made,  and  as  long  as  ova  or  Charcot-Leyden  crystals 
are  found  the  use  of  this  remedy  must  be  repeated.  Sometimes  thymol  is  vomited, 
and  in  rare  cases  proves  inactive.  In  these  the  male  fern  should  be  adminis- 
tered the  the  usual  way,  or  beta-naphtol,  .30  grains  at  a  dose,  or  eucalyptus  oil 
employed.  After  the  expulsion  of  the  worm,  the  therapeutic  indications  are  the 
same  as  for  advanced  anemia  from  any  other  cause.  Ashford  showed  that  by  the 
use  of  thymol  in  Porto  Rico  90  per  cent,  of  300,000  infected  persons  were  cured 
at  a  cost  of  60  cents  apiece  (Fig.  66). 

Filariasis  (Filaria  Sanguinis  Hominis). — Defmition  and  History. — ^The  group  of 
FilaricB  includes  a  number  of  species.  The  human  parasite  was  first  discovered  by 
Demarquai  in  1863  in  a  chylocele  and  demonstrated  in  the  peripheral  circulation 
by  Lewis  in  1872.  The  principal  varieties  affecting  man  are  the  following:  Filaria 
nocturna,  Filaria  diurna,  Filaria  perstans,  Filaria  demarquaii,  Filaria  ozzardi, 
Filaria  magalhaesi,  and  Filaria  loa.  Of  this  group  the  Filaria  nodurna  and  the 
Filaria  loa  are  the  only  ones  known  to  cause  definite  pathological  conditions. 

The  geographical  distribution  of  the  Filaria  nocturna  is  very  extensive.  It  is 
found  in  all  tropical  and  in  most  subtropical  countries.  Its  southerly  limit  of 
observation  is  Brisbane.  In  the  United  States  it  has  been  found  in  Alabama, 
Louisiana,  South  Carolina,  Pennsylvania,  Illinois,  and  New  York.  In  the  Samoan 
Islands  from  10  per  cent,  to  50  per  cent,  of  the  inhabitants  are  said  to  be  infected, 
and  in  the  Friendly  Islands  32  per  cent.  In  Porto  Rico  the  native  troops  showed 
12  per  cent.,  and  small  communities  may  have  as  high  as  70  per  cent,  of  the  total 
population  infected. 

Filaria  Nocturna. — -This  parasite  has  two  corporeal  and  one  extracorporeal 
phase.  First,  the  parent  worm,  whose  normal  habitat  is  the  lymphatic  sj'stem; 
second,  the  embryo  found  in  the  circulating  blood,  and  third,  the  intermediary 
stage  in  the  body  of  the  mosquito,  which  has  been  definitely  shown  to  be  the  inter- 
mediary host  for  this  parasite.  When  examined  in  a  drop  of  peripheral  blood  the 
embryonic  form  is  found  as  a  minute  transparent  worm,  one-eightieth  of  an  inch 
in  length  and  about  the  diameter  of  a  red  blood  corpuscle.  It  has  a  transparent 
sheath,  or  sac,  somewhat  longer  than  the  body  of  the  embryo,  and  is  usually  present 
in  very  great  numbers. 

The  most  striking  cahracteristic  of  this  filaria  is  the  periodicity  of  its  appearance. 
They  are  found  only  at  night  in  the  peripheral  circulation,  hence  the  name  Filaria 
nocturna.  In  the  daytime  they  entirely  disappear  and  retire  to  the  larger  vessels, 
particularly  the  vessels  of  the  lungs.  The  periodicity  may  be  reversed  by  causing 
the  patient  to  sleep  in  the  daytime,  when,  after  a  few  days,  the  embryos  are  found 
in  the  peripheral  blood  during  the  day  and  are  absent  at  night. 


344  DISEASES  DUE  TO  A  SPECIFIC  INFECTIOX 

Tlie  microscopic  demonstration  of  the  worm  is  easy.  The  blood  should  be 
drawn  near  midnight,  when  the  parasites  are  most  numerous.  A  hirge  drop  of 
blood  should  be  taken  and  a  thick,  coarse  spread  made.  The  slides  are  dried  in 
air  without  covers,  or,  if  it  is  desired  to  study  the  parasite  in  motion,  the  blood  rlrop 
is  covered  with  a  cover-slip  and  ringed  with  vaselin.  In  such  a  preparation  the 
filaria  retains  its  motility  for  days.  The  worms  are  quite  large;  an  inch  objective 
will  be  ample  for  the  search  and  demonstration. 

As  already  stated  the  mosquito  is  the  intermediary  host.  When  a  mosquito 
sucks  tlie  blood  of  a  patient  containing  filaria^  the  parasites  escape  from  their 
sheath  while  the  blood  is  still  in  the  stomach  of  the  insect.  Thence  they  pass  to 
the  thoracic  muscles.  In  this  location,  in  from  six  to  seven  days,  the  metamorphosis 
from  embryo  to  the  young  of  the  adult  form  takes  place.  The  minute  filarise 
migrate  to  the  proboscis  and  are  found  lying  in  pairs  in  the  labia,  whence  they  are 
imdoubtedly  carried  into  the  circulation  of  the  first  warm-bloodefl  animal  bitten 
by  the  insect.  The  possibility  of  the  filarise  being  passed  into  water  when  the  mos- 
quito lays  her  eggs,  and  being  carried  thence  into  the  stomach  in  drinking  water, 
is  also  to  be  remembered.  Female  mosquitoes,  both  of  the  culex  and  anopheles 
species,  are  capable  of  acting  as  the  intermediary  host. 

The  adult  form  of  the  parasite,  commonly  known  as  the  Filaria  bancrofti,  is  a 
long,  delicate,  nematode  worm.  It  is  from  three  to  four  inches  in  length  and  the 
thickness  of  a  coarse  hair  or  bristle.  The  sexes  are  distinct.  The  habitat  of  the 
parent  worm  is  the  lymphatic  system,  commonly  the  thoracic  duct,  although  any  . 
portion  of  the  peripheral  lymphatics  may  be  invaded.  There  may  be  only  one 
worm  of  each  sex  or  there  may  be  many. 

The  Filaria  diurna  presents  minor  differences  in  structure  and  occurrence  from 
the  Filaria  nocturna.  The  chief  difference  is  that  it  is  found  in  the  peripheral 
circulation  only  in  the  daytime.  It  is  supposed  that  the  Filaria  diurna  is  the 
embryonic  form  of  the  Filaria  loa.    Nothing  is  known  of  its  pathological  significance. 

The  Filaria  persians  is  common  in  certain  districts  of  West  Africa,  where  it 
occurs  in  as  much  as  50  per  cent,  of  the  population.  This  parasite  is  found  in  the 
peripheral  circulation  at  all  times,  day  and  night;  hence  its  name.  The  pathological 
significance  of  this  filaria  is  unknown.  It  was  for  a  time  supposed  to  be  the  cause 
of  sleeping  sickness,  and  was  also  found  very  commonly  in  association  with  craw- 
craw,  an  itching,  pustular  affection  of  the  skin. 

Pathology  and  Morbid  Anatomy. — Filariasis  causes  no  symptoms  in  the  large 
majority  of  cases.  The  embryos  are  innocuous.  When  symptoms  develop  they 
are  due  to  the  parent  worm  or  an  immature  product  of  the  parent  worm.  The 
lesions  produced  are  divided  into  two  broad  classes,  namely,  those  which  are  due 
to  lymphatic  varix  from  stasis,  and  those  due  to  edema  from  lymphatic  obstruction. 
The  parent  worms,  when  present  in  numbers,  may  mechanically  plug  the  thoracic 
duct  or  one  of  the  larger  lymphatic  trunks.  They  may  also  initiate  a  lymphangitis, 
with  thickening  and  occlusion  of  the  lymphatics.  Under  either  circumstance, 
stasis  and  retrograde  movement  of  the  lymph  current  are  inaugurated  and  eventu- 
ally a  compensatory  lymph  circulation  is  established.  The  result  is  engorgement 
of  some  portion  of  the  lymphatic  system  and  the  development  of  a  peculiar  group 
of  phenomena:  lymph  scrotum,  lymphatic  groin  glands,  varices  of  the  pelvic  or 
lumbar  lymphatic  trunks  or  of  the  lymphatics  of  the  bladder,  ureter,  or  kidney. 
As  these  varicosities  grow,  they  become  more  extensive,  and  rupture.  If  the 
rupture  be  in  the  genito-urinary  tracts,  chyluria  develops;  if  into  the  tunica  vagi- 
nalis, a  chylocele;  if  into  the  abdominal  cavity,  ch\lous  ascites.  These  are  the 
lesions  due  to  IjTnph  stasis  and  lymphatic  varices. 

In  the  second  group  the  lymph  stasis  is  associated  with  lymphangitis  followed 
by  obstruction,  resulting  in  the  formation  of  the  peculiar  solid  edema  and  the  huge 
hypertrophies  of  the  affected  tissues  known  as  elephantiasis. 


NEMATODES  345 

The  majority  of  cases  of  elephantiasis  are  clearly  due  to  filarial  disease.  The 
geographical  distribution  of  elephantiasis  and  filariasis  are  identical;  elephantiasis 
is  most  common  in  the  areas  most  severely  affected  by  filaria.  Lymphatic  varix 
and  lymph  scrotum  are  not  only  found  in  the  same  districts  as  elephantiasis,  but 
very  commonly  terminate  in  elephantiasis.  The  disease  is  also  seen  in  case?  of 
operative  removal  of  lymphatic  varices.  In  a  large  number  of  these  cases  the 
embryo  filaria;  cannot  be  demonstrated  in  the  peripheral  circulation.  This  is  due 
to  the  fact  that  the  parent  female  worm  lies  in  the  centre  of  the  inflamed  tissue  and 
because  the  embryos  cannot  pass  through  the  occluded  portion  of  tiie  lymphatic 
circulation.  Manson's  theory  as  to  the  direct  causation  of  elephantiasis  is  that 
the  parent  female  worm  migrates  to  one  of  the  peripheral  trunks.  While  in  this 
position  she  receives  an  injury  which  is  followed  by  premature  parturition  and  the 
expulsion  of  ova  instead  of  embryos.  These  ova  are  five  times  the  diameter  of  the 
embryos,  so  that  although  the  embryos  pass  freely  through  the  finer  lymphatic 
radicles  the  ova  block  up  the  smaller  lymph  channels,  forming  minute  emboli. 

Following  this  stage  of  embolism,  IjTnphangitis  with  inflammatory  thickening 
occurs.  When  the  inflammatory  process  subsides  the  deposit  is  in  small  part 
absorbed,  but  when  the  inflammation  recurs  an  additional  deposit  is  added  to  the 
remnant  of  the  first.  This  occurs  with  the  commonly  observed  clinical  history 
of  elephantiasis,  which  advances  by  crises  of  inflammation  and  a  general  symptom- 
complex  known  as  elephantoid  fever. 

As  already  stated,  filariasis  may  occur  without  any  symptoms  being  present 
until  the  lesions  just  described  develop. 

Symptoms. — Elephmitiasis. — The  most  common  location  of  elephantiasis  is  in 
the  legs;  next  in  the  scrotiun  of  the  male  and  the  labia  of  the  female.  It  occurs 
in  the  breast,  in  the  arms,  and  as  interstitial  or  pedunculated  masses  in  other  parts 
of  the  body.  These  tumors  occasionally  grow  to  enormous  dimensions.  A  scrotal 
tumor  of  50  pounds  is  not  at  all  uncommon,  and  one  has  been  reported  weighing 
224  pounds.  These  large  tumors  develop  as  described  with  elephantoid  fever. 
With  each  crisis  of  fever  and  IjTnphangitis  there  is  not  only  an  increase  in  the  size 
of  the  area  already  affected,  but  an  extension  into  new  territory. 

Elephantoid  fever  is  the  systemic  expression  of  the  lymphangitis  origmating  in 
filarial  varices  or  in  tissues  already  the  seat  of  elephantiasis.  The  attacks  recur 
at  varying  intervals  of  weeks  or  months.  Exciting  causes  may  be  slight  traumatism 
such  as  friction  of  the  clothing  over  the  occluded  Ij-mph  channels.  The  attack 
begins  with  rigor  and  high  fever,  with  all  the  usual  manifestations  of  febrile  disturb- 
ance, as  anorexia,  nausea,  and,  in  severe  cases,  delirium.  The  skin  over  the  inflamed 
lymphatic  area  is  hot,  tense,  and  red,  with  a  marked  degree  of  inflammatory  thicken- 
ing. After  persisting  a  few  days,  the  attack  ends  in  a  critical  sweat.  The  inflamma- 
tory thickening  remains.  The  attack  may  be  so  intense  as  to  result  in  the  formation 
of  abscess.  When  this  takes  place  in  superficial  lesions,  the  condition  is  readily 
recognized  and  the  treatment  is  obvious.  \^Tien  it  occiu-s  in  the  deeper  varices, 
as  in  the  pelvis  or  loin,  there  will  be  deep-seated  pain,  tenderness,  and  rapidly 
developing  sepsis. 

Hematochyluria  is  usually  paroxysmal  and  is  due  to  the  leakage  of  chyle  into 
some  portion  of  the  genito-urinary  tract.  The  common  location  of  the  leak  is 
in  the  lymphatics  surrounding  the  pelvis  of  the  kidneys  or  the  lymphatics  of  the 
bladder.  The  appearance  of  chyle  in  the  lu-ine  is  intermittent  and  is  not  accom- 
panied by  any  increase  of  symptoms.  The  urine  is  opaque  and  varies  in  color 
from  a  milky-white  to  a  deep  red  in  proportion  to  the  amount  of  blood  that  may 
be  mixed  with  the  chyle.  Chylous  urine  coagulates  on  standing  into  a  soft,  jelly- 
like clot.  In  a  few  hours  the  clot  contracts  and  forms  a  firm,  white  ball  floating 
in  a  milky  fluid.  Microscopically,  the  urine  contains  fat,  blood  cells  in  varying 
amount,  and  occasionally  embryo  filaria.     Chyluria  may  persist  for  many  years 


346  DISEASES  DUE  TO  A  SPECIFIC  IXFECTIOX 

without  great  deterioration  of  health.  The  only  symj^toms  may  be  a  dull  ])aiii  in 
the  loins  or  pelvis.  Osier  reports  a  case  of  intermittent  chj'luria  which  persistctl 
for  eighteen  years  without  any  special  discomfort.  When  chyle  escapes  in  large 
quantities,  clots  are  occasionally  formed  in  the  bladder  and  may  cause  urinary 
retention.  Medical  treatment  is  of  no  avail  in  this  conchtion,  but  the  patient 
should  be  put  at  rest  on  dry  diet,  with  as  great  restriction  as  possible  in  the  fatty 
elements  of  his  food.  Under  this  regimen  the  amount  of  chyle  may  be  notably 
diminished. 

Varicose  groin,  glands  is  a  varicose  condition  of  the  superficial  and  deep  inguinal 
lymphatics,  and  it  is  usually  bilateral.  It  gives  rise  to  doughy,  soft,  painless 
swellings  in  both  groins.  They  cause  little  trouble  until  lymphangitis  develops, 
when  they  may  become  very  painful.  They  have  been  mistaken  for  the  buboes 
of  plague,  and  are  commonly  mistaken  for  hernia. 

Lym.'ph  Scrotum. — In  this  condition  the  filarial  varLx  is  situated  in  the  lymphatics 
of  the  scrotum  and  is  usually  bilateral.  It  may  be  associated  with  the  enlargement 
of  the  groin  glands,  and,  like  that  state,  it  is  prone  to  accessions  of  lymphangitis. 
When  the  deeper  lymphatics  are  involved,  the  lymphangitis  may  extend  to  the 
testicle,  forming  what  is  known  as  filarial  orchitis. 

Treatment. — The  treatment  of  these  conditions  is  surgical.  Wlien  the  tumors 
become  so  large  as  to  be  a  burden  to  the  patient,  or  when  the  inflammatory  syni])- 
toms  cause  great  pain,  their  removal  should  be  undertaken.  The  removal  of  an 
enormous  scrotum  or  the  amputation  of  a  gigantic  limb  may  be  done  to  rid  the 
patient  of  a  drag  that  has,  by  its  sheer  weight,  anchored  him  to  his  bed  or  chair 
for  years.  These  growths  may  be  removed  with  comparatively  little  risk.  All 
surgical  treatment  in  filarial  disease  must  be  regarded  as  palliative  unless  the  parent 
female  worm  is  included  in  the  excised  tissues,  when  the  cure  will  be  a  definite  one. 

As  far  as  any  plan  of  treatment  aimed  at  the  destruction  of  this  parasite,  adult 
or  embryo,  is  concerned,  there  is  no  remedy  of  even  the  slightest  value.  During 
the  attacks  of  filarial  or  elephantoid  fever  the  aft'ected  part  should  be  elevated, 
cooling  lotions  should  be  applied,  and  the  patient  freely  purged.  After  the  acute 
symptoms  subside  elastic  bandages  should  be  tried,  and  frequently  give  great  relief. 

In  countries  where  filarial  diseases  are  common  segregation  is  impracticable, 
but  the  danger  of  dissemination  would  be  greatly  lessened  if  patients  harboring 
the  parasites  would  so  live  as  to  avoid  mosquitoes;  such  precautions  might  be 
advisable  for  sporadic  cases  in  countries  wherein  filariasis  is  only  occasionally 
introduced. 

Guinea-worm  Disease  (Dracontiasis). — Definition. — Guinea  Avorm  is  sometimes 
called   Dracunculus  mcdinensis,  or  Medina  worm. 

Distribution. — This  parasite  is  distributed  throughout  the  tropics.  It  was  known 
in  medicine  long  before  the  Christian  era,  and  there  is  some  reason  for  believing 
that  the  Biblical  mention  of  the  serpents  affecting  the  Israelites  near  the  Red  Sea 
were  these  parasites.  Though  very  widely  distributed,  the  infection  occurs  in 
sharply  defined  areas.  It  exists  on  the  west  coast  of  Africa,  particularly  on  the 
Gold  Coast,  in  Abyssinia,  Southern  Egypt,  and  the  Soudan.  In  Asia  it  occurs 
along  the  Caspian  Sea,  the  Gulf  of  Persia,  and  in  some  sections  of  British  India. 
It  was  common  enough  in  the  West  Indies  and  Tropical  America  during  the  days 
of  the  slave  trade,  but  seems  to  have  established  a  permanent  hold  only  in  a  few 
South  American  Islands  and  in  isolated  spots  in  Brazil.  In  the  United  States  this 
parasite  is  encountered  from  time  to  time  in  imported  cases,  although  at  least  three 
cases  have  been  recorded  in  persons  who  had  never  lived  in  or  visited  tropical 
regions.  Thus,  "\'an  liarlingen  reports  it  as  occurring  in  a  case  of  a  man  who  had 
never  lived  outside  of  Philadelphia ;  Jarvis,  in  the  case  of  a  man  who  lived  at  Fortress 
Monroe,  Va.,  for  thirty  years;  and  Walker,  in  a  case  from  Georgia. 

The  Dracuncidus  mcdinensis  is  a  nematode  worm.     We  have  definite  knowledge 


NEMATODES  347 

of  the  female  only.  The  adult  female  worm  is  cylindrical  in  form,  from  00  to 
80  cm.  in  average  length  and  about  2  mm.  in  thickness.  The  head  of  the  worm  is 
blunt,  with  a  triangular  mouth  and  eight  papili;ie.  The  tail  is  tapered  and  recurvated 
ventrally.  The  vascular  tube  and  alimentary  canal  extend  as  straight  canals  the 
length  of  the  worm,  ending  as  blind  pouches. 

Charles  found  in  the  mesentery  of  a  cadaver  two  female  guinea  worms  in  con- 
jugation with  two  smaller  worms.  These  worms  were  about  4  cm.  long  and  attached 
to  the  females,  which  were  ciuite  small,  about  14  cm.  from  the  head  end.  It  is 
assumed  that  these  were  males.  In  the  adult  female  the  uterus  occupies  almost 
the  entire  body  and  is  filled  with  myriads  of  tightly-coiled  embryos  averaging  0.0 
mm.  in  length. 

Fedschenko  and  Manson  have  shown  that  the  intermediate  host  of  the  guinea 
worm  is  a  minute  water  flea  {Cyclops  qitadricornis).  The  recently  escaped  embryos 
penetrate  the  cyclops,  in  which  they  pass  through  one  stage  of  larval  development 
lasting  about  six  weeks. 

It  is  assumed  that  infection  occurs  through  swallowing  the  cyclops  itself  or  the 
larva  in  drinking  water.  While  this  intermediate  stage  in  cyclops  is  the  usual 
history,  Plehn  has  shown,  experimentally,  in  monkeys,  that  direct  infection  by  the 
embryos  may  also  take  place. 

Negroes  and  the  laboring  classes  are  more  frequently  attacked  than  others, 
and  usually,  in  each  small  area,  the  infected  well  or  spring  may  be  identified.  The 
greater  number  of  cases  occur  at  the  close  of  the  hea\'y  rains,  probably  because  these 
conditions  are  then  more  favorable  to  the  development  of  cyclops. 

The  worm  is  taken  into  the  body  through  the  stomach.  The  males  and  females 
probably  pass  through  the  intestine  to  the  mesentery,  where  conjugation  takes 
place.  The  male  dies  and  becomes  calcified  or  absorbed  and  the  female  migrates 
in  the  connective  tissue  of  the  host.  In  these  migrations  she  usually  tends  toward 
the  lower  extremity  and  appears  in  the  foot  or  the  leg,  although  she  may  appear 
in  the  subcutaneous  tissues  of  the  trunk,  arm,  or  even  the  head.  AYhen  the  sub- 
cutaneous tissue  is  reached  complete  development  takes  place,  and  when  the 
embryos  are  ready  for  expulsion  a  small  boil  or  vesicle  forms,  which  bursts  and 
leaves  a  small  sinus  leading  down  to  the  head  of  the  worm.  The  period  of  incuba- 
tion from  the  ingestion  of  the  embryo  to  the  appearance  of  the  adult  embryo- 
bearing  female  in  the  subcutaneous  tissue  is  about  one  year.  The  migrations  of 
the  worm  are  not  attended  by  pain  or  any  other  symptoms. 

Symptoms. — At  the  time  of  development  of  the  vesicle  or  boil  there  may  be  some 
slight  febrile  disturbance,  and  there  is  slight  pain  from  the  local  irritation  and 
inflammation.  The  rupture  of  the  vesicle  leaves  a  flattened,  shallow  ulcer,  at  the 
bottom  of  which  is  a  small  opening.  At  this  opening  the  head  of  the  worm  may 
appear.  If  the  ulcer  be  douched  or  sprayed  with  cold  water  a  small  quantity  of  a 
milky  fluid  exudes  from  the  orifice,  or  the  uterus  of  the  worm  may  be  protruded  as  a 
delicate  tube  which  is  seen  to  fill  up  and  suddenly  empty  itself  of  a  few  drops  of 
milky  fluid  which,  examined  microscopically,  contains  mjriads  of  embryos.  Usu- 
ally when  parturition  is  completed,  or  nearly  so,  the  worm  spontaneously  leaves 
her  host.  In  a  case  reported  by  Francis,  in  which  five  worms  were  observed  in 
the  feet,  one  complete  worm  containing  its  embryos  and  measuring  twenty-six 
inches  was  passed  in  about  half  an  hour.  Usually  a  much  longer  period  is  required 
(fifteen  or  twenty  days)  before  the  worm  emerges.  Exceptionally,  parturition 
being  completed,  the  worm  dies,  becomes  encysted,  and  can  be  felt  as  a  firm, 
fibrous  cord  under  the  skin. 

Treatment. — The  older  method,  and  the  popular  one  with  the  natives,  is  to 
grasp  the  presenting  head  of  the  worm,  fix  it  to  a  smooth  stick,  and  gradually  wind 
her  out  by  twisting  out  a  few  inches  every  day.  By  this  method  the  worm  may 
easily  be  torn  and  a  swarm  of  embryos  liberated  in  the  subcutaneous  tissues.     In 


348  DISEASES  DUE  TO  A   SPECIFIC  IXFECTIOX 

the  case  reported  by  Francis,  a  temperature,  witli  morning  and  evening  variation 
between  9S.S°  and  104.5°  lasting  several  days,  occurred  after  rupture  and  retraction 
of  a  worm.  These  accidents  iiavc  occasioned  severe  infections,  resulting  in  death. 
Manson  advises  douching  with  cold  water,  application  of  a  cold  pack  or  cokl  baths 
to  hasten  expulsion  of  the  embryos  and  the  spontaneous  emergence  of  the  worm. 
Massage  and  electricity  have  been  used  with  success.  The  best  methods  of  treat- 
ment we  owe  to  the  suggestion  of  Emily.  He  advises  injection  of  (1.1  per  cent, 
solution  of  mercuric  chloride  into  the  head  of  the  worm  or  into  the  swelling.  This 
solution  causes  death  of  the  worm,  which  may  then  be  easily  extracted.  Similarly, 
Aoulkes  advises  injection  of  alcohol,  and  Tufnel,  pure  carbolic  acid. 

Prophylaxis  consists  in  careful  filtration  or  sterilization  of  drinking  water. 

Strongyloides  Intestinalis. — Definition. — Strong ijhldes  stercoralis  is  a  nematode 
worm  infecting  the  intestinal  canal.  When  present  in  large  numbers  it  causes  a 
chronic  diarrhea,  with  anemia  and  emaciation. 

Distribution. — This  parasite  is  widely  distributed  throughout  the  tropical  and 
subtropical  countries.  It  is  extremely  common  in  Cochin  China,  where  it  is 
supposed  to  be  the  cause  of  the  severe  diarrhea  of  that  country  known  as  Cochin- 
China  diarrhea.  Powell  has  found  it  in  India,  in  1.5  out  of  20  cases  of  anemia. 
It  has  been  observed  in  Martinique,  Sicily,  Egypt,  India,  Porto  Rico,  and  the 
Philippine  Islands.  In  Italy,  Germany,  Brazil,  and  California  it  has  been  fre- 
quently observed  in  association  with  uncinaria.  It  was  first  reported  in  the  United 
States  by  Thayer,  and  is  now  known  to  be  fairly  common  in  all  our  Southern 
States. 

Much  confusion  has  arisen  over  the  various  nematode  worms  resembling  this 
parasite.  These  are  now  believed  by  the  majority  of  observers  to  represent  mor- 
phological variations  of  the  same  worm.  The  following  classification  is  given  by 
M.  L.  Price: 

1.  The  rhabditiform  embryo,  formerly  known  as  Aiigiiilhda  stercoral i?,  found 
in  the  fresh  stools,  is  a. slender,  active  nematode  worm,  ()..3  mm.  long  and  0.04  mm 
broad. 

2.  Filariform  embryo  found  in  the  stools  after  standing  one  or  two  days,  and  sup- 
posed to  develop  from  the  rhabditiform  embryos.  The  embryo  is  twice  as  long 
as  the  preceding  form,  and  is  also  actively  motile. 

3.  The  sexually  difTerentiated  form,  RhahdUis  stercoral^,  which  may  be  developed 
from  the  preceding  in  five  days.  The  male  is  a  fine  nematode  worm  0.7  mm.  in 
length,  the  female  1  mm.  in  length,  which,  when  cultivated  cxtracorporeally, 
produces  filariform  embryos.     Finally  there  is: 

4.  The  parthenogenetic  mother-worm,  AnguUhda  intestinalis,  found  in  the 
intestinal  canal  at  autopsy.  A  slender  worm,  2  mm.  in  length,  easily  recognized 
by  the  string  of  five  or  six  eggs  in  the  centre  of  the  body.  Infection  probably 
takes  place  by  the  ingestion  of  the  filariform  embryo  in  water  or  on  uncooked 
vegetables.  Leichtenstern  has  experimentally  shown  the  incubation  period  to 
be  seventeen  days. 

Later  researches  have  disproved  much  of  the  pathological  importance  previously 
attached  to  this  parasite.  It  is  a  mistake,  however,  to  say  that  the  worm  has  no 
clinical  significance.  The  principal  symptom  is  a  continuous  diarrhea,  without 
pain  or  temperature  disturbance.  Secondarily,  intestinal  indigestion  develops 
and  )inirition  is  very  much  lowered.  As  a  consequence,  there  is  anemia  and  wasting. 
Blood  examination  shows  an  ordinary  anemia  and,  in  marked  contrast  with  other 
verminous  anemias,  shows  neither  leukocytosis  nor  eosinophilia. 

Treatment. — Thymol,  given  fasting,  in  the  same  manner  as  for  uncinariasis, 
is  the  best  remedy  for  expulsion  of  strongyloides.  If,  for  any  reason,  thymol 
should  fail  or  if  it  should  be  rejected,  or  the  jjatient  show  any  intolerance  to  the 
drug,  male  fern  should  be  used  in  large  doses. 


NEMATODES 


349 


Trichocephalus  Dispar. — The  Trichocephalu.i  dispar,  sometimes  called  a  "whip- 
worm," is  occasionally  found  in  the  intestinal  canal  of  man.  The  male  and  female 
worms  are  about  equal  in  size.  The  male  is  usually  coiled  in  a  spiral  form,  but 
the  female  is  nearly  straight.    The  posterior  portion  of  the  body  is  thicker  than 


A,  Egg  of  Cochiu-China  diarrhea  worm  (Strongyloides  stercoralis)  found  in  stools.  B,  Rliabditiform 
embryo  of  same,  from  the  stools.  C,  Filariform  larva  of  same  derived,  by  direct  transfoimation,  from  a 
rhabditiform  embryo.  The  figures  were  drawn  from  life,  as  seen  under  Leitz,  objective  7,  ocular  3. 
Bulletin  of  the  United  States  Marine  Hospital  Service,  No.  10,  1903.    (After  Thayer.) 


the  anterior  part,  and  by  the  slim  anterior  filament  the  parasite  embeds  itself 
in  the  mucous  membrane  of  the  intestine.  This  parasite  is  not  common  in  the 
United  States,  but  is  frequently  observed  in  France  and  Southern  Italy.  Its 
chief  area  of  development  is  in  the  cecum,  and  more  than  one  worm  is  usually 


350  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

present.  Sometimes  very  large  numbers  are  found.  It  is  supposed  to  possess 
no  pathological  significance  and  to  be  incapable  of  producing  serious  symptoms, 
but  some  writers  have  claimed  that  it  may  cause  diarrhea  and  anemia  of  a  serious 
character. 

CESTODES  OR  TAPEWORMS. 

Tapeworms  are  very  frequently  found  in  the  intestinal  canal  of  man.  .\s  their 
name  indicates,  they  are  flat,  broad,  white  parasites,  which  consist  of  segments, 
each  of  which  is  rectangular  in  shape,  but  somewhat  elongated.  Each  of  these 
segments  represents  a  single  individual.  From  the  head  the  segments  just  named 
develop.  The  technical  name  for  the  head  and  neck  is  the  "  scolex,"  and  for  the 
segment  "proglottis."  By  means  of  the  head  the  worm  is  attached  to  the  mucous 
membrane  of  the  intestine,  but  there  is  no  mouth  in  the  sense  that  an  opening 
exists  which  communicates  with  an  intestinal  canal.  Each  segment  of  the  worm 
is  hermaphroditic;  that  is  to  say,  each  segment  contains  male  and  female  organs 
of  reproduction. 

There  are  several  varieties  of  tapeworms.  The  most  frequently  found  are  the 
Teiiia  mediocanellata,  sometimes  called  the  Tenia  saginata,  or  unarmed  tapeworm, 
or  beef-worm,  the  Tejiia  solium  (pork-worm),  and  the  Tenia  echinococciis.  Less 
common  forms  are  the  BibothriDCCphahis  latus,  or  Russian  tapeworm,  derived 
from  eating  infected  fish;  the  Tenia  nana,  the  Tenia  confusa,  and  the  "double- 
pored  dog  tapeworm,"  Di'pylidimn  caninum.  The  Tenia  nana  is  sometimes 
called  the  Ilymenolepis  Jiana,  or  dwarf  tapeworm. 

The  Tenia  solium  usually  gains  its  entrance  into  the  intestinal  canal  of  man 
by  the  ingestion  of  imperfectly  cooked  pork,  the  Te7tia  mediocanellata  by  the  eating 
of  imcooked  beef,  and  the  Tenia  echinococcus  by  the  ingestion  of  food  which  has 
been  fouled  by  the  excrement  of  the  dog. 

All  tapeworms  pass  through  tliree  stages  of  existence.  The  segments  of  the 
worm  gi\'e  off  eggs  which  are  discharged  from  the  intestinal  canal  of  the  host, 
enter  the  alimentary  canal  of  some  animal,  and  are  hatched  out  as  parasites  which 
pass  through  the  wall  of  the  intestine,  gain  a  place  of  rest  in  the  muscles  or  other 
tissues,  and  there  form  cysts.  When  these  muscular  tissues  are  eaten,  the  parasite 
in  the  cyst  once  more  enters  the  alimentary  canal,  becomes  attached  to  its  mucous 
membrane,  and  from  it  is  developed  the  adult  worm. 

The  Tenia  solium  may  be  several  yards  in  length.  XX  one  time  it  was  thought 
to  be  solitary;  hence  its  name.  It  not  infrequently  happens,  however,  that  more 
than  one  worm  is  present.  The  head,  which  is  very  small,  scarcely  larger  than  a 
pinhead,  has  a  proboscis,  or  rostellum,  al)0ut  which  is  arranged  a  double  row  of 
horny  booklets.  The  booklets  in  the  anterior  row  are  larger  than  those  in  the 
posterior  row.  Below  these  are  four  sucking  disks  at  the  sides  of  the  head.  By 
these  means  the  worm  attaches  itself  to  the  bowel.  The  segments  of  the  worm 
are  about  10  to  12  mm.  in  length  and  from  5  to  G  mm.  wide,  but  they  vary  con- 
sideral)l\'  in  size;  those  nearest  the  neck  of  tlie  worm  being  shorter  and  narrower 
than  those  which  develop  several  feet  away  from  the  neck.  When  the  egg  of  the 
Tenia  solium  is  hatched  out  so  that  a  scolex  (or  head)  is  set  free,  and  this  parasite 
becomes  encysted  in  the  muscles  of  a  pig,  the  pork  is  said  to  be  "measly."  When 
it  finds  a  resting  place  in  the  muscles  or  the  brain,  or  other  parts  of  the  human 
being,  it  is  known  as  the  Cysticcrcns  celluhsa.  These  cysts  vary  in  size  from  that 
of  a  small  pea  to  that  of  a  bantam's  egg,  and  are  separated  from  the  surrounding 
tissues  by  a  formation  of  connective  tissue  which  acts  as  a  capsule. 

The  Tenia  mediocanellata  possesses  a  head  which  differs  materiall.v  from  the 
head  of  the  Tenia  solium.  There  is  no  rostellum  or  booklets,  but  there  are  four 
sucking  disks,  wliich  are  muc-h  nearer  the  point  of  the  head  than  they  are  in  the 

Tenia  solium:    This  worm  further  differs  from  the  Tenia  solium  in  addition  in 


CESTODES  OR  TAPEWORMS  351 

that  its  segments  are  generally  broader  and  shorter,  and  the  entire  worm  is  usually 
much  longer. 

This-  worm  may  reach  the  length  of  about  25  or  30  feet,  and  it  is  not  very  rare 
for  from  15  to  20  feet  of  a  worm  to  be  passed  intact.  When  the  scolex  of  this 
worm  is  found  in  the  muscles  of  cattle  it  is  called  the  Cyslicerciis  medhicandlata. 

In  Germany,  where  imperfectly  cooked  pork  is  largely  eaten,  the  Teniu  solium 
is  most  frequently  met  with,  but  in  this  country,  where  the  people  eat  largely  of 
beef,  the  Tenia  mediocanellata  is  much  more  common. 

The  Tenia  echinococcus  is  very  rarely  met  with  in  the  United  States.  It  is, 
however,  exceedingly  common  in  Australia.  This  worm  possesses  a  double  row 
of  booklets  and  four  sucking  disks.  It  is  rare  for  more  than  three  or  four  segments 
to  be  attached  to  any  one  head,  but  as  the  parasite  is  often  present  in  numbers 
many  disconnected  segments  may  be  discharged.  Like  the  other  forms  of  tape- 
worm, the  segments  increase  in  size  as  the  distance  from  the  head  is  increased. 
This  worm  does  not  inliabit  the  intestine  of  man,  but  produces  its  evil  influence  by 
reason  of  the  entrance  of  its  eggs  into  his  alimentary  canal,  from  which  place  they 
wander  into  other  parts  of  the  body,  forming  what  are  known  as  hydatid  cysts. 
In  other  words,  the  infection  of  human  beings  by  the  Tenia  mediocanellata  and  the 
Tenia  solium  is  quite  different  from  the  infection  of  human  beings  by  the  Tenia 
echinococcus,  for  in  the  first  cases  the  patient  swallows  the  parasite  when  it  has 
reached  the  second  stage  of  its  existence  and  is  prepared  to  develop  its  segments; 
whereas,  in  the  case  of  the  Tenia  echinococcus  the  patient  takes  food  which  has  in 
some  way  become  contaminated  by  the  fecal  discharges  of  the  dog,  which  fecal 
discharges  contain  the  eggs  of  the  parasite,  and  from  these  eggs  are  developed 
cysts.  A  patient  infected  by  the  Tenia  echinococcus  therefore  suffers  from  the 
cystic  stage  of  development  of  the  worm. 

The  hydatid  cysts  formed  in  this  manner  most  frequently  infest  the  liver,  but 
almost  any  portion  of  the  body  may  be  affected.  Such  cysts,  in  the  liver  in  particu- 
lar, are  always  surrounded  by  a  layer  of  connective  tissue  which  is  thrown  out  in 
an  endeavor  to  circiunscribe  the  invading  parasite.  The  wall  of  hydatid  cysts, 
therefore,  is  formed  of  two  layers;  the  outside  layer  is  lamellated  and  is  sometimes 
called  the  cuticula.  The  inner  wall  of  the  cyst  often  contains  muscular  fibres  and 
bloodvessels,  and  is  called  the  pa^ench^^natous  layer.  Not  rarely  the  primary 
cysts  give  rise  to  secondary  cysts  called  daughter-cysts,  and  these  daughter-cysts 
may  develop  in  themselves  cysts  which  are  called  granddaughter-cysts. 

On  the  inner  surface  of  these  cysts  the  scolices,  or  heads,  of  the  worm  are  formed. 
At  the  posterior  end  of  the  scolex  is  a  stem,  or  pedicle,  by  which  it  is  attached  to 
the  wall  of  the  brood  capsule.  In  some  instances  the  scolex  may  be  found  free 
inside  of  this  capsule.  In  most  cases,  after  the  cyst  has  existed  for  a  long  period 
of  time,  the  scolices  die,  the  fluid  is  absorbed,  and  a  granular  mass  remains.  This 
granular  mass  may  contain  the  booklets,  or  the  booklets  may  be  found  free  in 
the  contents  of  the  capsules,  or  in  the  primary  cyst  itself.  Occasionally,  a  hydatid 
cyst  is  found  which  is  sterile,  that  is,  in  which  neither  sub-cysts  nor  scolices  are 
developed. 

In  addition  to  the  scolices,  the  cysts  contain  a  clear,  limpid  fluid  which  sometimes 
becomes  turbid  after  the  cyst  has  existed  for  a  considerable  period  of  time,  the 
turbidity  being  due  to  disintegration  of  the  lining  layer  of  the  cj'sts  and  the  forma- 
tion of  crystals  of  cholesterin,  and  to  the  presence  of  lime-salts.  Occasionally 
the  cj-st  shrinks,  its  contents  become  inspissated  or  thickened,  and  the  entire  mass, 
including  the  connective  tissue  which  has  been  formed  around  the  cyst,  may  become 
calcified.  Sometimes,  too,  the  daughter-cysts  instead  of  growing  inside  grow 
outside.  Indeed,  this  variation  is  more  commonly  seen  in  man  than  it  is  in  animals 
that  are  aff'ected  by  this  parasite.     This  is  called  the  echinococcus  exogena. 

Under  the  narne  of  echinococcus  midtilocularis  a  variety  of  echinococcus  cj'st 


352  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

is  found  In  the  liver,  whlcii  is  characterized  by  a  somewhat  irregular  distribution 
of  groups  of  small  cysts  walled  off  by  connective  tissue,  as  are  tlie  larger  cysts 
already  described.  These  cysts  are  often  sterile;  that  is  to  say,  they  do  not  contain 
scolices  or  booklets.  It  is  probable  that  this  formation  is  due  to  a  somewhat 
difl'erent  parasite  from  the  ordinary  Tc7i!a  echinococcus. 

The  Bothrlocephalits  latus,  or  Dibothrwcephalv.'s  latus,  is  the  largest  of  all  human 
tapeworms,  and  has  very  broad,  square  segments.  The  head  is  egg-shaped,  but 
possesses  no  disks  or  booklets.  On  the  contrary,  its  head  is  marked  by  long  grooves 
by  which  it  attaches  itself  to  tlie  intestine.  Its  neck  is  longer  and  more  slender 
than  that  of  other  tapeworms.  Two  species  have  been  descriijed,  the  Bothrioceph- 
ahis  cordatvs  and  the  Bothriocephalus  cristatus.  Infection  by  this  parasite  occurs 
most  frequently  by  the  eating  of  imperfectly  cooked  fish,  probably  liecause  the 
eggs  de\'elop  to  some  extent  in  water  and  are  swallowed  by  various  fish,  in  whose 
flesh  the  cysts  are  formed  just  as  the  other  scolices  already  described  form  in  the 
flesh  of  the  hog  or  ox. 

Tenia  nana,  or  dwarf  tapeworm,  Hymenolepls,  is  only  from  one-fifth  to  two 
inches  in  length.  It  has  four  suckers  and  a  single  row  of  booklets  on  its  head. 
Stiles  states  that  it  may  be  present  singly  or  by  thousands,  and  is  probably  more 
frequent  than  is  generally  thought.  Its  intermediate  host  is  usually  the  rat,  from 
the  stools  of  which  food  is  infected.  In  the  rat  the  cyst  stage  may  occur  in  the 
intestinal  wall  and  is  called  a  cercocystis.  Like  other  tapeworms,  the  embryos 
burrow  into  the  wall  of  the  intestine,  but  do  not  remain  there,  falling  back  into  the 
lumen  of  the  bowel  to  reach  adult  development  with  eggs  in  about  fifteen  days. 
The  only  teniafuge  which  has  proved  effective  for  the  removal  of  this  worm  is 
aspidium. 

The  Tenia  cucinnerina  is  slightly  larger  than  the  Tenia  nann,  and  its  head 
possesses  four  rows  of  booklets.  It  is  not  infrequently  found  in  the  ileum  of  dogs 
and  cats,  but  rarely  aft'ects  man.  Its  scolices  inhabit  the  dog-louse  and  by  means 
of  this  parasite,  or  by  the  carrying  of  the  embryos  to  the  mouth  by  the  hands  after 
handling  a  dog  or  cat,  infection  of  a  human  being  may  take  place. 

Symptoms. — The  symptoms  produced  by  the  presence  of  tapeworms  in  the 
alimentary  canal  are  not  pathognomonic.  Not  infrequently  the  worms  exist 
for  a  long  period  of  time  without  their  host  having  any  knowledge  of  their  presence, 
and  the  infection  is  only  disco\'ered  by  the  chance  observation  of  one  or  more 
segments  in  a  stool.  The  patient  may  suffer  from  s\"m]Dtoms  of  gastro-intcstinal 
catarrh  produced  by  the  irritation  caused  by  the  worm,  and  sometimes  an  inordinate 
ajjpetite  is  present,  but  this  is  by  no  means  as  constant  a  s.Miiptom  of  tapeworm 
as  most  persons  imagine.  Not  infrerpiently,  the  host  of  a  tapeworm  suffers  from 
anorexia  rather  than  from  excessive  himger.  In  children  there  may  be  a  good 
deal  of  nervous  irritation  and  j^^'Pi-^ishncss. 

In  some  instances,  however,  the  presence  of  a  tapeworm  produces  a  very  much 
more  serious  train  of  symptoms,  which  consist  in  an  intrnxc  anemia  that  may  be 
so  severe  as  to  give  rise  to  the  suspicion  that  ])ernicious  anemia  is  present.  The 
Bothriocephalus  latus  is  said  to  be  more  jjrone  to  produce  graAc  anemia  than  any 
other  of  the  tapeworms. 

Treatment. — The  treatment  of  a  jiatient  infected  by  tapeworm  consists  in  the 
abstinence  of  all  ft)od  for  eighteen  hours  prior  to  tiie  administration  of  one  of  the 
following  drugs,  which  are  known  to  possess  the  power  of  so  paralyzing  or  killing 
the  worm  that  it  lets  go  its  hold,  and  then  is  readily  passed  from  the  bowel  under 
the  influence  of  a  purge.  One-half  to  one  drachm  of  the  oleoresin  of  asjiidium  may 
be  given  in  capsule  or  emulsion  to  an  adult,  and  followed  in  four  or  five  hours  by  a 
saline  purgative,  such  as  citrate  or  sulphate  of  magnesium  or  Rochelle  salts.  In 
other  instances  pelleticrine  given  in  the  dose  of  3  to  5  grains  may  be  used  under  the 
same  conditions.      It  is  commonly  given  in  syrupy  solution,  and  this  syrupy 


TREMATODES  353 

solution  is  put  up  in  a  small  container  which  holds  one  dose.  If  it  is  desired  pelle- 
tierine  may  be  followed  by  castor  oil  in  place  of  the  other  purgatives  named,  but 
castor  oil  must  not  be  used  after  aspidium  is  given,  as  it  aids  in  the  absorption  of 
the  drug  into  the  body  and  so  tends  to  poison  the  individual.  A  less  agreeable 
method  of  destroying  the  worm  is  to  administer  a  confection  made  of  pepo,  or 
pumpkin  seeds  which  have  been  deprived  of  their  hard  coverings  by  the  process  of 
bruising.  Several  drachms  of  these  seeds  are,  without  doubt,  very  efficacious. 
The  patient  should  always  be  instructed  to  pass  the  stool  through  a  sieve  and  not 
to  seek  so  much  for  the  segments  of  the  worm  as  for  the  small  head.  The  mere 
passage  of  a  large  number  of  feet  or  segments  does  not  indicate  in  any  way  that  the 
patient  is  permanently  relieved  unless  the  head,  from  which  other  segments  will 
grow  if  it  remains  in  the  bowel,  is  also  passed. 

TREMATODES. 

Definition. — A  large  number  of  worms  belonging  to  the  Trematodes  live  as 
parasites  in  the  body  of  man  or  of  the  lower  animals.  When  the  body  is  so  infested 
the  condition  is  said  to  be  one  of  Distoviatosis,  this  term  arising  from  the  fact  that 
the  word  Distoma  is  oftentimes  applied  to  these  parasites. 

Up  to  the  present  time  no  less  than  thirteen  species  of  Trematodes  or  Flukes 
have  been  described  as  occurring  in  human  beings.  Eleven  of  these  belong  to  the 
family  of  the  Fasciolida,  one  to  the  family  Paramphiscus,  and  one  to  the  family 
Schistosomidce . 

When  the  human  being  is  attacked  the  parasite  is  usually  found  in  the  genito- 
urinary tract,  where  it  causes  what  is  known  as  Bilharzia  Disease  or  Endemic 
Hematuria.  Less  commonly  it  infests  the  lung  and  the  condition  is  then  called 
Disiomaiosis  of  the  Lung,  Endemic  or  Parasitic  Hemoptysis  or  Lung  Fluke;  and 
it  is  also  met  with  in  the  liver,  forming  the  so-called  Liver  Fluke  or  Distomatosis 
of  the  Liver.  The  fluke  found  in  the  genito-urinary  tract  is  the  Schistosoma  hemato- 
bium,  that  met  with  in  the  lung  is  the  Paragonimus  westermanni,  sometimes  called 
the  Distovia  ringeri  or  Distoma  pidmonale,  and  that  discovered  in  the  liver  the 
Fasciola  hepatica  or  instead  Dicrococlium  lanceatuvi,  Opisthorchis  sinensis,  the 
Opisthorchis  felineus,  and  the  Opisthorchis  noverca. 

Bilharzia  Disease. — Bilharzia  disease,  or  endemic  hematuria,  is  due  to  the 
development  in  the  body  of  the  Schistosoma  hematobium,  and  is  characterized  by 
hematuria  and  the  formation  of  payillomatous  tumors  in  the  genito-urinary  tract. 

Etiology. — The  male  worm  is  about  4  to  15  mm.  in  length  and  0.6  mm.  in  breadth. 
The  female  averages  15  to  20  mm.  in  length  and  0.28  mm.  in  breadth.  The  male 
has  flattened  sides,  rolled  up  on  both  edges  so  as  to  form  a  deep  groove,  the  gyneco- 
phoric  canal,  in  which  the  female  lies  during  conjugation  (Fig.  68). 

History  and  Distribution. — Endemic  hematuria  has  been  observed  in  Egypt 
for  centuries.  At  the  present  day  it  is  said  to  be  present  in  fully  one-half  of  the 
population.  According  to  Looss  it  is  equally  frequent  in  Uganda.  It  is  practically 
limited  to  the  African  continent,  although  cases  have  been  reported  from  Cyprus 
and  Sicily,  and  Manson  reports  a  case  from  the  West  Indies.  It  occurs  frequently 
in  British  India,  but  always  as  an  imported  infection.  A  few  cases  have  been 
reported  in  the  LTnited  States  and  by  Holcomb  in  the  West  Indies.  The  parasitic 
nature  of  the  disease  was  discovered  in  1851  by  Bilharz. 

The  ova  of  these  worms  are  found  in  very  great  numbers  in  the  urine.  They  are 
oval,  and  have  a  marked  terminal  spine  and  contain  a  ciliated  embryo.  It  is 
supposed  that  the  spine  is  the  organ  by  means  of  which  the  embryo  bores  through 
the  peripheral  tissues.  Ova  with  lateral  implantation  of  the  spine  are  frequently 
observed.  Looss  supposes  these  are  examples  of  faulty  development,  and  that 
the  faulty  position  of  the  spine,  limiting  the  mobility  of  the  ovum,  is  the  reason 
23 


354 


DISEASES  DUE  TO  A   SPECIFIC  ISFECTIOS 


many  more  of  this  form  are  found  in  section  than  free.  In  urine  f)r  in  water  the 
embryos  very  soon  escape  from  the  ovum  and  move  about  very  acti\-ely  by  means 
of  their  cilia.  In  undikitcd  urine  they  die  when  it  cools.  In  water  they  remain 
active  for  a  long  time. 

The  embryos  are  probably  taken  into  the  stomach  in  drinking-water,  penetrate 
the  gastric  or  intestinal  wall,  and  they  develop  into  mature  worms.  Loo.ss  surmises 
and  brings  some  evidence  to  show  that,  like  the  uncinaria,  this  parasite  may  also 
penetrate  the  skin. 


Male  bilharzia  worm  carrying  the  female,  showing  the  papillffi  on  his  skin.    The  small  figure  is  a 
cross-section  showing  relative  position  of  the  sexes.     (Looss.) 

Pathology. — The  affected  bladder  is  covered  with  a  bloody,  tenacious,  mucous 
laj'er;  the  submucosa  is  greatly  thickened;  the  muscular  and  serous  coats,  as  a  rule 
are  unchanged.  In  older  cases  papillomata  are  found,  varying  in  size  from  a  small 
pea  to  large  tumors  filling  the  entire  bladder.  Microscopically  the  changes  consist 
in  marked  degeneration  of  the  epithelial  layers,  going  on  to  complete  destruction 
of  the  mucosa.  The  pseudomembranous  covering  then  consists  of  ova,  leukocytes, 
and  urinary  salts.  In  the  sulmiucosa  enormous  masses  of  ova  are  found,  many 
of  them  calcified.  The  papillomatous  tumors  spring  from  this  layer,  and  are  very 
similar  in  their  histological  structure  to  nasal  polypi.  Similar  changes  occur  in 
the  rectimi,  urethra,  ureter,  seminal  vesicles,  prostate,  and  uterus.  Secondarily 
these  lesions  produce  stricture,  urinary  fistulre,  pyelitis,  prostatitis,  and  urethritis. 

The  papillomatous  tumors  show  some  tendency  to  undergo  malignant  change, 
but  by  far  the  commoner  complication  of  the  disease  is  stone  formation.  In  old 
cases  a  beginning  deposit  of  lime-salts  is  found  in  the  mucus  covering  the  bladder 
wall,  as  small  calculi  embedded  in  the  folds  and  loculi.  In  other  cases  large,  free 
calculi  are  found  with  clumped  masses  of  calcified  ova  as  their  nucleus. 

Tvmiors  and  masses  of  ova  are  sometimes  found  in  the  pelvis  of  the  kidney, 
rarely  in  its  parench\Tna. 

Symptoms. — The  symptoms  vary  with  the  intensity  of  the  infection,  the  number 
of  adult  worms,  and  the  location  and  extent  of  the  lesions  already  described.  The 
only  constant  symptom  is  linnafvria.  The  amount  of  blood  present  in  the  urine 
may  be  so  small  as  only  to  be  evident  on  microscopic  examination,  or  so  large  as 
to  form  clots  of  appreciable  size  in  the  bladder.  As  a  rule,  the  blood  is  passed  at 
the  end  of  urination.  The  microscopic  examination,  in  doubtful  cases,  should 
therefore  be  directed  to  the  last  few  drops  of  urine  expelled.     In  the  large  majority 


TREMATODES  355 

of  cases  heviaturia  will  be  the  only  symptom.  In  the  severe  infections,  however, 
cystitis  usually  develops  and  becomes  very  troublesome.  Following  the  develop- 
ment of  inflammation  the  ordinary  symptoms  of  tuvior  or  siojie  develop.  In  severe 
cases,  with  diminished  resistance,  supjmration  of  these  lesions  occurs,  with  formation 
of  extensive  fistvlovs  tracts.  When  the  lesions  are  confined  to  or  are  most  marked 
in  the  bowel,  the  early  symptoms  may  resemble  acute  dysentery  and,  in  older  cases, 
chronic  dysentery,  with  pain,  tenesmus,  and  bloody  and  mucous  stools.  When 
tumors  occur  in  the  bowel  they  are  readily  recognized,  although  when  situated 
low  in  the  rectum  they  have  been  mistaken  for  hemorrhoids. 

The  urine  contains  red  blood  cells,  leukocytes,  principally  eosinophiles  and  poly- 
nuclear  cells,  besides  large  numbers  of  ova.  W^ith  these  the  ordinary  evidences 
of  an  extensive  chronic  cystitis  are  also  found.  The  number  of  ova  present  varies 
very  widely  and  bears  no  relation  to  the  amount  of  blood  in  the  urine.  When  they 
are  very  few  in  number  they  may  only  be  found  in  the  last  few  drops  of  urine  passed. 

The  blood  changes,  in  severe  cases,  are  marked.  There  is  a  pronounced  fall 
in  the  number  of  red  cells  and  a  still  greater  reduction  of  hemoglobin.  With  this 
there  is  a  moderate  degree  of  leukocytosis,  the  increase  consisting  almost  entirely 
of  eosinophile  cells,  which  are  present  in  proportion  varying  from  9  per  cent,  to  as 
high  as  52  per  cent. 

Diagnosis. — The  blood  condition  pointing  to  a  toxic  or  parasitic  anemia,  with 
the  demonstration  of  the  ova  in  the  urine,  make  the  diagnosis  of  Bilharzia  disease. 

Prognosis  depends  on  several  factors,  namely,  the  extent  of  the  infection,  the 
number  of  adult  worms  present,  and,  more  important  still,  the  conditions  favoring 
reinfection.  When  all  opportunity  for  reinfection  is  avoided,  as  by  removal  from 
the  endemic  area,  after  a  time  the  adult  worms  die,  and  eventually  all  the  ova  are 
evacuated.  This  process  may  be  a  very  long  one.  In  some  observed  cases  it 
has  extended  up  to  eight  years.  The  prognosis  also  depends  on  the  character  and 
extent  of  the  surgical  complications  and  sequelfe. 

Treatment. — There  is  no  treatment  that  will  influence  either  the  worm  or  the 
ova  in  the  slightest  degree.  All  the  anthelmintics  have  been  tried  and  found 
useless.  Similarly,  local  application  of  antiseptics  and  protoplasmic  poisons  to 
the  bladder  have  failed.  In  most  cases  the  hematuria  does  not  require  treatment. 
When  it  becomes  severe,  rest  in  bed  should  be  enjoined.  Cystitis  should  be  treated 
on  general  lines  by  local  medication,  as  well  as  the  internal  administration  of  uro- 
tropin,  salol,  benzoic  acid,  and  remedies  of  this  group.  The  complications  of  the 
disease,  such  as  stricture,  extensive  tumors  of  the  bladder  and  rectum,  accessible 
ulcerations  of  the  vagina  or  cervLx,  and  prostatic  involvement,  call  for  appropriate 
surgical  measures.  In  a  general  way,  all  the  conditions  which  predispose  to  or 
aggravate  cystitis  should  be  avoided.  These  are  exposure,  chill,  violent  muscular 
effort,  alcoholic  debauches,  spices,  and  highly  seasoned  food.  With  a  view  to 
obtaining  an  eventual  cure,  patients  should  if  possible  be  removed  from  the  endemic 
area.  When  this  is  not  possible,  proper  means  should  be  taken  to  ensure  a  good 
water  supply.  In  this  manner  the  constant  reinfection  of  the  patient  is  avoided. 
Similarly,  in  view  of  the  possibility  of  infection  through  the  skin,  sound  shoes 
should  be  insisted  on  and  work  in  alluvial  oozes  should  be  avoided. 

Distomatosis  of  the  Lung  {Lung  Flukes;  Endemic  or  Parasitic  Hemoptysis). — - 
The  lung  fluke  {Paragonimus  westermanni)  is  widely  distributed  in  Japan,  Formosa, 
Corea,  and  North  China.  It  has  been  carried  by  Oriental  emigrants  to  many  other 
countries.     Isolated  cases  have  been  reported  from  the  United  States  and  Mexico. 

The  parasite  is  a  small,  fleshy,  trematode  worm  or  fluke.  It  is  8  to  20  mm. 
long  and  6  mm.  in  its  transverse  diameter.  It  is  usually  found  in  the  lungs,  but 
has  been  observed  in  other  organs,  notably  the  liver  and  brain.  The  worms  dis- 
charge a  vast  number  of  ova.  These  ova  are  dark  brown,  oval,  0.08  mm.  long 
by  0.05  mm.  wide,  possess  a  small  operculum,  and  contain  a  ciliated  embryo. 


356  DISEASES  DUE  TO  A  SPECIFIC  IXFECTIOX 

They  are  found  in  great  luimhers  in  the  sputum.  Infection  prohahly  takes  place 
through  contaminated  water,  although  nothing  is  known  of  tlic  extracorporeal 
phases  of  the  parasites.  By  far  the  larger  percentage  of  cases  is  observed  in  young 
males.     Alcoholism  is  supposed  to  predispose  to  tlie  disease. 

Pathology. — Patches  are  scattered  all  over  the  lungs,  but  particularly  in  the 
periphery,  resembling  hemorrhagic  infarcts.  On  section  these  ])atches  are  found 
to  be  infiltrated  and  honeycombed  with  small  tunnels  and  cavities,  each  of  which 
contains  one  or  more  distoma  and  masses  of  eggs.  Occasionally  large  cavities 
are  formed  by  coalescence  of  the  smaller  lesions. 

In  cases  in  which  the  parasite  invades  the  brain,  analogous  conditions  are  found, 
but  they  are  almost  entirely  limited  to  the  cortical  areas. 

Symptoms. — The  commonest  symptom  is  chronic  morning  cough,  with  a  rusty, 
prune-juice,  or  bloody  sputum.  The  amount  of  blood  in  the  sputum  may  be  so 
small  as  to  be  only  demonstrable  by  the  microscope,  or  there  may  be  periodical 
and  severe  hemorrhages  from  the  lungs.  The  rusty  color  of  the  sputimi  is  due 
not  only  to  the  blood  and  the  bloody  pigments  contained  in  it,  but  also  to  the  large 
numbers  of  dark  brown  ova.  The  sputum  also  contains  eosinophile  cells,  Charcot- 
Leyden  crystals,  and  elastic  fibres.  The  course  of  the  disease  is  essentially  chronic. 
Cases  last  from  ten  to  twenty  years  without  much  discomfort  and  without  much 
deterioration  in  the  general  health,  excepting  where  marked  secondary  anemia 
results  from  repeated  and  severe  hemorrhages. 

Prognosis. — The  prognosis  is  good,  excepting  in  the  rare  instances  in  which 
hemorrhage  is  sufficiently  severe  to  cause  a  fatal  ending.  When  the  parasite 
attacks  the  brain,  epileptic  symptoms  have  been  observed  and  the  prognosis  is 
grave. 

Treatment. — A  large  number  of  drugs  have  been  administered  to  patients  suffering 
from  this  condition,  both  by  the  mouth  and  by  inhalation,  in  the  hope  that  benefit 
might  accrue.  It  is  evident  that  the  nature  of  the  lesions  renders  any  therapeutic 
measure  of  little  value. 

Distomatosis  of  the  Liver  {Liver  Fhikes). — Li\er  flukes  occur  endemically  in 
certain  sections  of  Japan.  For  instance,  Baelz  estimates  that  20  per  cent,  of  the 
inhabitants  of  Okayama  Province  are  infected  with  the  liver  fluke.  Inouye  found 
in  various  sections  from  19  per  cent.  to.  71.9  per  cent,  of  the  population  infected. 
Infection  has  been  carried  all  over  the  world  by  Oriental  emigrants.  In  the  United 
States  an  entirely  analogous  affection  is  seen  in  cats  and  cattle  and  several  cases 
have  been  met  with  in  man. 

The  parasite  commonly  invades  the  biliary  tract  or  the  pancreatic  duct,  and  is 
also  found  in  the  duodenum,  the  stomach,  and  spleen.  The  obstruction  of  the 
biliary  ducts  by  the  parasites  causes  dilatation  and  chronic  catarrh.  There  is  also 
overgrowth  of  the  hepatic  connective  tissue,  with  atrophy  of  the  parenchyma. 
Small  but  constant  hemorrhage  from  the  biliary  passages  may  cause  a  grave 
anemia. 

Postmortem  the  parasites  are  found  in  great  numbers  in  the  walls  of  the  gall- 
bladder and  biliary  ducts,  or  free  in  the  ducts.  They  lie  in  small,  cyst-like  cavities 
connecting  witli  the  gallbladder  or  ducts. 

Symptoms. — The  symptoms  depend  on  the  number  of  worms.  The  first  symptom 
is  rapid  enlargement  of  the  liver,  with  voracious  appetite.  The  liver  may  reach 
to  the  umbilicus,  it  is  tender  on  palpation,  and  there  are  recurring  attacks  of  jaun- 
dice. Sooner  or  later  diarrhea  begins,  and  with  it  marked  failure  of  nutrition. 
The  patient  becomes  weak,  emaciated,  and  anemic.  The  diarrhea  in  marked  cases 
is  severe,  and  the  movements  contain  much  blood,  besides  the  ova  of  tlie  parasites. 
Later,  dropsy  of  the  legs  and  belly  develop,  and  the  patient  dies  exhausted.  The 
course  of  the  disease  is  very  chronic,  and  likewise  depends  on  the  number  of 
parasites.    Recovery  never  takes  place. 


MYIASIS  357 

Treatment. — There  is  no  treatment  save  the  use  of  stimulants  and  good  food. 

With  the  idea  of  prophylaxis  Inouye  advises  against  drinking  or  swimming  in 
canal  water  or  eating  raw  fish  or  mussels.  He  states  that  in  one  region  notably 
infected  with  the  disease  the  mortality  from  distomatosis  has  been  reduced  to  zero 
by  following  these  simple  precautions. 


PARASITIC  INFUSORIA. 

The  parasitic  infusoria  which'  are  found  in  man  are  protozoa  of  the  sub-class 
flagellata.  They  are  rarely  met  with.  The  Plagiomonas  urinaria  has  been  found 
in  the  urine  of  a  man  who  suffered  from  chronic  suppuration.  The  Trichomonas 
vaginalis  is  found  in  acid  vaginal  mucus,  and  the  Trichomonas  hominis  has  been 
found  in  the  bowels  and  stools.     Thej'  all  possess  but  little  clinical  interest. 


CHIGGER  (SAND  FLEA). 

The  chigger,  or  sand  flea  {Pulex  penetrans),  is  distributed  widely  over  tropical  and 
many  parts  of  subtropical  America  and  the  West  Indies.  It  is  supposed  to  have  been 
carried  in  1872  from  South  America  to  Africa.  At  present  it  is  widely  distributed 
on  both  African  coasts  and  in  certain  sections  of  India.  It  is  a  very  common  pest  in 
the  Philippine  Islands,  where  it  is  known  as  "tungau."  The  chigger  is  a  minute, 
reddish-brown  flea,  and  attacks  man  and  animals.  When  impregnated  the  female 
attaches  herself  to  the  skin  surfaces  and  burrows  under  the  skin,  head  first.  Ovula- 
tion takes  place  in  the  cutaneous  tissue  and  the  female  increases  to  the  size  of  a 
small  pea.  If  unmolested  the  ova,  when  mature,  are  expelled  through  the  point 
of  entrance,  through  which  also  the  female  is  ultimately  extruded.  The  chiggers 
may  vary  in  number  from  one  to  several  hundred.  They  usually  lodge  in  the  feet 
and  legs,  but  the  hands,  arms,  genitals,  and  face  may  also  be  invaded.  The  bite 
of  the  insect  causes  little  pain,  and  the  female  is  usually  detected  when  she  com- 
mences to  enlarge  beneath  the  skin.  There  is  then  intolerable  itching,  with  for- 
mation of  small  papules,  with  red,  inflamed  heads,  and  a  black  spot  on  the  summit. 
The  papules  become  pustular,  discharge,  form  small  ulcers,  and  eventually  heal, 
leaving  small,  pitted  scars.  When  the  lesions  are  numerous,  particularly  when 
neglected  in  the  unclean  and  the  physically  deteriorated,  extensive  infections  and 
sloughing  wounds  may  occur.     Rarely  tetanus  and  phagedenic  areas  develop. 

Treatment. — Treatment  consists  in  complete  enucleation  with  a  needle  or  the 
point  of  a  fine  scalpel.  Chloroform,  turpentine,  infusion  of  tobacco,  mercurial 
ointment,  and  the  essential  oils  allay  the  itching  and  kill  the  parasites.  The 
essential  oils,  particularly  the  oil  of  eucalyptus,  act  not  only  as  a  cure,  but  also  as 
a  preventive  against  the  bites  of  the  insects. 


MYIASIS. 

Infection  of  Larvae  of  the  Diptera. — Screw-worm  (Lucilia  Macellaria),  the 
larva  of  the  common  blue-bottle  flesh  fly,  a  very  common  fly  in  the  United  States, 
West  Indies,  and  South  America,  causes  infection  in  man  tlirough  the  female 
laying  her  eggs  on  wounds  in  the  skin  and  in  the  noses  or  ears  of  people  sleeping 
in  the  open.  During  the  campaign  at  Santiago  de  Cuba,  in  1898,  numerous  cases 
of  infection  by  this  larva  were  seen  in  wounds  and  abrasions  about  the  feet  of  the 
men  and  horses.  In  the  tropics  they  have  also  been  seen  attacking  the  vagina  of 
recently  delivered  women.     The  eggs  deposited  in  these  locations  hatch  out  in  a 


358  DISEASES  DUE  TO  A  SPECIFIC  INFECTION 

few  hours  into  the  larvfE,  known  as  the  screw-worm  on  account  of  the  circles  of 
minute  spines  running  around  the  body  of  the  worm  very  mucii  as  does  the  thread 
of  a  screw.  The  hirvffi  are  about  three-quarters  of  an  inch  in  Icngtli.  They  are 
extremely  active,  and  burrow  widely,  causing  extensive  destruction  of  all  the  tissues. 
On  account  of  the  circles  of  spines  they  are  extremely  difficult  to  extract  from  their 
burrows  in  firm  tissue.  Screw-worm  infections  of  the  nose  are  very  ])ainful  and 
exceedingly  fatal.  The  larvic  bore  into  the  frontal  and  ethmoidal  sinuses,  and 
eventually  may  even  enter  the  brain.  There  is  intolerable  pain  at  the  bridge  of 
the  nose,  with  a  bloody,  fetid  discharge  from  the  nostrils.  A  very  large  percentage 
of  the  cases  die  from  extension  of  the  infection  into  the  sinuses  or  meninges.  When 
the  larviie  develop  in  the  ear  they  penetrate  the  tympanic  cavity,  causing  severe 
otitis  media  and  even  fatal  meningitis.  Numbers  of  such  cases  have  been  reported 
by  army  surgeons  from  the  Rio  Grande  border. 

Treatment. — Treatment  consists  in  the  injection  of  strong  parasiticides,  such  as 
carbolic  acid  and  chloroform.  Better  still,  chloroform  is  taken  up  on  a  small 
probe  tipped  with  absorbent  cotton,  and,  \\ath  a  good  light,  the  nose  or  ear  is 
explored  and  each  worm  as  it  lies  embedded  in  the  tissues  is  touched  with  the 
chloroform-saturated  cotton.  This  kills  them  immediately  and  they  may  then  be 
readily  extracted  with  small  forceps.  In  superficial  wounds  the  destruction  of  the 
larvne  is  much  more  simple. 

Intestinal  Myiasis. — The  larvse  of  diptera  are  very  frequently  found  in  the 
alimentary  canal  of  man.  They  usually  gain  entrance  by  being  swallowed  on 
fly-blown  food.  No  less  than  nineteen  different  species  have  been  identified  in 
human  evacuations.  As  a  rule  no  symptoms  are  produced,  and  the  first  the  patient 
knows  of  the  existence  of  the  larviE  is  to  find  perhaps  a  copious  mass  of  them  in 
the  stools.  In  tropical  climates  the  passage  of  larvte  is  very  much  more  frequent 
than  in  temperate  countries,  for  obvious  reasons  connected  with  the  difficulty 
of  preserving  food  supplies.  The  appearance  of  the  larvre  is  usually  viewed  with 
the  greatest  alarm  by  the  patients,  but,  as  a  rule,  they  are  entirely  harmless.  Occa- 
sionally they  produce  some  symptoms  of  gastro-intestinal  disturbance,  such  as 
vomiting,  diarrhea,  and  abdominal  pains.  Free  purgation  is  indicated  whenever 
larvte  are  seen  in  the  stools,  to  ensure  evacuation  of  those  remaining.  For  this 
purpose  calomel  is  the  best  drug,  as  it  exercises  not  only  an  evacuant  but  a  toxic 
effect  on  the  larva;. 

Dermatobia  Cyaniventris. — This  common  American  fly  deposits  its  eggs  on  the 
skin  of  man  and  cattle.  The  larvte  penetrate  the  cutaneous  structure,  producing 
large  pustular  lesions  (locally  known  as  ver  macaque).  Besides  this  fly  there  are 
great  numbers  of  diptera  whose  larvte  attack  the  skin  of  man.  In  all  of  them  the 
lesions  are  similar  to  that  above  described.  In  America  these  are  principally 
the  Musca  vomitoria  the  ordinary  blue-bottle  fly,  and  the  bot-fly  of  the  ox  and  sheep. 


TUMBU-FLY  DISEASE. 

This  is  a  condition  met  with  in  Sierra  Leone  and  elsewhere  on  the  west  coast  of 
Africa.  The  larviB  of  the  Tumbu-Fly,  or  Cordylobia  an1hro])oi)hagia,  burrow 
under  the  skin  and  produce  sore  and  tender  spots,  the  opening  in  the  skin  being 
maintained  for  breathing  and  excrementitious  purposes.  The  maggot  is  about 
half  an  inch  long  and  can  be  squeezed  out  of  its  burrow.  The  infection  may  be 
multiple  or  single. 


DISEASES  OF  THE  KESPIRATORY  SYSTEM. 


DISEASES  OF  THE  NOSE. 

ACUTE  CORYZA. 

Definition. — Acute  coryza  is  an  Inflammation  of  the  nasal  mucous  membrane, 
characterized  in  its  early  stages  by  hyperemia,  redness,  and  swelling,  and  followed 
by  free  secretion  of  mucus  and  serum. 

Etiology. — Without  any  doubt  acute  coryza  is  an  infectious  malady,  although  it 
usually  follows  exposure  to  cold  or  wet.  The  exposure  produces  a  condition 
favorable  to  the  growth  of  the  micro-organisms  which  cause  the  disease.  No  single 
organism  has  been  isolated,  and  in  some  cases  several  are  probably  active  at  once. 
Coryza  is  a  conspicuous  symptom  of  certain  forms  of  influenza  and  may  be  produced 
by  a  number  of  micro-organisms,  among  which  the  pneumococcus  should  be  men- 
tioned. Hajek  claims  to  have  isolated  an  organism  called  the  Diplococciis  coryzw, 
which  he  believes  is  responsible  for  the  malady.  The  Micrococcus  catarrhalis,  the 
pneumococcus  and  the  bacillus  of  influenza  are  the  most  frequent  causes. 

The  disease  can  be  transmitted  from  one  person  to  another,  probably  by  droplets 
of  infected  discharge,  the  susceptibility  of  an  individual  depending  upon  both  a 
local  and  general  lowering  of  vital  resistance.  The  breathing  of  vitiated  air,  as 
in  badly  ventilated  theatres  and  steam  cars,  and  of  dust-laden  atmospheres,  as  in 
certain  industries,  is  a  frequent  predisposing  cause.  The  possibility  of  a  diphtheritic 
origin  in  certain  cases  should  not  be  overlooked.  Damp  cold,  even  if  of  moderate 
degree,  is  more  provocative  of  the  disease  than  dry  cold. 

Pathology  and  Morbid  Anatomy. — The  pathology  of  acute  coryza  is  that  of  an 
ordinary  catarrhal  inflammatory  process  affecting  a  mucous  membrane.  The 
bloodvessels  of  the  submucosa  become  hyperemic,  and  from  them  an  extravasation 
of  white  blood  cells  and  red  corpuscles  takes  place,  accompanied  by  a  transudation 
of  serum,  which  increases  the  swelling,  and  finally  escapes  upon  the  surface  of  the 
mucous  membrane,  to  be  thrown  ofT  with  the  desquamated  epithelium.  The  mu- 
cous glands  secrete  an  excess  of  mucus  laden  with  dead  epithelial  cells  and  leukocytes 
or  pus  corpuscles.  As  recovery  takes  place,  the  inflammatory  exudate  in  the 
submucosa  is  absorbed,  the  dead  epithelial  cells  are  replaced  by  young  cells,  and 
in  this  manner  the  process  of  repair  is  completed. 

■  Symptoms. — The  symptoms  of  acute  coryza  consist  in  primary  chilliness  and  some 
restlessness  and  in  a  sensation  of  dryness  of  the  nasal  viuccnts  membrane  of  the  part 
affected.  This  is  accompanied  by  a  loss  of  the  sense  of  smell  and  by  a  dull  frontal 
headache,  probably  due  to  congestion  in  the  frontal  sinus.  There  is  frequently 
severe  sneezing,  due  to  the  irritation  of  the  nasal  nerves  by  the  inflammation  and 
to  the  tickling  of  the  serum  over  the  angry  mucous  membrane.  The  voice  sounds 
as  if  the  nose  was  "stopped  up."  As  the  disease  progresses,  large  amounts  of 
mucopurulent  material  are  discharged  from  the  nostrils  and  find  their  way  back 
into  the  nasopharynx.  The  constitutional  symptoms  are  often  quite  severe,  and 
consist  in  chilliness  and  flushes  of  heat,  followed  by  relaxation  of  the  capillaries 
of  the  skin  and  more  or  less  perspiration.     Aching  in  the  head,  in  the  muscles,  and 

(359) 


360  DISEASES  OF  THE  XOSE 

the  small  of  the  back  are  prominent  synii)tonis,  indicating  that  the  k)eal  nasal  jjrocess 
is  not  the  only  part  disonlered,  but  that  other  parts  are  indirectly  affected.  With- 
out doubt,  tiic  two  chief  causes  of  these  symptoms  are  the  loss  of  large  amounts 
of  liquids  by  the  nose,  something  like  U  to  2  pints  a  day  in  some  cases,  and  the 
absorption  of  toxic  materials  due  to  the  infection. 

Diagnosis. — The  acute  rhinitis  due  to  an  oncoming  attack  of  measles,  or  that  due 
to  an  attack  of  hay  fever,  are  the  two  states  that  most  closely  resemble  true  coryza. 
In  infants  the  possibility  of  the  attack  being  due  to  syphilis,  "syphilitic  snuffles," 
must  be  considered. 

Treatment. — The  treatment  of  acute  coryza  consists,  if  the  patient  is  seen  in 
the  stage  of  onset,  of  the  use  of  a  saline  purgative  to  deplete  the  system  and  unload 
the  bowels,  and  in  the  internal  use  of  full  doses,  20  to  30  grains  every  hour  for  five 
doses,  of  bicarbonate  of  sodium  in  water  or  instead  10  grains  of  aspirin  with  1  grain 
of  camphor  every  four  hours.  In  other  cases  the  well-known  combination  called 
"rhinitis  tablets"  may  be  given.     These  consist  of — 

I^ — Quininae  sulphatis gr.  j. 

CamphoriE gr.  J. 

Ext.  belladonnae gr.  ,\. — M 

Sig. — One  or  two  every  thirty  minutes  till  six  are  talvcn. 

The  nasal  mucous  membrane  should  be  washed  by  a  gentle  spray  of  normal 
salt  solution,  followed  by  a  spray  of — 

I^ — Cocainffi  hydrocliloridi gr.  iv. 

Chloretoni gi'-  ij- 

Aquae  destillat q.  s.  ad  fsj. — M 

Sig. — Apply  as  a  spray. 

Followed  by  a  spray  of — 

I^ — Antipyrini gr.  x. 

Coeaina;  hydrocliloridi gr.  j. 

Aqua;  camphora; foiij- 

Aquas  destillat q.  s.  ad  fjj. — M. 

This,  in  turn,  should  be  followed  by  a  spray  of  menthol  in  the  proportion  of 
6  grains  to  the  oimce  of  liquid  albolene. 

In  many  instances  a  hot  foot-bath  and  a  dose  of  5  to  10  grains  of  Dover's  jiowder 
may  be  used  to  abort  an  attack. 

After  the  disease  is  well  on  its  way,  it  is  bound  to  run  its  course.  We  can  only 
give  relief  by  using  a  type  of  nasal  treatment  like  that  just  suggested  and  in  cleansing 
the  nasal  chambers  of  mucus. 

When  the  attack  has  run  its  course  the  consequent  debility  is  best  controlled 
by  the  use  of  fresh  air,  arsenic,  ammonium  benzoate,  and  bitter  tonics. 

CHRONIC  NASAL  CATARRH. 

Definition. — Chronic  nasal  catarrh,  as  its  name  implies,  is  a  chronic  inflammatory 
state  of  the  nasal  mucous  membranes,  frequently  due  to  repeated  attacks  of  the 
acute  variety,  or  occasionally  coming  on  more  insidiously.  When  it  is  well  de- 
veloped the  tissues  of  the  nasal  chambers  are  relaxed  and  somewhat  edematous, 
the  secretion  is  abnormal  in  character  and  in  quantity,  and  this  pathological  con- 
dition is  often  subject  to  acute  exacerbations  due  to  exposure  to  the  usual  causes 
of  coryza. 

Etiology. — The  causes  of  chronic  nasal  catarrh  are,  as  just  stated,  repeated 
attacks  of  acute  coryza  and  continued  exposure  to  the  action  of  irritating  dust 
or  of  cold,  moist  air,  laden  with  infectious  materials.     The  condition  may  be  of 


ATROPHIC  NASAL  CATARRH  361 

syphilitic  origin  or  arise  from  depleted  vitality  from  constitutional  disorders,  such 
as  Bright's  disease.  Foreign  bodies  should  be  searched  for,  particularly  if  the 
patient  is  a  child,  and  nasal  growths  may  be  found  as  a  cause,  iilthougli,  as  a 
rule,  the  catarrh  causes  the  formation  of  growths. 

Pathology. — An  examination  of  the  nasal  mucous  membrane  in  cases  of  this 
disease  shows  that  the  bloodvessels  are  distended  and  have  lost  their  normal 
elasticity,  this  favors  congestion  when  other  parts  are  chilled.  Exudation  into 
the  connective  tissues  takes  place,  and  so  this  structure  becomes  thickened  and 
enlarged.     At  this  stage  the  condition  is  sometimes  called  hypertrophic  rhinitis. 

Repeated  or  protracted  irritation  induces  hyperplasia  of  the  connective  tissue 
of  the  submucosa,  continued  epithelial  exfoliation,  glandular  atrophy,  and  sclerotic 
changes  in  all  the  layers  of  the  mucous  membrane.  In  the  earlier  stages  these 
changes  are  those  already  mentioned  when  discussing  acute  corj^za;  later  cell 
proliferation  and  leukocytic  accumulation  in  the  nasopharyngeal  submucosa 
greatly  thicken  the  membrane,  particularly  over  the  turbinates  and  the  septum 
{hypertrophic  rhinitis),  while  organization  (fibroid  change)  increases  the  fibrous 
tissue  in  the  areas  involved,  followed  by  contraction  with  atrophy  of  erectile, 
glandular,  and  even  nerve  tissues  (atrophic  rhinitis).  This  lessens  secretion,  which 
tends  to  inspissate,  form  scabs,  and  decompose,  causing  the  fetid  emanations  to 
which  the  name  "ozena"  has  been  given. 

Extension  to  one  or  more  of  the  facial  sinuses,  necrosis  of  bone,  or  invoh'ement 
of  the  Eustachian  orifice  or  tube  are  possibilities  constantly  to  be  remembered. 

Symptoms. — ^The  symptoms  of  this  stage  of  the  disease  consist  in  a  constant 
secretion  in  excess  of  nasal  mucus,  which  passes  in  large  part  into  the  postnasal 
and  nasopharyngeal  spaces.  This  secretion  may  be  thin  and  liquid  or  thick  and 
mucopurulent,  and  is  apt  to  vary  in  quantitj^  with  exposure  to  cold  or  dust.  The 
secretion  is  so  thick  that  it  readily  becomes  inspissated  and  partly  blocks  the  nasal 
passages,  and,  furthermore,  becomes  loaded  with  bacteria,  so  that  it  may  be  some- 
what fetid. 

Treatment. — The  treatment  consists  in  maintaining  nasal  cleanliness  by  an 
ordinary  nasal  douche-cup,  to  be  used  night  and  morning,  employing  in  it  normal 
salt  solution  or  Dobell's  solution  warmed  to  the  temperature  of  the  body.  The 
physician  should  also  cleanse  the  parts,  when  the  patient  visits  him,  by  a  mild 
alkaline  wash,  and  when  no  acute  exacerbation  is  present  the  hypertrophied  mucous 
membrane  over  the  middle  turbinate  should  be  cocainized  and  then  lightly  touched 
with  a  small  electrocautery,  a  piece  of  oiled  cotton  being  placed  between  the  spot 
cauterized  and  the  nasal  septum,  to  prevent  adhesions  from  forming  during  the 
period  of  acute  swelling  which  follows  the  operation.  Care  should  be  taken  to 
keep  the  parts  clean  for  several  days  to  prevent  infection,  if  the  patient  is  primarily 
anemic  or  debilitated.  This  treatment  should  not  be  resorted  to  before  the  general 
health  is  improved  by  tonics. 


ATROPHIC  NASAL  CATARRH. 

Definition. — In  this  condition  the  nasal  mucous  membrane  and  the  underlying 
tissue  undergo  atrophy  and  contraction,  with  the  result  that  the  bloodvessels  of 
the  part  are  occluded  or  destroyed. 

Etiology. — Atrophic  nasal  catarrh  follows  the  chronic  type  of  ordinary  nasal 
catarrh  as  a  late  condition.  At  times  it  seems  to  be  due  to  some  congenital  defect 
in  the  shape  of  the  nasal  chambers,  and  in  some  cases  it  begins  to  develop  as  the 
result  of  one  of  the  acute  infectious  diseases. 

Pathology. — The  chief  change  is  an  atrophy  of  the  cells  of  the  nasal  mucoue 
membrane  and  an  overgrowth  of  the  submucous  connective  tissue,  which  is  prone 


362  DISEASES  OF  THE  NOSE 

to  undergo  contractile  changes.  This  cuts  off  blood  su])ply  and  increases  the 
atrophic  process. 

Symptoms. — These  consist  in  the  formation  of  scabs,  or  crusts  of  thickened, 
tenacious  mucus,  which  are  usually  infected  by  many  pathogenic  germs.  Some 
ulceration  of  the  nasal  septum  may  appear,  and  the  patient  may  complain  of  a 
constant  feeling  of  dryness  and  irritation,  or  occlusion  of  the  nasal  passages. 

The  nasopharyngeal  mucous  membrane  is  often  dry  and  shiny  in  appearance. 
When  the  condition  is  far  advanced  a  state  of  fetid  ozena  develops,  in  which  the 
breath  of  the  patient  becomes  fetid  beyond  the  power  of  words  to  describe  it. 
Nothing  equals  it,  except  the  breath  in  a  case  of  pulmonary  gangrene. 

The  sense  of  smell  is  practically  destroyed  by  the  process,  and  the  patient  is  often 
ignorant  of  how  disagreeable  his  breath  has  become. 

Prognosis. — The  outlook  for  a  cure  of  this  condition  is  luifavorable.  The  bad 
odor  can  usually  be  relieved. 

Treatment. — The  patient  should  be  told  to  use  a  nasal  douche-cup  with  warm 
Dobell's  solution  twice  a  day.  Kyle  recommends  1  drop  of  ordinary  coal  oil 
dropped  into  each  nostril  after  this.  The  physician  should  see  the  patient  every 
few  days,  cleanse  the  nasal  chambers,  and  a  1 :  500  solution  of  formaldehyde  may 
be  used  on  an  applicator.  Excellent  results"  have  followed  the  use  of  a  5  per 
cent,  ointment  of  scarlet  red. 

HAY  FEVER. 

Definition. — Hay  fever  is  an  inflammation  of  the  nasal  mucous  membrane  which 
occurs  period icall J''  and  usually  at  a  time  of  the  year  when  certain  plants  are  in  a 
given  stage  of  growth.  Associated  with  the  localized  inflammation,  there  is 
often  present  an  asthmatic  condition,  in  which  a  sense  of  oppression  is  well  de- 
veloped. In  other  instances  true  asthmatic  attacks  ensue.  Hay  fever  is  often 
called  "autumnal  catarrh,"  "rose  cold,"  "ragweed  fever,"  or  "periodic  rhinitis." 

Distribution. — The  prevalence  of  hay  fever  depends  largely  upon  the  presence 
in  the  air  of  the  pollen  of  certain  plants,  and  in  those  parts  of  the  country  where 
these  plants  do  not  grow  the  disease  is  unknown.  It  is  more  rare  in  England  than 
in  America,  but  much  more  common  in  these  countries  than  elsewhere,  being  com- 
paratively rare  in  France  and  Germany.  Negroes  and  Indians  are  apparently 
immune,  and  the  lower  classes  very  frecjuently  escape,  the  disease  being  chiefly 
a  malady  of  the  so-called  upper  classes.  The  disease  is  comparatively  rare  after 
the  fortieth  year  and  affects  males  oftener  than  it  affects  females. 

Etiology. — There  are  two  chief  factors  in  the  development  of  hay  fever,  namely, 
an  idiosyncratic  state  of  the  patient  and  the  presence  of  an  exciting  cause  in  the 
atmosphere.  INIuch  discussion  has  taken  place  as  to  what  the  condition  is  that 
renders  the  patient  peculiarly  liable  to  this  affection.  In  some  cases  it  seems  to  be 
a  neurosis  of  the  nasal  cavities  or  a  local  disease;  in  others  it  is  probably  a  type  of 
anaphylaxis.  In  every  case,  however,  there  is  a  condition  of  nasal  hyperesthesia 
which  renders  the  nasal  mucous  membrane  extremely  sensitive  to  irritants.  Many 
sufferers  from  hay  fever  present  irregularities  in  the  nasal  chambers  which  may  aid 
in  predisposing  them  to  attacks  of  the  malady. 

The  second  cause  of  hay  fever  in  the  great  majority  of  cases  is  the  presence  in 
the  air  of  pollen  from  some  plant,  cliiefly  "ragweed."  Pollen  is  not  the  only  cause, 
however,  for  typical  attacks  occur  in  certain  persons  at  seasons  of  the  year  when 
no  pollen  is  present,  the  condition  being  induced  by  some  irritating  dust  or  vapor 
which  in  no  way  influences  the  ordinary  individual. 

Pathology  and  Morbid  Anatomy. — In  the  state  of  the  nasal  mucous  membrane 
there  is  nothing  peculiar  to  hay  fever,  which  presents  on  examination  the  evidences 
of  an  acute  catarrlial  iiiflanuiiation  with  swelling  and  h,\-peremia  of  the  parts 
iiivoh'ed. 


HAY  FEVER  363 

Symptoms. — The  symptoms  of  "hay  cold"  are  usually  sudden  in  onset  and  often 
appear  on  a  certain  day  which  the  patient  can  foretell,  and  nearly  always  at  a 
definite  period  in  the  year,  for  the  reason  already  given.  An  acute  rhinitis  develops 
with  irritation  of  the  7iasal  vincous  vievihrane,  and  the  running  of  salty  Huid  from 
the  nostrils  irritates  the  nares  and  the  upper  lip.  The  conjunctival  mucous  mem- 
brane is  irritated  and  inflamed,  and  the  eyes  are  tearful,  partly  because  of  this 
condition  and  partly  because  the  tear  ducts  to  the  nose  are  stopped  by  the  swelling 
of  the  mucous  membrane.  PhotopJiohia  and  neuralgic  pains  in  the  head  are  often 
present  and  add  greatly  to  the  patient's  misery.  Frontal  headache  is  constant 
and  severe,  and  tinnitus  and  fulness  of  the  head  are  also  annoying  sjTnptoms.  Some 
deafness  may  be  present.  Associated  with  these  sjTnptoms  the  patient  often  has 
marked  systemic  depression  and  wretchedness  with  great  mental  depression. 

On  examining  the  mucous  membrane  of  the  nose  there  is  found  undue  pallor, 
in  long-standing  cases,  which  is  not  to  be  expected  when  inflammation  is  present. 
If  a  probe  is  touched  to  the  mucous  membrane  patches  of  hyperesthesia  are  dis- 
covered, as  evidenced  by  sudden  severe  sneezing  and  other  signs  of  acute  irri- 
tation. 

The  attack  is  prone  to  persist  as  long  as  the  patient  remains  exposed  to  the  cause, 
and  upon  his  removal  from  exposure  may  cease  almost  as  speedily  as  it  came  on. 
In  cases  in  which  a  reflex  asthma  due  to  the  nasal  irritation  ensues  the  patient  may 
becoine  a  chronic  asthmatic,  even  if  the  hay  cold  disappears. 

Prognosis. — The  outlook  for  cure  in  the  affection  is  not  good  unless  the  patient 
can  go  away  to  a  resort  where  the  cause  does  not  exist,  for  a  certain  length  of  time 
each  year.  So  far  as  life  is  concerned  it  never  endangers  it,  but  if  the  disease 
produces  vital  depression  it  undoubtedly  increases  the  susceptibility  to  other 
diseases.  The  patient  can  be  comforted  by  the  statement  that  the  attacks  stop 
or  diminish  in  many  cases  after  forty  years  of  age. 

Treatment. — A  competent  rhinologist  should  always  be  asked  to  correct  all 
nasal  irregularities  during  the  period  of  quiescence,  and  the  physician  should 
correct  any  faulty  nutritional  state  by  the  use  of  ordinary  exercise,  a  good  diet, 
and  the  use  of  the  salicylates,  or  bitter  tonics  with  arsenic  to  improve  the  state  of 
the  mucous  membranes  in  general.  Not  infrequently  good  results  follow  the 
use  of  30  grains  of  phosphate  of  sodium  in  a  cup  of  hot  water  before  breakfast, 
given  to  stimulate  the  gastroduodenohepatic  glands.  In  other  cases  salicylate 
of  sodium  in  10-grain  doses  or  salol  may  be  used.  These  measures  and  the  resort 
to  a  region  free  of  the  exciting  cause  in  the  autumn  months  are  the  prophylactic 
measures.  A  sea  voyage  usually  confers  complete  immunitj'  if  taken  at  the 
proper  time  of  year,  and  sometimes  residence  at  some  mountain  resort  does  like- 
wise, particularly  if  the  altitude  is  very  great. 

In  the  way  of  local  treatment  for  the  attack  the  swollen  mucous  membranes 
may  be  constricted  by  the  application  of  a  solution  of  adrenalin  chloride  1 :  5000, 
and  after  this  is  done  the  parts  may  be  washed  with  a  mild  alkaline  spray  like 
Dobell's  solution  or  normal  salt  solution  which  has  been  warmed.  After  this  is 
done  the  cocaine  solution  and  the  antipyrin  solution  recommended  for  acute  coryza 
may  be  employed  and  finally  the  parts  coated  by  the  use  of  the  spray  of  menthol 
and  camphor  named  in  that  article. 

Within  the  last  few  years  several  attempts  to  produce  immunity  to  hay  fever 
by  the  use  of  preparations  of  golden  rod  and  ragweed  have  been  attempted,  the 
patients  taking  them  for  some  time  before  the  time  of  an  attack  in  the  hope  that 
they  would  not  suffer  from  the  disease.  This  plan  has  not  so  far  proved  very 
successful. 

Dunbar,  of  Hamburg,  claims  to  have  isolated  a  toxin  from  the  pollen  of  certain 
plants,  and  by  giving  it  to  horses  produced  an  antitoxic  serum  which,  he  states, 
will  protect  a  susceptible  person.     This  is  not  used  hy'podermically,  but  is  dried, 


364  DISEASES  OF  THE  LARYNX 

mixed  with  sugar  of  milk,  and  then  finely  triturated.  A  small  part  of  this  powder 
is  to  be  snuft'cd  up  the  nose.  When  it  is  desired  to  use  the  remedy  in  the  eyes 
the  fluid  scrum  is  employed.     It  succeeds  in  some  cases  and  fails  in  others. 

EPISTAXIS. 

Etiology. — Nosebleed  is  due  to  many  different  causes,  chiefly  traumatic.  The 
condition  only  concerns  us,  from  the  medical  stand-point,  when  it  develops  as  a 
result  of  lesions  in  the  nasal  cavities  or  in  the  course  of  the  infectious  diseases, 
or  in  cases  of  heart  disease  in  which  there  is  cephalic  congestion.  Occasionally 
it  occurs  in  very  plethoric  persons  after  severe  exercise,  and  in  them  it  may  be  a 
beneficial  condition. 

Severe  nasal  hemorrhage  usually  arises  from  an  ulcer  on  the  nasal  septum,  from 
cardiac  disease,  the  commonest  lesion  being  mitral  disease,  and  in  typhoid  fever 
as  one  of  the  prodromes.  Occasionally  it  is  a  desperately  persistent  state  in  hemo- 
philia, and  even  more  rarely  it  seems  to  be  of  the  nature  of  vicarious  menstrua- 
tion. Sometimes  it  is  a  manifestation  of  blood  dyscrasia,  as  in  leukemia.  (See 
Hemophilia.) 

Treatment. — The  treatment  consists  in  plugging  the  nostrils  with  cotton,  if 
necessary  saturating  the  cotton  with  adrenalin  chloride  1 :  2000,  and  in  compressing 
the  artery  on  the  upper  lip  near  the  nose  by  pushing  it  against  the  jaw-bone.  Inter- 
nal measures  are  usually  unnecessary  and  useless.  Horse  or  human  serum  may 
be  injected  hypodermically  in  some  cases. 


DISEASES  OF  THE  LAKYNX. 

ACUTE  CATARRHAL  LARYNGITIS. 

Definition. — x\cute  laryngitis,  or  acute  catarrh  of  the  larynx,  is  an  inflammation 
of  the  mucous  membrane  lining  the  larynx,  as  a  result  of  which  there  is  more  or 
less  loss  of  voice,  or  aphonia,  and  perhaps  a  sense  of  constriction  or  respiratory 
oppression. 

Etiology. — This  condition  arises  as  a  result  of  any  factor  which  directly  causes 
irritation  of  the  laryngeal  mucous  membrane,  such  as  the  inhalation  of  irritant 
vapors  or  dust.  In  some  cases  the  inhalation  of  cool  and  damp  air  produces  like 
effects,  particularly  if  the  voice  has  been  used  much  before  the  exposure.  Indirectly 
it  arises  as  the  result  of  getting  the  body  chilled  in  a  cold  wind  after  exercise,  and 
in  still  other  cases  it  seems  to  be,  at  least  in  part,  due  to  some  disorder  of  metabolism 
whereby  gouty  conditions  ensue,  and  these  in  turn  cause  laryngeal  inflammation 
by  some  indirect  efi'ect  when  the  voice  is  much  used.  Another  cause,  particularly 
in  the  case  of  children,  is  "mouth-breathing,"  which  permits  the  air  unnioistened 
by  the  nasal  chambers  to  pass  over  the  laryngeal  surface.  In  still  other  instances 
it  arises  as  a  complication  of  one  of  the  acute  infectious  diseases,  as  influenza  and 
of  hay  fever.  The  possible  diphtheritic  origin  of  acute  laryngitis,  especially  in 
children,  should  never  be  overlooked. 

Pathology. — The  inflammation  of  the  laryngeal  mucous  membrane  is  precisely 
like  that  of  mucous  membranes  elsewhere,  except  for  the  fact  that  glandular  tissue 
is  quite  scarce  in  these  parts,  antl  so  there  is  but  little  mucus  secreted  even  if  a 
considerable  amount  of  inflammatory  exudate  takes  place  in  the  tissues  beneath 
the  mucous  membrane.  The  desquamation  of  epithelial  cells  and  the  presence 
of  dead  leukocytes  cause  the  secretion  to  be  white  and  tenacious,  and  the  conges- 


ACUTE  CATARRHAL  LARYNGITIS  365 

tion  of  the  bloodvessels  gives  rise  to  a  sense  of  tightness  in  the  laryngeal  box  which 
is  distressing.  As  the  congestion  decreases  the  process  of  regeneration  in  the 
epithelial  cells  and  submucous  tissues  takes  place,  secretion  becomes  more  profuse, 
and  perfect  recovery  ensues. 

Symptoms. — The  patient  finds  it  difficult  to  develop  the  full  resonance  of  his 
voice  and  often  single  words  in  a  sentence,  or  all  the  words,  are  spoken  somewhat 
huskily  owing  to  failure  to  move  the  vocal  bands  as  readily  as  in  health.  There 
is  a  sense  of  tightness  in  the  larynx  and  even  aching  pain  may  be  present.  In 
some  cases  hoarseness  is  the  only  symptom,  but  in  others  the  loss  of  voice  is  com- 
plete. Speech  at  this  time  is  often  so  painful  that  the  patient  endeavors  to  avoid 
conversation. 

An  examination  of  the  laryngeal  mucous  membrane  at  this  time  will  reveal 
marked  redness  and  hyperemia  and  even  small  punctiform  hemorrhages  may  be 
seen,  particularly  if  the  patient  has  repeatedly  and  violently  endeavored  to  clear 
his  throat  by  hawking  or  coughing.  The  ventricular  bands  are  swollen,  and  this 
may  be  the  chief  cause  of  the  loss  of  voice,  for  it  often  happens  that  the  vocal  cords 
escape  the  inflammatory  process.  In  other  cases  the  edges  of  the  glottic  opening, 
the  epiglottis,  and  the  mucous  membrane  over  the  arytenoids  are  inflamed. 

As  the  process  proceeds  secretion  is  begun  and  small  particles  of  mucus  are 
occasionally  coughed  up.  This  is  particularly  apt  to  occur  after  severe  coughing 
in  the  morning  in  order  to  dislodge  inspissated  mucus.  The  masses  expectorated 
are  often  distinctly  purulent,  and  discolored  with  soot  if  the  patient  lives  in  a  city. 
Secretion  gradually  becomes  more  profuse.  Pain  disappears  and  the  voice,  which 
has  been  whispering,  becomes  hoarse  and  coarse  in  character,  certain  words  which 
require  effort  being  sounded  with  difficulty.  Finally  the  voice  recovers  its  normal 
tone  and  the  attack  is  over. 

Diagnosis. — Care  should  be  taken  that  sudden  attacks  of  hoarseness  are  not 
considered  as  due  to  simple  catarrhal  laryngitis,  until  the  possibility  of  diphtheria 
is  excluded  by  a  thorough  examination  of  the  throat  and  larynx.  This  is  particu- 
larly important  in  children.  In  adults  the  possibility  of  aneurysm,  tuberculosis, 
papilloma,  and  syphilis  should  not  be  forgotten. 

Prognosis. — The  prognosis  is  always  good  as  to  recovery  if  the  exciting  cause 
is  removed. 

Treatment. — The  treatment  of  acute  laryngitis  consists  primarily  in  removing 
the  cause.  If  irritant  dusts  are  present  the  patient  must  not  be  exposed  to  them, 
and  if  the  outside  atmosphere  is  raw  and  cold  he  must  be  kept  in-doors  until  recov- 
ery takes  place.  When  a  gouty  diathesis  underlies  the  condition  the  salicylates 
should  be  freely  used  in  the  form  of  salicin,  5  grains  three  or  four  times  a  day,  and 
the  vegetable  salts  of  potassium,  such  as  the  citrate,  be  given  freely.  About  the 
neck  may  be  fastened  a  capsicum  draft,  or,  if  this  is  not  to  be  had,  a  folded  hand- 
kerchief should  be  wrung  in  cold  water  and  laid  upon  the  larynx,  being  immediately 
covered  by  a  cloth  or  piece  of  flannel,  which  is  bound  around  the  neck.  The  cold 
compress  is  promptly  changed  to  a  warm  compress  by  the  heat  of  the  body,  and 
this  acts  favorably  upon  the  local  inflammation  beneath.  The  air  of  the  room  in 
which  the  patient  is  to  sleep  or  rest  during  the  day  should  be  kept  well  moistened 
by  steam  disengaged  by  a  bronchitis  kettle  or  by  adding  pieces  of  unslaked  lime 
to  a  tub  of  water.  Into  the  water  in  the  bronchitis  kettle  may  be  placed  a  few 
grains  of  menthol  if  it  is  desirable  to  exercise  a  very  sedative  effect,  and  the  patient 
should  be  forbidden  to  go  into  any  cold  rooms  or  hallways.  A  hot  mustard  foot- 
bath and  a  hot  lemonade  with  a  drachm  of  sweet  spirit  of  nitre  at  bedtime  to  produce 
sweating  is  also  useful,  or  a  dose  of  Dover's  powder  may  be  ordered  if  the  patient 
is  an  adult.  Kyle  recommends  the  use  of  tablets  of  y^t^  grain  of  pilocarpin  every 
hour  for  four  doses,  or  if  it  is  important  to  attempt  to  abort  the  disease  he  suggests 
the  use  of  5  to  10  drops  of  dilute  nitric  acid  in  water  every  hour  for  three  doses, 


366  DISEASES  OF  THE  LARYNX 

and  tlien  every  two  hours  for  two  doses.     This  often  gives  temporary  relief  if  it 
does  no  permanent  good. 

For  the  hoarseness  and  thick  secretion  of  the  stage  of  convalescence  benzoate 
of  soda  or  of  ammonia,  in  10-grain  doses  three  times  a  day,  are  useful,  or  10  grains 
of  ammonium  chloride  may  be  given  thrice  a  day  in  licorice  and  water.  In  still 
other  cases  terpin  hydrate  in  the  dose  of  a  teaspoonful  of  the  elixir  every  three 
horn's  may  be  used. 

CHRONIC  CATARRHAL  LARYNGITIS. 

Symptoms. — Chronic  catarrh  of  the  larynx  is  characterized  by  chronic  hoarseness, 
by  constant  clearing  of  the  throat  in  an  endeavor  to  speak  clearly,  and  finally, 
in  severe  cases,  by  ulceration  of  the  laryngeal  mucous  membrane.  Not  rarely 
after  a  period  of  rest  the  patient  finds  that  after  the  first  few  words  his  voice  forsakes 
him,  or,  instead,  he  may  find  that  if  speaking  is  difficult  at  the  beginning  it  become 
more  easy  as  exercise  limbers  up  the  infiltrated  muscles  and  engorged  mucous 
membrane. 

Pathology. — Pathologically  the  condition  is  characterized  by  chronic  engorge- 
ment of  the  minute  bloodvessels,  thickening  of  the  mucous  membrane,  and  even 
infiltration  of  the  submucous  tissues  and  the  laryngeal  muscles.  If  this  process 
persists  for  any  length  of  time  sufficient  infiltration  may  be  present  to  become 
unabsorbable  and  thus  cause  permanent  alteration  in  the  character  of  the  voice. 
Not  rarely  there  is  thickening  and  swelling  of  the  pharyngeal  tissues  as  well,  and 
the  tonsils  are  the  seat  of  chronic  lymphoid  changes.  Spots  of  ulceration  may 
de\'elop  between  the  arytenoid  cartilages. 

Diagnosis. — As  stated  in  the  article  on  Tuberculosis,  hoarseness  which  is  persistent 
should  always  be  carefully  investigated,  as  it  often  is  due  to  tuberculosis  or  sj-philis, 
or  even  papilloma.  When  it  is  due  to  aneurysm  the  laryngoscope  will  usually 
reveal  one  cord  paral.yzed,  and  when  due  to  syphilis  the  history  of  the  patient  and 
the  benfit  produced  by  specific  treatment  must  be  noted.  In  persons  of  advanced 
years  the  possibility  of  malignant  growth  must  be  considered. 

Treatment. — The  treatment  consists  in  the  maintenance  of  cleanliness  and  free 
secretion  in  the  upper  respiratory  tract  by  the  use  of  alkaline  sprays  and  nasal 
douches.  To  the  larynx  itself  a  spray  of  almnnol  (.3  per  cent,  solution)  may  be 
applied  every  second  day.  The  use  of  tobacco  and  alcohol  should  be  forbidden 
and  the  liver  and  kidnej's  kept  active  by  mild  alkaline  purges  and  diuretics.  Tonics 
to  the  general  system,  such  as  phosphorus,  arsenic,  and  sometimes  iron,  particularly 
the  syrup  of"  the  iodide  are  usefiU. 

EDEMATOUS  LARYNGITIS. 

Defiiution. — Edema  of  the  larynx  occurs  as  an  acute  affection,  occasionally 
of  such  a  severe  degree  that  it  endangers  life.  It  is  essentially  an  acute  cellulitis 
of  the  laryngeal  tissues,  and  when  it  involves  the  upper  part  of  the  larynx  in  par- 
ticular it  is  called  edema  of  the  glottis. 

Etiology. — Edema  of  the  larynx  is  far  more  frequently  due  to  injury  than  to 
any  other  cause,  and  in  many  instances  is  produced  by  the  inhalation  of  irritant 
vapors  or  fumes.  The  only  cases  I  have  seen  have  been  due  to  the  patient  attempt- 
ing to  swallow  ammonia  water  undiluted,  which  both  by  actual  contact  of.  the 
fluid  with  the  pharynx  and  of  the  fumes  with  the  larynx  has  caused  serious  respira- 
tory distress.  Another  traumatic  cause  is  fracture  of  the  laryiLX,  as  by  throttling 
or  other  injury.  Of  the  non-traumatic  causes  we  find  that  acute  infiammations 
in  other  parts  may  be  provocative  of  this  state,  as,  for  example,  tonsillar  abscess 
with  inflammation  of  the  adjacent  tissue  gradually  extending  to  the  larynx.    Some- 


EDEMATOUS  LARYNGITIS  3G7 

times  it  ensues  as  a  result  of  grave  lesions  in  the  cartilages  of  the  larynx,  as  in  the 
chondritis  arising  in  typhoid  fever,  or  even  in  scarlet  fever  in  association  with  the 
development  of  the  "collar  of  brawn."  Infection  by  the  staphylococcus  or  strepto- 
coccus of  the  perilaryngeal  tissues,  the  floor  of  the  mouth  or  pharynx  (as  in  Ludwig's 
angina)  may  extend  to  the  epiglottis  and  larynx.  While  often  an  infection,  it 
may  arise  in  the  course  of  some  affection  characterized  b\'  widespread  edema,  as 
Bright's  disease  or  chronic  heart  disease,  and  so  appear  to  have  a  dropsical  origin. 

Pathology. — The  condition  of  edema  of  the  larynx,  as  its  name  implies,  depends 
upon  the  extravasation  of  fluid  into  the  submucous  tissues,  producing  an  edema 
or  hydrops  of  the  part,  which  is  nearly  always  of  an  inflammatory  origin. 
This  swelling  may  in^'olve  all  the  laryngeal  structures  equally  and  even  extend 
well  along  the  trachea.  In  mild  cases  the  parts  affected  are  not,  however,  seriously 
disorganized,  and  the  swelling  may  disappear  as  rapidly  as  it  came  on,  leaving 
behind  it  little  trace  of  its  existence.  In  fatal  cases  the  swelling  is  usually  found 
at  autopsy  to  have  largely  disappeared,  although  the  parts  may  be  red  and  inflamed 
and  somewhat  relaxed.  In  such  cases  the  microscope  commonly  shows  a  serous, 
or  serofibrinous,  suffusion  of  the  affected  tissues,  the  exudate  containing  a  varying 
number  of  leukocytes.  In  other  cases  the  submucous  and  even  the  perilaryngeal 
tissues  may  be  infiltrated  by  pus,  diffuse  suppurative  interstitial  laryngitis,  a  most 
fatal  disease. 

Ssraiptoms. — With  the  onset  of  this  condition  several  characteristic  s\-mptoms 
at  once  develop,  namely,  impairment  of  the  voice,  siridulous  or  labored  breathing, 
manifestly  due  to  laryngeal  obstruction,  and  increasing  cyanosis.  The  patient 
is  uncomfortable  if  lying  down,  and  is  more  easy  when  sitting  up  and  leaning 
forward.  The  tissues  adjacent  to  the  larynx  may  be  swollen  and  the  patient,  if 
unable  to  speak,  points  appealingly  to  his  larjTix. 

In  some  instances  a  state  of  chronic  edema,  due  to  heart  or  renal  disease,  may 
ensue,  which  is  rarely  so  severe  or  as  pressing  for  relief  as  is  the  acute  malady. 

Diagnosis. — Difficult  larjTigeal  breathing  may  be  due  to  a  larjTigeal  crisis  in 
locomotor  ataxia  or  to  the  lodgment  of  a  foreign  body  in  the  larynx.  These  con- 
ditions should  be  excluded  before  the  physician  decides  that  edema  is  the  cause 
of  the  illness.  Aneurysm  of  the  aorta  may  produce  severe  lar\Tigeal  svinptoms 
by  pressure  on  the  larj-ngeal  nerves,  and  in  children  retropharyngeal  abscess  may, 
by  rupture  or  pressure,  produce  somewhat  similar  symptoms. 

Prognosis. — In  the  absence  of  virulent  sjinptoms  the  prognosis  is  usually  favorable 
even  if  the  sjTnptoms  are  severe,  provided  that  when  they  appear  the  physician 
is  ready  to  give  relief  by  intubation  or  tracheotomy.  If  the  edema  is  due  to  the 
inhalation  of  irritating  vapors  and  the  lower  respiratory  tract  is  involved  in  the 
infiammatory  process,  the  prognosis  is,  of  coiu-se,  very  grave. 

Treatment. — The  treatment  consists  in  the  administration  of  an  active  saline 
purge  to  deplete  the  vascular  system,  and  the  setting  free  of  steam  from  a  bronchitis 
kettle  in  the  air  of  the  room  in  which  the  patient  lives.  To  the  water  in  the  kettle 
may  be  added  a  few  grains  of  menthol  for  its  soothing  influence  on  the  laryngeal 
mucous  membrane.  A  10  per  cent,  solution  of  alumnol  may  be  sprayed  into  the 
larynx  for  its  astringent  effect.  When  the  edema  arises  as  a  complication  of  renal 
or  cardiac  disease  and  is  part  of  a  general  tendency  to  anasarca,  so  active  a  piu-ge 
as  elaterium  or  colocynth  is  indicated  to  remove  fluid  from  the  body,  and  a  hot 
pack  may  be  used  to  cause  sweating  if  the  heart  is  strong  enough  to  stand  it.  The 
use  of  pilocarpine  for  this  purpose  is  unwise,  because  it  is  so  prone  to  cause  pul- 
monary edema.  When  the  laryngeal  obstruction  becomes  marked  it  may  be 
necessary  for  the  physician  to  quickly  perform  intubation  or  tracheotomy,  but 
while  he  should  be  prepared  to  do  so  at  any  moment  it  is  scarcely  necessary  to 
add  that  tracheotomy  should  be  done  only  as  a  last  resort. 


368  DISEASES  OF  THE  LARYXX 


SPASMODIC  LARYNGITIS. 


Definition. — Spasmodic  laryngitis,  sometimes  called  "spasmodic  croup,"  or 
"false  crou]j"  in  distinction  from  diphtheria  or  true  croup,  is  a  condition  of  acute 
laryngeal  catarrh  involving  the  raucous  membrane  in  the  region  of  the  glottis, 
and  resulting  in  swelling  of  those  parts,  so  tliat  the  ingress  and  egress  of  air  is 
difficult.  The  spasm  of  the  laryngeal  muscles,  while  it  aids  in  producing  the  symp- 
toms, is  really  of  secondary  importance  as  compared  to  this  swelling. 

Etiology. — In  the  past  it  was  customary  to  consider  spasmodic  croup  a  disease 
in  itself.  We  now  know  that  it  is  a  symptom  depending  upon  several  causes, 
some  of  which  are  external,  some  internal.  Appearing  as  it  does  almost  always  in 
children  between  one  and  six  years,  but  sometimes  persisting  in  its  occurrence  up 
to  puberty,  it  depends  chiefly  upon  rickets  or  malnutrition,  the  presence  of  postnasal 
adenoids,  which  make  the  child  a  mouth-breather,  or  to  some  defect  in  the  nose, 
which  causes  the  same  condition.  In  some  instances  errors  in  diet  before  retiring 
to  bed  seem  to  precipitate  an  attack.  Of  the  external  causes  which,  however, 
are  only  active  in  those  who  have  a  tendency  to  attacks  of  this  aft'ection,  may  be 
mentioned  furnace-heated  air,  which  is  so  dry  and  dusty  that  if  the  child  is  a  mouth 
breather  the  larynx  becomes  rapidly  drj'  and  irritated.  An  acute  coryza  may  also 
bring  on  an  attack  in  that  it  causes  mouth-breathing. 

Treatment. — The  treatment  is  evident  from  what  has  just  been  said.  It  may 
be  divided  into  two  parts,  that  for  the  relief  of  the  attack  and  that  for  the  cure 
of  the  underlying  causes. 

When  any  sign  of  croup  is  manifested  the  nurse  should  place  1  or  2  grains  of 
menthol  in  the  bowl  of  a  dry  spoon  and  heat  it  over  a  gas  jet  or  lamp.  This  sets 
free  in  the  air  of  the  room  the  menthol  vapor  and  soothes  the  laryngeal  mucous 
membrane.  If  the  attack  is  well  developed  the  nurse  should,  in  addition,  disengage 
from  a  bronchitis  kettle  steam  laden  with  menthol,  or  with  oil  of  pine  and  oil  of 
eucalyptus,  in  the  proportion  of  15  drops  of  each  in  the  water  in  the  kettle  or  on 
the  sponge  usually  placed  in  its  neck  or  spout.  Internally  a  dose  of  5  to  10  grains 
of  bromide  of  sodium  may  be  given  in  syrup,  and  over  the  larynx  should  be  placed 
a  compress  wrung  in  hot  or  cold  water. 

For  the  prevention  of  future  attacks  the  child  should  be  relieved  of  adenoids 
or  enlarged  tonsils,  should  receive  proper  diet  and  tonics  if  rachitic,  and  should 
sleep  in  a  bronchitis  tent  if  the  larynx  is  irritable.  A  sponge  loaded  with  cold 
water  may  be  sopped  upon  the  skin  o\-er  the  larynx  every  morning  to  impro\'e  its 
vascular  tone. 

TUBERCULOUS  LARYNGITIS. 

Definition. — As  its  name  implies,  tuberculous  laryngitis  is  due  to  the  presence 
of  the  Bacillus  tuberculosis  in  the  laryngeal  tissues  and  the  consequent  development 
therein  of  miliary  or  larger  tubercles.     (See  Tuberculosis.) 

Etiology. — In  the  vast  majority  of  cases  of  laryngeal  tuberculosis  the  infection 
is  secondary  to  pulmonary  disease,  and  is  due  to  infection  of  the  larynx  by  the 
sputum  which  the  patient  coughs  up,  or  by  direct  extension  from  below  upward. 
In  rare  instances  it  is  undoubtedly  a  primar\-  affection.  I  have  had  such  a  case 
under  my  care  while  writing  this  article.  As  in  tuberculous  infection  in  other  parts 
there  must  be,  in  addition  to  the  presence  of  the  bacillus,  a  susceptibility  to  infection, 
or  one  acquired  by  general  or  local  lowering  of  vitality.  This  disease  occurs  most 
commonly  in  males  between  twenty  and  thirty  years  of  age. 

Pathology. — Here,  as  elsewhere  in  the  body,  the  development  of  tubercles  takes 
place  by  leukocytic  migration  and  the  proliferation  of  cells,  and  is  accompanied 
by  the  closing  of  bloodvessels  and  the  necrosis  of  the  masses  formed,  followed  bj'' 
breaking  down  and  escape  of  the  cheesy  material,  and  the  production  of  ulcers 


TUBERCULOUS  LARYNGITIS  369 

in  the  laryngeal  mucous  membrane.     As  the  process  of  infiltration  proceeds  the 
perichondrium  is  attacked  and  necrosis  takes  place  in  the  laryngeal  cartilages. 

In  many  other  parts  of  the  body  the  system  makes  efforts  at  repair,  so  that, 
even  if  the  disease  ultimately  wins  the  battle,  evidences  of  an  active  defense  can 
be  recognized ;  but  in  the  larynx  it  very  commonly  happens  that  no  such  reparative 
or  protective  process  occurs,  and  this  is  one  of  the  reasons  why  the  malady  is  so 
rarely  cured.  In  some  cases  the  infectious  process  takes  on  some  of  the  aspects 
of  a  tumor,  a  tuberculoma,  manifesting  a  tendency  to  infiltration  and  induration, 
with  but  little  inclination  to  ulceration. 

Symptoms. — There  are  few  maladies  which  present  such  a  distressing  picture 
of  suffering  as  does  laryngeal  tuberculosis.  The  loss  of  voice,  which  permits  speech 
only  with  great  effort,  cuts  off  the  patient  from  pleasant  intercourse  with  friends 
and  from  expressing  any  but  his  most  urgent  needs,  and  then  only  with  great  pain 
and  effort.  The  thickening  of  adjacent  tissues  nearly  always  makes  swallowing 
most  difficult  and  painful,  and  for  this  reason  urgent  thirst  must  be  satisfied  with 
but  one  swallow  of  water.  The  same  dysphagia  makes  the  use  of  solid  food  impos- 
sible and  the  taking  of  liquid  nourishment  almost  so,  yet  the  patient  cannot  combat 
the  malady  unless  well  nourished.  Because  of  these  factors  and  the  constant  pain 
and  loss  of  sleep,  the  loss  of  weight  in  laryngeal  tuberculosis  is  often  extraordinary, 
almost  equalling  that  seen  in  some  cases  of  malignant  growth  elsewhere. 

In  the  earlier  stages  the  loss  of  voice  and  constant  discomfort  in  the  larynx  may 
be  the  only  symptoms.  Cough  is  present  in  all  cases  to  some  extent,  and  is  often 
exceedingly  painful.  After  all  the  muscles  about  these  parts  have  had  their  action 
inco-ordinated  by  direct  infiltration  or  disordered  nerve  supply,  particles  of  food 
get  into  the  larynx  and  cause  spasm  and  pain  which  is  insufferable. 

A  careful  examination  of  the  chest  wall  will  reveal  in  most  cases  some  tuberculous 
focus. 

If  the  laryngoscope  is  used  in  the  early  stages,  an  acute  hyperemia  may  be  found, 
but  in  the  chronic  type  the  appearance  will  be  that  of  marked  local  anemia.  A 
tuberculous  lesion  may  be  found  in  the  epiglottis,  whence  it  gradually  passes 
downward,  or  the  disease  may  begin  below  the  cords  and  work  its  way  upward. 
These  tuberculous  areas  are  composed  of  small  nodules  or  swellings  which  are 
hjTDeremic  in  the  acute  cases  and  anemic  in  the  chronic  cases.  As  these  nodules 
grow  they  may,  by  their  mere  mechanical  presence,  cause  obstruction  to  free 
respiration.  The  infiltration  of  the  epiglottis  becomes  marked,  and  the  mucous 
membrane  may  become  dotted  by  a  multitude  of  small,  yellow  tubercles  which  are 
easily  recognized.  These  break  down  and,  having  done  so,  form  small  ulcers  which 
coalesce  and  form  larger  areas  of  ulceration.  Comparatively  rarely  the  vocal 
cords  develop  tiny  vegetations. 

Diagnosis. — The  discovery  of  a  pulmonary  tuberculous  process  in  the  presence 
of  hoarseness,  which  is  persistent  and  does  not  clear  up  under  the  ordinary 
treatment  for  acute  or  chronic  laryngitis,  raises  a  suspicion  of  the  tuberculous 
character  of  this  malady  at  once.  In  syphilitic  laryngitis  the  history  of  the  patient, 
the  reddened  areola  about  the  ulcers,  and  the  presence  of  signs  of  syphilis  elsewhere 
will  aid  the  diagnosis.  From  carcinoma  of  the  larynx  we  can  separate  tuberculous 
laryngitis  by  the  fact  that  the  former  disease  occurs  as  a  single  new  growth  in  a 
person  who  is  usually  past  the  period  of  life  in  which  tuberculosis  is  prevalent. 

Prognosis. — The  prognosis  is  most  unfavorable  even  in  cases  seen  in  the  early 
stages,  because  the  ability  to  carry  on  repair  in  these  tissues  is  so  poor  and  because 
experience  has  taught  us  that  these  cases  rarely  recover. 

Treatment. — The  treatment  in  laryngeal  tuberculosis  can  be  carried  out  only 

by  a  skilled  and  dexterous  laryngologist.     Even  in  his  hands  it  may  cause  much 

distress  and  pain.     In  the  hands  of  the  tyro  clumsy  handling  is  probably  worse 

than  useless.     For  the  palliation  of  the  condition  and  of  the  suffering  the  parts 

24 


370  DISEASES  OF  THE  BRONCHI 

may  be  sprayed  with  peroxide  of  hydrogen  followed  by  a  mild  allcaliiie  sohition, 
and  these  in  turn  by  a  spray  containing  menthol  5  grains,  oil  of  sandal-wood  5 
minims,  and  lifjuid  albolene  1  ounce,  (ieneral  tonic  treatment  such  as  is  used  in 
all  cases  of  tuberculosis,  with  careful  feeding,  is  essential.  As  a  rule,  the  i)atient 
should  avoid  high  altitudes,  particularly  if  they  are  windy,  as  the  drying  of  the 
mucous  membrane  increases  discomfort  in  the  lar\nx. 


SYPHIUTIC  LARYNGITIS. 

Etiology. — Syphilis  of  the  larynx  appears  during  the  secondary  and  tertiary 
stages  of  the  disease.  In  the  secondary  stage  it  may  amount  to  nothing  more 
severe  than  hyperemia  or  erythema,  such  as  is  usually  met  with  in  ordinary  acute 
catarrhal  laryngitis,  but  in  other  instances  mucous  patches  develop,  which  are 
most  numerous  about  the  aryepiglottic  folds,  the  region  of  the  vocal  cords,  the 
arytenoid  cartilages,  and  on  the  edges  of  the  epiglottis.  If  active  treatment  is 
instituted  they  usually  readily  yield,  but  they  may  become  distinct  ulcers.  When 
these  heal  there  may  be  sufficient  thickening  of  the  parts  to  cause  permanent 
hoarseness. 

Tertiary  syphilis  appears  in  the  larynx  as  a  diffuse  or  circumscribed  gummatous 
growth,  which  usually  attacks  the  epiglottis,  the  cords,  and  the  posterior  wall 
of  the  larynx,  causing  thickening  and  infiltration  of  the  tissues,  and  finally  ulcera- 
tion of  the  surface  in  some  instances.  The  cicatrization  of  the  ulcers,  or  sclerosis 
of  areas  by  infiltration,  may  cause  stenosis  and  distortion  of  the  laryngeal  wall. 

Symptoms. — The  symptoms  are  hoarseness  and  loss  of  voice,  but  pain  is  rarely 
present. 

Diagnosis. — The  diagnosis  is  based  on  a  history  of  syphilitic  infection  or  by  the 
finding  of  evidence  of  syphilis  and  by  the  relief  which  follows  specific  treatment. 
Tuberculous  ulceration  is  not  so  rapid  in  its  development  and  the  patient  reacts 
to  tuberculin.  Further  than  this,  in  syphilis  the  upper  surface  and  in  tuberculosis 
the  lower  surface  of  the  epiglottis  is  usually  affected.  From  malignant  growth 
of  the  larymx  syphilis  is  separated  by  the  fact  thaf  the  ulcer  is  solitary  in  epithelioma. 

Prognosis. — The  prognosis  is  good  if  treatment  is  used  early,  before  the  stage 
of  ulceration  is  well  developed.  After  ulcers  have  become  deep  and  severe  they 
may  be  healed  by  treatment,  but  cicatricial  contractions  necessarily  appear  as 
healing  goes  on. 

Treatment. — The  treatment  consists  of  iodide  of  potassium,  salvarsan,  and  the 
mercurials,  as  in  other  cases  of  syphilis.     (See  S\'philis.) 


DISEASES  OF  THE  BRONCHI. 

ACUTE  CATARRHAL  BRONCHITIS. 

Definition. — Acute  bronchitis  is  an  inflammation  of  the  bronchial  tubes  which 
is  usually  confined  almost  entirely  to  the  mucous  membrane  lining  them. 

History. — Bronchitis  has  been  recognized  as  a  distinct  condition  for  many  cen- 
turies. It  was  not,  however,  until  the  early  part  of  the  nineteenth  century  that 
this  term  was  used  to  describe  the  condition  now  under  discussion,  when  Badham, 
in  England,  and  Franck,  in  Germany,  first  employed  this  term.  As  with  many 
other  diseases  in\'olving  the  thoracic  organs,  a  clear  description  of  the  pathological 
condition  was  first  given  to  us  by  the  French  physician  Laennec. 


ACUTE  CATARRHAL  BRONCHITIS  371 

Distribution. — Acute  bronchitis  is  a  disease  which  occurs  in  all  parts  of  the  world, 
but  it  affects  chiefly  the  inhabitants  of  those  regions  in  which  the  climate  is  moder- 
ately cold  and  raw,  and  where  the  degree  of  humidity  in  the  atmosphere  is  high. 
On  the  other  hand,  hot  and  dry  portions  of  the  earth's  surface  are  usually  free 
from  this  disease.  Another  important  factor  in  its  prevalence  is  sudden  changes 
of  temperature  and  the  prevalence  of  cold  winds  laden  with  moisture.  For  these 
reasons  the  disease  is  most  frequent  at  those  times  of  the  year  when  sudden  changes 
of  temperature  are  apt  to  occur,  anfl  therefore  is  commonly  met  with  in  the  late 
winter  and  early  spring  months. 

Etiology. — The  etiology  of  acute  bronchitis,  so  far  as  external  influences  are  con- 
cerned, has  just  been  described.  In  a  goodly  number  of  cases,  practically  in  all, 
it  is  probable  that  micro-organism.s  ha\-e  much  to  do  with  the  development  of 
the  disease,  and  that  the  primary  hyperemia  and  congestion  of  the  bronchial 
mucous  membrane  is  due  to  the  exposure  of  the  surface  of  the  body  to  external 
influences  and,  to  a  slight  degree,  to  the  passage  over  the  bronchial  mucous  mem- 
brane of  an  atmosphere  which,  because  of  its  physical  condition,  is  irritating  to 
these  parts.  It  is  a  well-known  clinical  fact  that  exposure  of  the  surface  of  the 
body  to  cold  seems  to  be  followed  by  congestion  of  the  bronchial  mucous  membrane, 
and  that  this  actually  takes  place  has  been  proved,  first,  by  experiments  upon 
animals,  and,  second,  by  observations  upon  man.  Thus,  it  is  possible  by  the 
external  application,  alternately,  of  heat  and  cold  to  the  upper  portions  of  the 
thorax  to  produce  great  changes  in  the  capillary  circulation  of  the  larynx  and 
trachea  and  probably  the  bronchial  mucous  membrane  as  well. 

Much  depends,  too,  upon  the  general  health  of  the  patient  who  is  exposed  to 
the  provoking  causes  which  have  just  been  named.  Strong,  hearty,  or  robust 
individuals  who  have  a  well-balanced  circulation  and  elastic  bloodvessels  frequently 
suffer  from  no  pulmonary  incouA-enience  from  exposiu-e,  but  persons  who  have 
been  enfeebled  by  disease,  or  by  advancing  years,  or  those  who  are  very  young 
frequently  suffer  from  such  a  severe  congestion,  and  it  may  produce  fatal  conse- 
quences. Bronchitis  is  also  not  rarely  the  result  of  an  inflammatory  process 
which  begins  higher  up  in  the  respiratory  tract  and  extends  to  the  tubes.  Prac- 
tically all  acute  infections  of  the  lung  also  produce  some  bronchial  inflamma- 
tion. 

So,  too,  any  condition  of  cardiac  or  renal  disease  which  impairs  circulatory 
activity  is  exceedingly  prone  to  render  the  patient  susceptible  to  this  form  of 
inflammation.  We  find,  therefore,  that  acute  bronchitis  is  a  disease  which  is 
most  prevalent  in  infancy  and  old  age,  and  it  is  entirely  competent,  at  these  two 
periods  of  life,  to  produce  death  if  it  is  present  in  a  severe  form.  Those  who  have 
been  attached  to  the  departments  for  children  in  large  hospitals  cannot  fail  to 
have  been  impressed  with  the  very  great  frequency  of  this  disease  in  the  winter 
months,  and  also  with  its  rarity  among  the  adults  who  come  to  the  same  institution 
for  various  ailments. 

Both  sexes  are  equally  prone  to  suffer  from  acute  bronchitis,  but  it  is  more 
frequently  met  with  in  males  because  males  are  more  exposed  to  the  provoking 
causes  than  females. 

Certain  of  the  acute  infectious  diseases  very  strongly  predispose  to  this  malady. 
Thus,  it  is  nearly  always  present  in  a  well-developed  form  in  a  case  of  measles, 
even  when  that  disease  is  present  in  a  mild  form.  Again,  there  are  but  few  cases 
of  typhoid  fever  which  do  not  have  a  certain  amount  of  bronchitis. 

The  reason  that  bronchitis  so  frequently  complicates  cardiac  disease  depends 
upon  the  intimate  relationship  between  the  circulation  in  the  lungs  and  the  right 
side  of  the  heart,  for  the  bronchial  veins  open  into  the  vente  azygos  and  the  superior 
intercostals,  and  so  are  intimately  connected  with  the  right  side  of  the  heart.  These 
bronchial  veins  also  anastomose  closely  with  the  pulmonary  veins,  and  so  valvular 


372  DISEASES  OF  THE  BRONCHI 

disease  which  results  in  congestion  of  the  right  side  of  the  lieart  naturally  tends  to 
produce  a  disturbance  of  the  circulation  in  the  bronchial  mucous  membrane. 

When  emphysema  of  the  lungs  is  present  the  coincident  bronchitis  is  really 
due  to  two  causes:  first,  the  congestion  of  the  right  side  of  the  heart  which  is  so  apt  to 
ensue  in  emphysema,  and,  second,  the  pathological  changes  in  the  heart  result 
in  imj)airment  of  the  bronchial  circulation.  On  the  other  hand,  bronchitis  some- 
times leads  to  emphysema.     These  affections  are  therefore  interactive. 

There  are  three  other  important  etiological  factors  in  the  jjroduction  of  brmi- 
ehitis  which  must  be  considered.  The  first  of  these  is  the  inhalation  of  irritant 
gases  or  vapors,  producing  what  is  known  as  acute  traumatic  bronchitis.  The 
second  is  the  inhalation  of  dust.  These  dusts  may  be  vegetable,  animal,  or  mineral 
in  their  origin.  Sometimes  all  three  forms  are  combined.  Finally  there  can  be 
no  doubt  that  the  inhalation  of  various  micro-organisms  may  result  in  bronchial 
infection. 

Of  the  forms  of  dust  which  produce  bronchitis  we  find  that  vegetable  dust  seems 
to  be  the  most  frequent  cause. 

That  form  of  bronchitis  which  most  frequently  follows  the  inhalation  of  irritant 
vapors  or  gases  is  seen  in  persons  who  have  been  exposed  to  anunonia  fumes, 
irritating  smoke,  or  to  chlorine  gas.  Another  form  of  local  irritation  producing 
bronchitis  is  that  which  is  seen  in  large  cities  which  are  hea\"ily  veiled  with  smoke 
and  fog.  Thus,  in  the  city  of  London  the  particles  of  moisture  in  the  air  become 
loaded  with  the  sooty  materials,  and  so  evaporation,  even  in  houses  which  are 
fairly  well  heated,  is  greatly  impaired,  and  the  fog  penetrates  in-doors.  As  a 
result  the  frequency  of  acute  bronchitis  is  greatly  increased  in  London  in  those 
seasons  of  the  year  in  which  these  fogs  are  prevalent,  and  the  mortality  of  chronic 
bronchitis  is  wonderfully  increased  at  these  times.  So  powerful  an  influence  do 
these  deleterious  factors  exercise  that  it  is  a  well-known  fact  that  the  mortality 
in  the  citj'  of  London  may  be  doidjled  in  those  weeks  in  which  the  fog  is  present. 
Thus,  on  some  occasions  the  mortality  is  as  high  as  4G  per  cent,  as  against  an 
ordinary  death  rate  of  about  18  per  cent.  The  deaths  from  diseases  of  the  respira- 
tory organs  rose  on  one  occasion  from  415  per  week  to  994  per  week  during  the 
prevalence  of  a  dense  fog.  Of  these,  694  were  due  to  bronchitis  and  1S5  to  jineu- 
monia.  Probably  most  of  them  were  bronchopneumonia  complicating  chronic 
bronchitis.  That  this  increase  was  due  to  the  fog  and  not  to  the  other  conditions 
of  the  climate  is  proved  by  the  fact  that  a  similar  increase  in  mortality  did  not 
take  place  in  surrounding  pro^dncial  cities  and  towns.  These  facts  are  well  empha- 
sized by  West  in  his  well-known  book  upon  Diseases  of  the  Orcjans  of  Respiration. 

The  micro-organisms  infecting  the  bronchial  mucosa  are  the  i)neimiococeus, 
which  is  most  common;  Friedliinder's  bacillus,  the  Streptococcus  pijoyencs,  and  the 
pyogenic  staphylococci.  The  Klebs-Loeffler  bacillus  is  usually  present  in  the 
bronchitis  which  complicates  diphtheria.  In  some  cases  of  bronchitis  additional 
micro-organisms  have  been  found,  such  as  the  Bacillus  ti/pliosus,  Bucillm  c.oli 
comiiiinils,  and  various  forms  of  fungi.  Li  most  instances,  however,  bronchitis 
is  polymicrobic  in  origin,  and  it  is  often  im]iossiblc  to  decide  what  organism  is  the 
primary  infecting  agent. 

Prevention. — Acute  bronchitis  can  only  be  j^rcxcntctl  by  proper  care  of  the 
general  health,  by  proper  clothing,  and  by  the  avoidance  of  climatic  influences 
which  are  known  to  be  deleterious.  Persons  who  ha\'e  learned  by  experience  that 
they  are  peculiarly  susceptible  to  the  various  provoking  causes  nameil,  should, 
by  change  in  climate  or  occupation,  avoid  these  various  causes  of  irritation. 

Pathology  and  Morbid  Anatomy. — Acute  bronchitis  is  characterized  by  hyperemia 
and  swelhng  of  the  mucous  membrane  lining  the  bronchial  tubes,  accompanied 
by  some  infiltration  of  the  submucous  tissues.  At  first  there  may  be  an  almost 
total  secretion  or  undue  dryness  of  the  surface  involved,  but  very  soon  the  engorged 


ACUTE  CATARRHAL  BRONCHITIS  373 

mucous  glands  begin  to  pour  out  into  the  lumen  of  the  tubes  considerable  quantities 
of  mucus,  which  also  soon  contains  epithelial  cells  coming  from  the  lining  of  the 
glands  themselves  and  from  the  surface  of  the  mucous  membrane  as  well.  Leuko- 
cytes, which  haye  undergone  diapedesis,  as  they  do  iia  all  acute  inflammatory 
processes;  are  also  present,  and  even  red  blood  cells  may  be  seen.  A  similar  extra- 
vasation of  red  cells  may  also  take  place  into  the  submucosa,  and,  escaping  on  the 
surface  tinge  the  sputum.  In  the  smaller  bronchi  the  lining  epithelium  may  be 
cast  off  in  shreds,  and  if  the  inOammation  is  intense,  we  ma\'  find  the  tubes  almost 
or  completelj^  closed,  with  resulting  capillary  bronchitis  or  sufl'ocative  catarrh. 
By  the  extension  of  the  inflammation  to  the  peribronchial  tissues  and  the  pul- 
monary alevoli  there  is  developed  a  bronchopneumonia.  (See  Bronchopneumonia.) 
As  recovery  takes  place  the  dead  epithelium  and  extravasated  cells  are  expelled 
from  the  tubes  by  coughing,  and  new  epithelium  is  developed  from  deeper  layers 
of  cells.  Sometimes,  particularly  when  a  large  number  of  infecting  micro-organisms 
are  present,  the  sputum  is  distinctly  purulent.  When  bronchial  inflammation 
persists  for  any  length  of  time,  or  the  attacks  are  frequently  recurrent,  permanent 
thickening  of  the  submucosa  results.  This  fibrosis  may  extend  to  adjacent  struct- 
ures (peribronchitis),  or  be  continuous  with  the  increased  fibrous  tissue  of  clu-onic 
interstitial  pneumonia. 

Symptoms. — The  symptoms  of  acute  bronchitis  can  be  divided  into  three  stages, 
namely,  that  of  onset,  the  stage  of  profuse  secretion,  and  the  stage  of  convalescence. 

In  the  stage  of  onset  there  may  be  a  chill,  which  usually  is  not  severe;  a  short, 
dry  cough  which  may,  by  its  persistence,  be  annoying,  and,  owing  to  the  dry  and 
inflamed  state  of  the  mucous  membrane  of  the  bronchial  tubes,  be  distressing 
because  of  the  soreness  or  paiii  it  produces  under  the  sternum.  If  the  degree  of 
swelling  of  the  mucous  membrane  is  marked,  there  may  be  a  sense  of  oppression, 
and  the  breathing  may  be  a  little  quickened.  The  temperature  of  the  body  is 
usually  not  much  above  normal  in  the  adult,  but  in  children  it  is  often  as  high  as 
102°  or  even  103°,  and  the  pulse  is  apt  to  be  rapid  in  direct  proportion  to  the  degree 
of  fever.  Auscultation  at  this  time  reveals  an  increased  roughness  of  the  inspiratory 
or  expiratory  bronchial  sounds,  and  perhaps  a  few  dry  rales  between  the  shoulder- 
blades.   • 

In  the  second  stage  there  is  a  disappearance  of  the  soreness  in  the  chest,  but 
the  cough  may  be  persistent,  and  is  more  or  less  productive  of  expectoration  of 
mucopurulent  material.  Febrile  movement  continues  if  that  symptom  has  been 
present  earlier.  The  pulse  is  but  slightly  quickened  and  auscultation  reveals, 
particularly  over  the  bronchial  tubes  posteriorly,  large,  moist  rales  and  rhonchi. 

The  duration  of  an  attack  of  acute  bronchitis  rarely  exceeds  ten  days  to  two 
weeks,  and  is  often  shorter  than  this. 

Treatment. — The  treatment  of  acute  bronchitis  divides  itself  into  two  parts: 
that  part  which  is  devoted  to  allaying  the  inflammation  in  its  early  stages,  and  that 
which  is  directed  toward  the  dissipation  of  the  results  of  the  inflammation  after 
it  has  been  present  for  some  days.  In  the  early  stage  no  better  remedy  can  be 
administered  internally  than  a  prescription  which  contains  in  each  dose  J  drachm 
of  syrup  of  ipecac  and  1  teaspoonful  to  2  teaspoonfuls  of  the  official  liquor  potassii 
citratis  of  the  United  States  Pharmacopeia.  This  should  be  administered  every 
three  or  four  hours. 

If  cough  is  an  annoying  symptom,  and  there  is  much  pain  in  the  chest,  Dover's 
powder  may  be  given  to  an  adult  in  the  dose  of  2  or  3  grains  every  three  or  four 
hours  until  10  grains  have  been  taken.  A  mustard  plaster  may  be  applied  to  the 
chest,  back  and  front,  or  the  thorax  may  be  rubbed  with  ammonia  liniment  or 
with  chloroform  liniment.  In  children  a  very  useful  counter-irritant  application 
to  the  chest  is  1  drachm  of  the  oil  of  amber  in  2  tablespoonfuls  of  sweet  oil.  If  the 
patient  be  a  child,  and  if  the  air  of  the  bed-room  is  particularly  dry  and  irritating, 


374  DISEASES  OF  THE  BROXCIU 

because  it  is  furnace-heated,  much  relief  can  be  obtained  by  diseiiKagiMf^  a  small 
quantity  of  steam.  This  may  be  given  oft'  from  a  tea-kettle  wiiich  is  ke|)t  boiling 
constantly,  or  may  lie  obtained  by  flropping  large  pieces  of  unslaUe<l  lime  into  a 
tub  of  water.  It  is  probable  that  when  the  latter  procedure  is  resorted  to  the  air 
of  the  room  not  only  contains  an  extra  amount  of  moisture,  but  fine  particles  of 
lime,  which  act  ad\antageously  upon  the  lironchial  mucous  membrane. 

If  the  evidences  of  bronchial  irritation  are  very  marked,  the  patient,  whether 
he  be  an  adult  or  a  child,  should  sleep  in  a  bronchitis  tent.  A  bronchitis  tent,  it 
will  be  remembered,  consists  in  a  tent-like  arrangement  of  sheets  spread  over  the 
bed,  and  resting  upon  four  corner  sticks,  one  of  which  is  tied  to  each  corner  of  the 
bed.  Under  this  canopy  the  patient  will  have  plenty  of  air,  and  the  steam  from 
a  kettle  can  be  disengaged  within  its  confines.  If  necessary,  1  or  2  grains  of  menthol 
may  be  added  to  the  hot  water  every  two  or  three  hours.  In  other  instances 
the  bronchial  irritation  will  be  greatly  soothed  bj'  pouring  into  the  boiling  water  a 
tablespoonful  of  a  mixture  composed  of  equal  parts  of  compound  tincture  of  benzoin, 
oil  of  eucalyptus,  and  oil  of  pine. 

After  secretion  has  begun  to  form  in  the  secondary  stage  of  acute  bronchitis 
it  then  becomes  necessary  to  administer  not  sedatives,  but  stimulant  expectorants, 
and  of  these  chloride  of  ammonium,  without  any  doubt,  is  usually  followed  by  the 
best  results.  From  5  to  10  grains  of  this  drug  may  be  given  with  equal  parts  of 
the  fiuidextract  of  licorice  and  water  every  four  or  five  hours  to  an  adult,  and,  if 
cough  is  excessive,  \  grain  of  sulphate  of  codeine  or  20  drops  of  paregoric  may 
be  added  to  each  dose.  Under  the  influence  of  this  remedy  the  expectoration  of 
yellow  or  mucopurulent  sputum  is  at  first  increased,  but  at  the  end  of  twenty-four 
or  fortj'-eight  hours  the  quantity  diminishes. 

When  there  seems  to  be  lack  of  secretion,  the  compound  licorice  mixture  of  the 
United  States  Pharmacopceia,  which  contains  a  small  quantity  of  tartar-emetic, 
may  be  used  in  place  of  the  plain  extract  of  licorice  just  named.  If  for  any  reason 
the  cough  and  expectoration  persist  and  do  not  diminish  under  the  use  of  the 
chloride  of  ammonium,  we  may  give  with  advantage  5  to  10  minims  of  the  oil  of 
sandal-wood  in  capsules,  three  or  four  times  a  day.  Other  patients  do  well  at 
this  time  if  they  receive  5  minims  of  the  oil  of  eucalyptus  in  capsules  three  times 
a  day.  The  latter  remedy,  howe\'er,  is  quite  apt  to  disorder  the  stomach.  Another 
very  valuable  remedy  in  the  secondary  stage  of  bronchitis,  to  promote  expectora- 
tion, is  terpin  hydrate,  which  is  best  given  in  the  form  of  an  elixir,  dose,  a  teaspoon- 
ful,  and  which  may  be  much  increased  in  its  efficiency  if  to  each  dose  is  added  yj  of 
a  grain  of  heroin,  or  j  of  a  grain  of  codeine  sulphate.  The  dose  of  terpin  hydrate 
is  from  2  to  5  grains  four  times  a  day,  but  in  obstinate  cases  larger  doses  may  be 
administered.  Terebene  may  also  be  given  in  capsules  in  the  dose  of  5  minims 
three  or  four  times  a  day.     Oil  of  sandal  wood  is  also  useful. 

If  the  general  nutrition  of  the  patient  is  not  good  and  he  seems  somewhat  debili- 
tated, the  employment  of  cod-liver  oil,  or  syrup  of  iodide  of  iron,  in  moderate 
doses,  will  often  produce  the  most  advantageous  results  at  this  stage  of  the  illness. 

CHRONIC  CATARRHAL  BRONCHITIS. 

Definition  and  Symptoms. — By  chronic  bronchitis  is  meant  a  condition  in  which 
there  exists  a  chronic  inflammatory  process  in  the  bronchial  mucous  membrane, 
as  a  result  of  which  the  patient  suffers  from  cough  and  the  expectoration  of  thick, 
mucopurulent  sputum.  When  \mcomplicated  there  is  no  febrile  movement  in 
association  with  this  condition,  nor  is  there,  as  a  rule,  any  loss  of  flesh  or  impairment 
of  the  general  health.  It  may  be  regarded  as  a  subacute  continuation  of  an  acute 
cold.  The  chief  objection  to  the  term  "chronic  bronchitis"  is  that  it  so  often  is 
applied  by  the  careless  or  ignorant,  or  by  those  who  wish  to  use  an  euphemism, 


BRONCHIECTASIS  .  375 

to  designate  a  far  more  serious  condition,   such  as  pulmonary  tuberculosis  or 
bronchiectasis. 

Treatment. — The  treatment  of  ciironic  bronchitis  is  practically  identical  with 
that  of  the  later  stages  of  the  acute  form,  which  has  just  been  described,  but  the 
most  important  thing  for  the  physician  to  do,  to  whom  is  presented  a  so-called 
case  of  chronic  bronchitis,  is  to  carefully  exclude  tuberculosis  or  cardio-renal 
disease  as  causative  factors  in  the  case.  Many  cases  of  so-called  chronic  bron- 
chitis are  treated  for  weeks  with  ordinary  expectorants  when  tuberculosis  is 
present  or  Blight's  disease  is  the  real  cause  of  the  disorder. 

BRONCHIECTASIS. 

Definition. — Bronchiectasis,  as  its  name  implies,  is  a  condition  in  which  the 
bronchial  tubes  are  dilated.  This  dilatation  may  occur  in  three  forms,  namely, 
the  cylindrical  or  fusiform,  the  saccular,  and  the  trabecular  or  moniliform.  The 
first  of  these  is  the  only  true  type  of  bronchiectasis,  but  the  other  forms  are  those 
most  commonly  met  with. 

The  disease  is  not  common  in  its  well-developed  form.  If  we  combine  the  statis- 
tics of  the  Brompton  Hospital,  of  London,  with  those  of  Biermer  and  Wiiligk, 
we  find  that  in  8144  autopsies  bronchiectasis  was  found  in  about  4  per  cent.  These 
are,  however,  postmortem  figures,  and  do  not  represent  a  certain  proportion  of 
cases  which  do  not  come  to  autopsy  because  of  a  respiratorj^  ailment. 

Etiology,  Pathology,  and  Morbid  Anatomy. — The  saccular  form  is  common  in  adults, 
and  when  it  is  present,  the  limg,  at  autopsy,  contains  one  or  more  saccules,  or 
globular  cavities,  which  usually  are  not  very  large,  but  may  be  the  size  of  a  small 
lemon.  These  cavities  or  open  spaces,  when  large,  are  due  not  only  to  simple 
dilatation  of  the  bronchi,  but  to  involvement  of  the  surrounding  tissues  as  well, 
and  their  walls  are  composed  of  parts  of  the  bronchial  tubes  and  thick  connective 
tissue  which  has  been  formed  in  part  as  the  result  of  chronic  inflammatory  changes, 
the  lung  tissue  having  undergone  fibroid  change.  Sometimes  these  spaces  are 
filled  with  thickened,  inspissated  secretion,  and  seem  like  closed  cavities.  It  is 
readily  seen,  therefore,  that  the  difterentiation  between  this  state  and  fibroid 
phthisis  (see  Tuberculosis  of  the  Lung),  so-called,  may  be  by  no  means  easy,  par- 
ticularly as  these  pouches  may  become  infected,  ulcerate,  and  really  form  small 
abscesses. 

The  trabecular  form  is  still  less  a  true  bronchiectasis,  and  yet  it  is  the  condition 
most  commonly  met  with,  and  to  which  the  term  bronchiectasis  is  most  frequently 
applied.  It  consists  in  irregular  cavities  with  smooth  linings,  which  cavities  are 
surrounded  by  dense  walls  of  overgrown  connective  tissue  which  do  not  contain 
any  signs  of  remnants  of  the  tissues  of  the  bronchial  tubes.  On  the  contrary, 
the  only  relation  borne  by  the  bronchial  tube  to  such  a  cavity  is  that  it  forms 
the  trabeculse  with  the  atrophied  bloodvessels.  These  cavities  are  often  joined 
one  to  another  by  openings,  so  that  the  lung  may  be  thoroughly  riddled  with 
spaces  more  or  less  well  filled  with  secretion. 

Cylindrical  bronchiectasis  (Figs.  69  and  70)  is  usually  developed  in  children  as 
the  result  of  strain  upon  the  bronchial  tubes  produced  by  the  violent  efforts  in 
whooping-cough  or  measles.  It  probably  depends  primarily  upon  inherent  weak- 
ness of  the  muscular  and  elastic  coats  of  the  tubes.  The  affected  bronchus  is 
uniformly  dilated  in  its  entire  circumference  for  a  considerable  distance,  and  this 
dilatation  may  be  so  great  that  its  calibre  is  increased  to  twice  or  thrice  the  normal. 
In  other  instances  it  is  dilated  in  sections,  with  a  normal  or  nearly  normal  calibre 
between. 

When  bronchiectasis  occurs  in  the  saccular  and  trabecular  type  it  is  a  subacute 
or  chronic  disorder,  and  results  from  chronic  infiammation  of  the  bronchial  tubes. 


376 


DISEASES  OF   THE  BRONCHI 


with  resulting  atrophy  of  the  elastic  and  muscular  coats.  Of  the  provoking  causes 
influenza  is  an  important  factor.  Another  cause  is  the  progress  of  cicatricial  or 
cirrhotic  change  in  the  pulmonary  parenchyma,  which,  as  it  ])r()cec(ls,  distorts 
the  bronchial  tubes,  narrowing  them  in  some  places  and  widening  tlicni  in  others. 
In  other  instances  it  can  be  readily  understood  how  cjironic  thickening  of  the  visceral 
laj-er  of  tlie  pleura  may  so  result.  In  still  others  a  localized  bronchiectasis  may 
be  caused  by  the  entrance  of  a  foreign  body. 


Bronchiectasis,  originating  in  acute  lobar  pneumonia.  Marked  saccular  and  cylindrifal  dilatations 
with  a  large  gangrenous  cavity  in  the  middle  lobe.  Duration  eleven  months.  From  a  case  under  the 
care  of  Dr.  Maguire.  Dr.  Barty  King.  (Brompton  Hospital  Musc'um.  Scottish  Medical  and  Surgical 
Journal.) 


The  influence  of  age  in  the  development  of  the  various  tji^es  of  bronchiectasis 
is  quite  noteworthy.  Cylindrical  dilatation  is  largely  a  condition  limited  to  child- 
hood and  the  saccular  and  trabecular  types  are  chiefly  met  with  in  adults.  It 
has  been  thought  by  some  physicians  that  the  latter  forms  occur  with  increasing 
frequency  as  old  age  is  approached,  but  the  statistics  of  Barty  King  indicate  that 
the  age  incidence  of  the  pure  type  is  from  thirty  to  forty  years.  Thus,  53.1  per 
cent,  of  his  cases  occurred  between  twenty  and  forty  years.  The  same  observer 
places  the  proportions  of  the  two  sexes  as  77  per  cent,  in  males  and  23  per  cent, 
in  fcmnlcs. 

Symptoms. — The  symptoms  of  bronchiectasis  naturally  vary  greatly  witli  the 
form  of  the  disease  which  is  present.  Cmigh  of  severe  degree  may  be  considered 
the  most  constant  of  them  all.  This  cough  is  peculiar  in  that  in  many  cases  it  is 
particularly  severe  in  the  morning,  persisting  until  the  patient  has  rid  his  dilated 
and  feeble  bronchi  of  the  secretions  which  have  accumulated  in  them  during  the 


BRONCHIECTASIS  377 

night.  Not  only  is  this  cough  peculiar  in  this  respect,  but  it  not  infrequently 
happens  that  the  patient,  after  a  prolonged  attack  of  coughing  which  is  unpro- 
ductive, is  enabled  to  get  rid  of  a  large  quantity  of  sputum,  which  may  come  away 
in  a  gush  or  which  may  not  be  dislodged  until  by  some  change  in  posture  drainage 
from  the  bronchiectatic  area  can  take  place. 


Cylindrical  bronchiectasis.     A  typical  case.     Dr.  Barty  King.     (St.  Thomas'  Hospital  Museum. 
Scottish  Medical  and  Surgical  Journal.) 

The  sputum  is  also  somewhat  characteristic,  for  it  is  often  grayish-brown  in 
appearance,  somewhat  fetid  in  odor,  and  separates  when  placed  in  a  glass  into  three 
layers,  the  upper  one  brownish  and  thin,  the  second  one  mucoid,  and  the  third 
granular  and  filled  with  dead  epithelial  cells  and  pus  corpuscles.  This  lower 
layer  also  contains  large  crystals  of  the  fatty  acids  and  crystals  of  hematoidin. 
The  sputum  is  so  distinctly  purulent  that  it  may  closely  resemble  that  expectorated 
in  cases  of  pulmonary  abscess,  a  resemblance  still  fiu-ther  increased  by  the  fact 
that  it  may  be  extremely  fetid.  It  is  not  nummular,  as  in  many  cases  of  phthisis, 
and  it  rarely  contains  elastic-tissue  fibres,  which  is  of  some  importance  in  differential 
diagnosis.  Fever  is  usually  not  present  unless  the  purulent  process  in  the  bronchi 
is  marked  and  septic  absorption  results.  An  additional  symptom,  sometimes 
met  with,  is  hemoptysis  from  ulceration  of  a  bloodvessel. 

The  physical  signs  of  bronchiectasis  have  little  about  them  that  is  distinctly 
characteristic,  and  for  this  reason  an  absolute  diagnosis  may  be  difficult  or  impossible 
unless  the  lesions  are  so  far  advanced  as  to  have  affected  the  whole  lung  and  caused 
alteration  in  the  configuration  of  the  chest.  When  the  bronchiectatic  spaces 
or  cavities  are  large  the  physical  signs  are  practically  identical  with  those  of  pul- 
monary tuberculosis  with  cavity  formation;  but  there  is  this  important  difference, 
namely,  that  the  cavities  in  tuberculosis  are  commonly  apical  while  the  cavernous 


37S  DISEASES  OF  THE  BRDXrUI 

hroathiiig  of  hroiichioctasis  is  usually  most  marked  near  the  l)asc.  Tlic  i)liysical 
si{;ns  of  cavity  Formation  also  vary  with  the  condition  of  the  cavity— that  is,  whether 
it  is  full  of  secretion  or  emi)ty,  and  therefore  a  change  in  the  patient's  ])osition,  and 
cough  with  exi)ectorati()n,  may  cause  \ery  great  changes  in  the  results  obtained  l>y 
examination  by  auscultation  and  i)ercussion.  Loud,  moist  rales  and  amphoric 
breathing  may  l)e  present. 

Diagnosis. — It  is  manifest  from  what  has  just  been  said  that  the  differential 
diagnosis  of  bronchiectasis  from  pulmonary  tuberculosis  may  l)e  quite  difficult 
and,  indeed,  impossible  in  certain  cases,  for  it  not  uncommonly  happens  that  a 
superficial  dilated  and  sacculated  area  in  the  lung  gives,  on  auscultation  and 
percussion,  physical  signs  which  are  identical  with  those  which  are  produced  in 
pulmonary  tuberculosis  with  cavity.  The  presence  of  tubercle  bacilli  and  of 
yellow  elastic  tissue  in  the  sputum,  of  hectic  fever,  of  rapid  loss  of  flesli,  and  of 
night-sweats  point  to  tuberculous  infection.  Another  useful  difi'erential  point  is 
the  fact  that  in  tuberculosis  the  cavity  is  usually  at  the  apex,  whereas  in  bronchiec- 
tasis it  is  lower  down  in  the  lung.  Still  another  point  is  that  the  patient  is  not  as 
ill  as  in  tuberculosis,  and  can  get  about  year  after  year  unless  some  acute  inter- 
current pulmonary  malady  intervenes. 

On  the  other  hand,  bronchiectasis  and  pulmonary  tuberculosis  may  exist  simul- 
taneously. Thus,  in  68  cases  of  bronchiectasis  observed  by  Trajanowski,  21 
occurred  in  individuals  who  were  aflfected  with  phthisis,  and  in  75  autopsies  on 
individuals  who  died  from  phthisis  Wilson  Fox  found  bronchiectasis  in  27  cases. 
Twenty-one  were  of  the  fusiform  variety  and  six  were  saccular. 

Complications. — Hemoptysis,  as  a  complication  of  bronchiectasis,  is  rarely  severe 
and  occurred  in  Barthez's  cases  16  times  out  of  39  cases.  Grainger  Stewart  met 
with  it  3  times  in  8  cases,  and  Fowler  met  with  it  14  times  in  35  cases.  Three  of 
these  cases  were  tuberculous.^ 

Another  complication  is  rheumatoid  arthritis.  I  have  recently  had  a  case 
under  my  care  in  which,  after  many  years  of  chronic  bronchiectasis,  a  maiden 
lady  developed  multiple  arthritis,  and  in  the  course  of  a  few  weeks  became  com- 
pletely disabled.  Sometimes  no  more  serious  joint  difficulties  arise  than  swelling 
of  the  finger-joints  and  clubbing  of  the  finger-tips,  with  incurvation  of  the  nails, 
or  the  case  develops  true  pulmonary  osteo-arthropathy.  The  joint  complications 
are  probably  septic  in  origin.  Pulmonary  gangrene  may  also  develop,  and  Duret 
has  operated  on  such  cases  with  success. 

Brain  abscess  may  arise  from  a  septic  focus  in  bronchiectasis. 

Cyanosis  and  dyspnea  on  exertion  are  such  constant  symptoms  that  they  can 
scarcely  be  considered  as  complications. 

When  we  consider  the  state  of  the  tissues  involved  we  can  readily  understand 
how  readily  a  septic  bronchopneumonia  may  be  de\'eloped  in  these  cases,  either 
as  a  result  of  direct  extension  of  the  inflammatory  process  from  the  area  primarily 
involved,  or  by  the  inspiration  into  other  parts  of  the  lung  of  septic  material  during 
paroxysms  of  coughing. 

Prognosis. — This  depends  upon  the  state  of  the  patient's  health,  the  ])resence 
or  absence  of  sepsis,  and  the  presence  or  absence  of  tuberculous  infection.  In 
severe  forms  the  health  is  greatly  impaired.  Recovery  from  the  condition  itself, 
if  it  be  well  developed,  is  manifestly  impossible.  Nevertheless,  life  ma\-  continue 
for  many  years. 

Treatment. — The  treatment  of  well-de\-eloped  bronchiectasis  can  he  only  pallia- 
tive. Once  the  condition  of  dilatation  of  the  bronchial  tubes  has  been  established, 
it  is  evident  that  they  cannot  be  brought  back  to  their  normal  calibre.  On  the 
other  hand,  in  the  early  stages  of  bronchiectasis,  much  can  be  done  in  the  way  of 

'  For  some  of  the  cases  in  Freucli  literature  see  Devic  and  Bertier,  Lyon  medical,  January,  1904. 


FIBRINOUS  BRONCHITIS  379 

palliative  treatment.  It  is  a  mistake,  however,  to  give  sedatives  to  control  the 
cough  unless  the  cough  is  so  excessive  that  it  materially  interferes  with  sleeping 
and  eating,  for  cough  is  a  measure  designed  by  nature  to  rid  the  dilated  tubes  of 
the  secretions  which  certainly  do  harm  if  they  are  retained.  Ordinarily,  expectorant 
remedies  cannot  be  expected  to  do  as  much  good  as  they  do  in  ordinary  eases  of 
bronchitis.  The  best  to  be  employed  are  creosote  in  doses  of  3  to  5  minims  three 
or  four  times  a  day ;  guaiacol  in  the  dose  of  3  minims  three  times  a  day,  or  guaiacol 
carbonate  in  the  dose  of  3  grains  three  times  a  day.  In  some  instances  much  good 
follows  the  administration  of  a  mixture  containing  iodide  of  ammonimn.  Still 
other  cases  are  benefited  by  the  chloride  of  ammonium. 

It  must  not  be  forgotten  that  many  cases  of  bronchiectasis  which  have  lasted 
for  some  years  suffer  as  well  from  feebleness  and  dilatation  of  the  right  side  of  the 
heart,  and  the  degree  of  cyanosis  and  dyspnea  on  exertion  can  be  much  decreased 
by  the  administration  of  small  and  continuous  doses  of  digitalis  or  strophanthus, 
and,  in  some  instances,  by  the  proper  use  of  strychnine.  A  certain  amount  of 
rest  in  bed  or  on  a  couch  every  day  is  very  ad\-isable;  and  if  the  patient  seems  to 
have  great  difficulty  in  expectorating  the  contents  of  certain  cavities,  exiDeriments 
should  be  made  with  different  postures  to  determine  that  in  which  the  cavity  is 
most  easily  drained,  and  he  should  be  instructed  to  take  this  posture  in  order  to 
avoid  prolonged  and  exhausting  spells  of  coughing. 

Within  the  last  few  years  a  number  of  clinicians  have  warmly  advocated  the 
employment  of  intratracheal  injections  of  medicaments  in  cases  of  bronchiectasis. 
Various  mixtures  have  been  employed,  of  which  perhaps  the  most  popular  have 
contained  menthol,  guaiacol,  olive  oil,  or  albolene.  They  do  little  good.  In 
other  instances,  asserted  good  results,  so  far  as  elimination  of  the  sjinptoms  are 
concerned,  have  followed  the  inlialation  of  various  drugs,  such  as  the  vapor  of 
chloride  of  ammonium,  creosote,  and  tar. 

So  far  as  climatic  treatment  is  concerned,  these  patients  should  carefully  avoid 
high,  dry  altitudes,  and  should  resort  to  hill  altitudes  or  the  seaside  resorts, 
unless  the  latter  are  too  damp,  in  which  case  the  drier  places  must  be  sought,  as, 
for  example,  Thomasville,  Georgia;  Lakewood,  New  Jersey,  or  some  similar  spot 
not  too  near  the  sea,  where  there  is  a  sandy  soil  and  a  heavy  pine  growth.  Such 
patients,  too,  should  be  warned  of  the  danger  of  complications  which  may  follow 
exposure  to  sudden  changes  of  temperature  and  to  wet,  and  should  wear  flannels 
next  to  the  skin  all  the  year  round,  if  possible,  to  avoid  chilling  the  surface.  If 
these  precautions  are  taken,  the  greater  amount  of  time  spent  in  the  fresh  air  the 
better,  as  in-door  life  for  these  patients  is  disadvantageous  if  the  climate  is  at  all 
suitable  to  their  condition. 

FIBRINOUS  BRONCHITIS. 

Definition. — Fibrinous  bronchitis  is  an  exceedingly  rare  affection,  characterized 
by  the  formation  of  a  fibrinous  exudate  which  makes  a  cast  of  the  bronchial  tubes. 
As  ordinarily  observed  it  is  in  no  way  related  to  diphtheria,  in  which  disease, 
however,  casts  of  the  larynx  and  trachea  and  even  of  the  bronchial  tubes  sometimes 
form. 

Etiology. — The  cause  of  this  strange  affection  is  practically  unknown.  When 
it  occurs  as  a  complication  or  sequel  of  other  diseases,  it  seems  to  bear  no  relation 
to  them  save  that  of  coincidence.  The  condition  is  much  more  frequent  in  males 
than  in  females,  and  is  not  particularly  prone  to  occur  at  any  particular  age.  West 
states  the  youngest  case  recorded  is  four  years  of  age,  and  the  oldest  seventy-two 
years.  It  has  occurred  more  frequently  after  acute  croupous  pneumonia  and 
during  the  progress  of  pulmonary  tuberculosis  and  ordinary  chronic  bronchitis 
than  in  other  maladies,  but  its  occurrence  in  these  affections  is  not  sufficiently 


380  DISEASES  OF  THE  BRONCHI 

constant  to  justify  us  in  considering  that  these  relationships  are  direct.     In  some 
instances  it  is  associated  with  the  presence  of  mitral  disease  of  the  lieart. 

Pathology. — The  casts  when  expelled  are  found  to  he  comfjosed  of  masses  of 
gelatinous  or  pulpy-looking  material  which,  when  floated  in  water  or  carefully 
spread  upon  a  glass  surface,  are  found  to  be  in  the  form  of  the  bronchial  tubes; 
sometimes  even  of  the  smaller  tubes.  The  casts  are  tough  and  yellowish-white 
in  appearance,  and  many  are  composed  of  fibrin  in  which  may  be  foiuid  white 
blood  cells  and  epithelium  from  the  bronchial  mucous  membrane.  Other  casts 
contain  no  demonstrable  fibrin,  but  are  rich  in  mucin.  Whether  they  are  distinct 
forms  or  altered  fibrinous  casts  is  not  known.  The  cast  may,  be  hollow  or  filled 
with  gelatinous  mucus.  It  is  a  curious  fact  that  these  casts  may  form  without 
resulting  in  serious  lesions  of  the  lining  membrane  of  the  tubes,  for  even  the  epithe- 
lial lining  of  the  bronchial  tubes  may  not  be  found  seriously  impaired  after  a  cast 
is  thrown  off  (Fig.  71). 

Fig.  71 


Cast  from  a  case  of  fibrinous  bronchitis. 

As  the  affection  is  very  rare,  and  still  more  rarely  causes  death,  wc  know  com- 
paratively little  of  its  true  morbid  anatomy.  Sometimes  casts  have  been  found 
at  autopsy  when  the  condition  was  not  suspected  to  be  present,  and  in  other  cases 
in  which  casts  had  been  thrown  off  in  life  none  have  been  found  at  the  postmortem. 

Symptoms. — The  symptoms  of  fibrinous  bronchitis  chiefly  consist  in  severe 
attacks  of  cough  and  dysjmea,  the  cough  being  an  efl'ort  to  dislodge  the  membrane 
and  the  dyspnea  the  result  of  the  obstruction  to  the  respiration.  Sometimes  the 
dyspnea  has  been  quite  urgent,  but  it  has  usually  been  ahiiost  completely  relieved 
after  the  cast  is  e.xpelled.  This  expulsion  of  a  cast  may  occur  once  in  a  lifetime, 
once  in  several  weeks,  once  in  several  days,  or  several  casts  may  be  expelled  in  one 
day.  Rarely  the  formation  of  a  cast  suggests  periodicity.  While  the  cough  is 
usually  severe  in  the  efi'ort  to  dislodge  the  exudate,  the  expulsion  may  be  readily 
accomplished.  Occasionally  hemoptysis  complicates  the  case,  usually  amounting 
to  nothing  more  than  slight  streaking  of  the  expelled  membrane,  but  in  other 
instances  the  bleeding  is  quite  profuse.     The  blood  comes  from  the  bronchial, 


BRONCHIAL  ASTHMA  381 

not  from  the  pulmonary  vessels.  Fever  may  be  present  in  the  acute  cases,  but  is 
usually  absent  in  the  more  chronic  ones. 

Diagnosis. — This  condition  must  be  separated  from  diphtheria,  which  can  be 
done  by  the  absence  of  false  membrane  in  the  fauces  and  larynx;  from  croupous 
pneumonia,  which  is  possible  by  reason  of  the  absence  of  the  fever  and  other  signs 
of  that  disease;  and  from  foreign  bodies  in  the  air  passages,  which  cause  dyspnea 
and  violent  attacks  of  cough;  by  the  history  of  the  patient. 

Prognosis. — The  prognosis  as  to  return  of  the  disorder  is  bad,  as  most  cases 
suffer  from  recurrence,  although  acute  cases  in  which  complete  recovery  has  occurred 
have  been  reported.  In  regard  to  the  effect  of  the  disease  on  life  it  may  be  said 
that  this  varies  greatly  with  the  general  state  of  the  patient's  health  and  upon  the 
gravity  of  the  diseases  which  are  associated  with  it. 

In  cases  with  no  grave  complications  recovery  may  be  expected  in  a  majority. 

Treatment. — The  only  plan  of  treatment  which  has  proved  itself  of  value  in  a 
sufficient  number  of  cases  to  be  regarded  with  any  confidence  is  the  use  of  iodide 
of  potassium  in  full  doses.  Some  patients  seem  to  be  made  more  comfortable 
by  the  inhalation  of  steam.  Climatic  change  is  often  essential,  and  Southern 
California,  or  Florida,  or  Madeira,  may  be  resorted  to. 

BRONCHIAL  ASTHMA. 

Definition. — Strictly  speaking,  the  word  "asthma"  may  be  applied  to  any  con- 
dition in  which  the  respiration  is  labored  and  difficult,  but  in  medicine  it  is  most 
commonly  used  to  describe  a  condition  of  difficult  breathing  due  to  constriction 
of  the  bronchial  tubes  and  further  narrowing  of  their  calibre  by  swelling  of  the 
mucous  membrane  lining  them.  This  state  of  spasm  of  the  bronchial  muscle 
fibres  and  hyperemia  of  the  mucous  membrane  depends  upon  a  neurosis.  This 
neurosis  may  arise  in  turn  from  a  large  number  of  causes,  all  of  which  probably 
exercise  their  influence  through  the  pneumogastric  nerves. 

It  is  unfortunate  that  the  term  "asthma"  has  also  been  applied  to  labored 
breathing  due  to  various  toxemias,  such  as  uremia  and  the  coma  of  diabetes. 
Renal  disease  may,  it  is  true,  indirectly  produce  true  asthma,  but  this  word  ought 
not  to  be  applied  to  that  form  of  labored  breathing  in  which  there  is  no  swelling 
or  spasm  of  the  sort  described  in  the  preceding  paragraph.  The  term  asthma 
is,  therefore,  used  in  this  article  to  mean  bronchial  asthma. 

Etiology. — The  cause  of  asthma  in  many  cases  cannot  be  determined,  and  in 
some  persons  it  is  evidently  due  to  some  lack  of  stability  in  the  nervous  control 
of  the  bronchial  tubes.  In  others  the  asthmatic  attack  arises  because  of  the 
inhalation  of  bad  air,  which  acts  as  an  irritant  to  the  respiratory  tract,  either 
because  of  the  state  of  the  atmosphere  itself  or  because  the  air  is  laden  with  dust 
The  influence  exercised  by  the  atmosphere  in  producing  asthmatic  attacks  is 
very  great  and  varies  in  different  cases  to  an  extraordinary  degree.  Mere  impurity 
of  the  air  has  little  to  do  with  this  influence  in  some  cases.  Thus,  I  had  under 
my  care  an  old  man,  from  a  healthy  country  district  in  Pennsylvania,  who  came 
to  Philadelphia  to  get  relief  from  nightly  attacks  of  asthma.  Without  any  treat- 
ment the  severity  of  the  attacks  diminished  when  he  breathed  city  air  on  the  level 
of  the  street,  dust  laden  though  it  was,  and  his  attacks  ceased  entirely  so  long  as 
he  remained  in  a  private  room  of  the  fifth  floor  of  the  Jefferson  Hospital,  where 
there  was  less  dust,  but,  perhaps,  more  smoke  and  gas  from  the  neighboring  chim- 
neys. In  other  instances  gases  or  fumes,  as  from  coal  or  arsenic,  produce  an  attack, 
and  in  still  others  the  patient  only  suffers  at  that  season  of  the  year  when  the  pollen 
of  certain  plants  or  flowers  is  set  free.  For  this  reason,  sufferers  from  "hay  fever" 
often  suffer  from  asthma,  since  the  exciting  causes  of  both  states  are  present, 
namely,  a  respiratory  neurosis  and  the  irritants  in  the  air. 


382  DISEASES  OF  THE  RROXCHI 

In  still  other  cases  the  cause  lies  in  the  system  of  the  patient  and  does  not  come 
from  outside.  There  is  some  justification  for  the  view  that  the  condition  in  certain 
cases  is  a  form  of  anaphylaxis;  that  is,  the  patient  is  sensitized  by  hcrcditv-  or 
acquirement  to  certain  proteid  substances.  Thus  an  ethmoiditis  or  tnuiljlc  in 
the  frontal  sinus  with  pus  formation  may  cause  the  a})sorption  of  a  minute  amount 
of  proteid  that  will  induce  an  attack  of  anaphylaxis  in  a  sensitized  individual. 
Again  certain  persons  who  are  sufferers  from  gout  will  occasionally  ha\'e  attacks 
of  asthma,  just  as  they  have  pain  in  the  toe  or  soreness  in  the  voluntary  muscles; 
and,  again,  it  not  imcommonly  happens  that  persons  who  have  an  unstable  nerve 
supply  to  the  bronchial  tubes  have  an  attack  of  asthma  if  exposed  to  great  cold 
or  if  they  have  a  slight  bronchial  congestion  due  to  this  cause.  So,  too,  such  persons 
may  be  seized  with  an  attack  as  the  result  of  great  physical  weariness  or  of  nervous 
excitement,  and  it  by  no  means  rarely  happens  that  feebleness  of  the  heart,  which 
results  in  poor  circulation  in  the  lungs,  produces  a  seizure  in  susceptible  per,sons. 
Such  a  case  is  called  one  of  "cardiac  asthma."  In  other  instances  deficient  activity 
of  the  kidneys  produces  indirectly  a  similar  seizure  or  so-called  "  iriial  asthma." 
In  some  cases  great  acidity  of  the  stomach,  and  the  various  forms  of  indigestion, 
reflexly  provoke  an  attack  through  the  gastric  fibres  of  the  vagus  ner\-es. 

The  nervous  mechanism  whereby  an  asthmatic  seizure  is  produced  is  supposed 
to  be  as  follows:  The  control  of  the  circulation  in  the  bronchial  mucous  membrane, 
and  of  the  muscular  fibres  controlling  the  bronchial  tubes,  resides  in  the  vagus 
nerves,  which  possess  efferent  and  afferent  fibres,  not  only  connected  with  the 
lungs,  but  with  the  stomach  and  heart  as  well.  There  are  also,  in  all  probability, 
fibres  which  indirectly  connect  the  nasal  mucous  membrane  with  the  \-agus. 
Certain  causes  of  irritation  acting  upon  the  respiratory,  gastric,  and  cardiac  fibres 
of  the  vagus  give  rise  to  an  afferent  impulse  sent  to  the  vagus  centre,  and  this  in 
turn  results  in  the  irradiation  of  an  efferent  impulse  to  the  bloodvessels  in  the 
bronchial  mucosa  and  to  the  bronchial  muscular  fibres,  whereby  the  tubes  are 
constricted,  the  mucous  memlirane  becomes  swollen,  and,  in  afldition,  secretion 
takes  place,  which  aids  in  obstructing  still  further  the  smaller  tubes. 

Pathology  and  Morbid  Anatomy. — The  pathology  of  this  condition  has  been 
described  in  part  in  the  preceding  paragraph.  The  morbid  change  which  is  mani- 
fest is  the  engorgement  of  the  mucous  membrane,  the  thick,  ^•iscid,  bronchial 
secretion,  and  the  spasm  of  bronchial  tubes. 

The  morbid  anatomy,  unless  secondary  conditions  arise,  is  nil,  for  with  the 
disappearance  of  the  attack  the  lungs  attain  their  normal  state  within  a  short 
time.  It  is  only  when  repeated  attacks  of  asthma  occur  that  the  patient  as  a 
consequence  suffers  from  chronic  bronchitis,  emphysema,  or  bronchiectasis, 
although,  if  a  single  attack  is  very  severe,  he  may  de\elop  bronchopneumonia, 
particularly  if  exposed  to  cold  and  dampness. 

The  chest  of  the  asthmatic  patient,  who  has  suffered  from  this  disease  for  man\- 
years,  is  usually  like  that  of  pulmonary  emphysema  in  its  configuration,  and  if 
the  disease  be  jjrcsent  in  early  life,  when  the  chest  is  very  pliable,  a  "  pigeon-l)reast" 
may  be  developed,  and  a  well-marked  Harrison's  groove  may  be  seen.' 

In  most  instances  in  which  asthma  has  been  present  for  years  the  heart  undergoes 
dilatation  and  hypertrophy,  particularly  on  the  right  side,  and  its  beat  may  be 
quite  feeble  if  hypertrophy  has  not  fully  compensated  for  the  dilatation.  Second- 
arily, these  cardiac  changes  may  result  in  hepatic  and  renal  congestion. 

The  scanty  sputum  which  is  expelled  by  asthmatic  patients  possesses  in  many 
instances  peculiarities  which  are  pathognomonic.  This  sputum,  if  examined, 
is  found  to  contain  little  lumi)s  or  balls,  which,  if  they  are  teased  out  on  a  plate  of 
glass  placed  on  a  black  background,  are  found  to  consist  of  minute  curls  or  twisted 

'  "Harrison's  groove"  is  that  depression  which  begins  at  the  sternum  at  the  attachment  of  the  seventh 
or  eighth  rib,  and  extends  backward  in  the  line  of  the  ribs  toward  the  axilla. 


ME^MCmAL  ASTH3IA  3S3 

ffiJbiresv  iimi  f (Ojmmi  iwo*  ramJlike-  tJiie-  ciarfs  of  luair  oa  a  eM«i''s  heati.  These  curls  are  caHeti 
"" C'winKhrummm'.ii  ■ffimB.fJ^  aiisd  ied  tfcirir  fbfldls  are  foamd  crystals  ot'  the  fatty  acinij, 
tlw  soHcaJfai  "^  (."hmmnH-LHyiign  ettfatmbJ'  T&at  fatty  acwis  are  present,  however, 
B,  demied  fey  miKfiiiiiy.  Thins,  GecwJhaifli  and  Taslett  thj-nlr  these  curls  are  related 
to  ttft*'  caste  fflf  fiJurimsHiis  SHnsMucMtiS),  airad  they  pro  tat  oat  that  such  easts  frequently 
sJmoiw  twBife  <or  ^iiirail  temiiiiniafiMis.  Hc^iaanji  ft'irnW  the  terminal  bronchioles 
SBjnp  spjiajl  imi  ffinmnni- 

Betlioffe-  aumd  dnng;  aim  atfiaiek  o£'  pme  heoBtiai^  asdiraa  there  es  an  extraordinary' 
MBCirease  mm  tlie  imniiDljer  ol  eosranopMles  ia  tJiie  Hood.  This  eosiniophilia  b  said 
W0/&.  to  ©cCTir  inB  cases  off  nemail  and  caardiae  asfihntai. 

S^mg^oBss- — Tlie-  ^yTmiptoons;  oil  spasuMidBC-  or  btoaeJiiial  asthma,  in  weH-develloped 
Ciiises>,  iBTO'  rwj  typscail.  The  patieflt  usuaHly  retires  to  bed  perfectly  well  and^wakes 
at  imiidmiiig)tiitt,  air  inii  tJne  eaurlhr  morraiiig  with,  a  sense  of  mtenxe  dy.i-pnea^  oppren^'wrir 
wMichi  imaiy  he  s&i  se-ineire'  as  toi  seeiiii;  tO'  threaten  death:  from  asph^ida,  bat  death 
noreir  (Oiccimrs  im  aum  afiteidt  innomni  this  cacBse.  The  attitude  of  the  patient  suiferfng 
fooami  asttimimia  bs  imost  dauraieteirKtic-.  M  he  b  in  bed  he  sits  op  and  places  his  hands 
tfflfft  of  luinini  (jam  itfee  mattiress,  sO'  as  t0>  sopport  himself  in  that  posture  which  will 
amaMe  luiinm  to  iDBeJfe  anEsSSasy  moiscles  of  respiratiGn  to  the  greatest  possible 
estemtL  His  wewpiimUmmm  me  Uemdr  Ms  brow  £5  covered  with  sweat,  and  his  face 
is  at  ffiisfi:  amsEOJiiis  aund  pale',  and  them  eymiKMed  and  iisid.  The  efforts  at  iospiration 
amd  ^^MiratBom  aire  fiDjrci&le,  bcifc  the  chest  has  the  appearance  of  distention,  since 
•jflne  iraitereffistaJl  spaces  aire-  oiftem  mmdiily  fol,  and  the  anterior  portion  of  the  thorax 
fe  efcvated.  Tlie  diffiemllty  mider  which  the  patient  labors  is  that  he  retains  in 
Sbk  Aest  am  esiess  off  air  wEnicfe  h^i-t  become  vitiated,  but  which  he  cannot  expel, 
and  theirrfaae  he  tais  moi  roomi  for  firesh  air.  The  condition  is  rather  one  of  difficult 
e^mafiiBm  lliaiiii  of  (ffiffieriEllt  inspiratioiDL  Owing  to  the  great  shortness  of  breath 
the  jBataemt  is  ajftom  nmniaMe'  t®  speak  except  in  a  wheper,  and  speaks  bat  a  word  or 
tsB®  wifih.  eaA  toeattSn.  "One  smpsrSraal  veins  are  engorged.  The  urine  during  an 
afftack  fe  ffiftton  smrmStf/  amd  heaviEy  feaded  with  urates,  but  after  the  attack  it  b 
fflftani  passed  im  laigje  cpiaffltLEties,  amd  is  dlear  and  limpid. 

TlDe  attast  imay  Ikst  firoiim  a  haM  hsmsr  to'  several  hours,  and  leaves  the  patient 
qmitte  estauisted.  In  soime  instances,  with  the  passing  of  the  seizure,  almost  total 
K^fflratoiry  idfef  follows,  hmk  in  most  eases  some  dyspnea  per^ts  for  several 
hiffliraiH^  amd  cyan©^  may  be  piressat  tiM  aM  respiratory  difficulty  fe  relieved.  If 
Ae  d^ree  of  idli^  k  stiSsignt  t0>  permit  sleep,  the  patient  Tway  be  snfficientDy 
lestted  to  attsrf  toi  feiui^mess;  the  fiiDfflloiwing  day,  but  in  the  majority  of  cases  this  is 
imiiMj^Me,  or  at  least  inadv^fefe,  because  of  the  fiatigue,  the  weak  condition 
d  tfee  hear:  -mi  I'lims  from!  the  ejects  of  the  attack,  and  the  presence  of  the  bron- 
diife  and  :y:z,\siA  secretion,  whick  maiy  result  in  fetal  bronchopneumonia  if 
tine  jtatce-:  :.f  7_:"  "rry  prndent  as  to  exposure. 

DiagEESZi  — T^T  history  of  the  attack,  in  its  modle  of  onset  and  subseqinemt 
dwielbpiEez:;,  zr'  .-'-  ^  i-'-.  ^^  -»;f;  ^-i^y.  The  duty  of  the  physician  is  to  dsco'ver, 
iff  pxossibfe-,  thr  ■  '  '  "  ■  ..-d  remove  it,  resting  confident  that  asthma 
K  alwaiys  a  f—     '  '    .      -■-li.se.    The  physical  signs  present  in  an  attack 

are  very  _.:. ..-;.::-:  r"..  -  _ii  cne  eariy  stages  acBCultation  reveals  harsk  bronchial 
bceathiimg-  "^".:_  ii_t^::v-  ral?s.  TArhich  may  be  scattered  here  and  there  through 
thie  chiest,  ansi  tawing  to.  tliT  :  -^  „'■-•:  'r-T^atory  cyde  it  may  seem  as  if  one  part 
«jff  tine  hm^  does  mejt.  esf.i:il  r_L^  _:.i:„T\\Lily  witk  the  other  parts.  When  the 
attack  fe  wfM  des^dojied  the  drtfrcult  passage  of  air  through  the  narrow  tnbes  resnits 
im  tbe  stil  gireatrar  dereJopmeiLt  of  musicai  stounds,  which  may  be  described  as 
resCTuIifag  those  made  fey  a  litter  of  —:—-'---  'dttens  or  crying  poppies.  These 
tot-amd-firK,  losffld,  Hm^Bacal  tales,  widelh^  :  -    -.  iigh  both  lungs,  are  so  character- 

Bstie  oi  i&S!  asthmatic-  patieiiit  as  to.  nuiic  :^c  -^u.^';lOsb  certain  in  many  cases. 

ThCTe  fe  offlie  cfsmditioffl  frojim  which  asthmiai  ie  the  later  stages  must  fee  caflrefoiMy 


384  DISEASES  OF  THE  BRONCHI 

separated,  namely,  that  of  pulmonary  edema.  Aside  from  tlic  fact  that  the  under- 
lying cause  of  pulmonary  edema  is  often  serious  renal  disease,  and  therefore  a 
dangerous  state  deserving  recognition,  the  history  is  often  given  of  previous  attacks 
of  shortness  of  breath,  or  even  of  wlieezing  respirations;  and  the  i)hysical  signs 
in  the  later  stage  of  bronchial  asthma,  when  widely  diffused  and  musical  moist 
rales  are  heard,  may  not  differ  materially  from  those  of  pulmonary  edema,  since 
musical  moist  rales  and  some  impairment  of  resonance  on  percussion  may  be 
present  in  this  condition  as  well.  In  spasmodic  croup  the  obstruction  to  respira- 
tion is  so  clearly  laryngeal  and  the  chest  is  so  free  from  widely  dilfused  rales  that 
the  diagnosis  is  not  difficult,  and  in  laryngeal  spasm  due  to  locomotor  ataxia  the 
same  freedom  from  musical  rales  in  the  chest  again  enables  us  to  make  a  differentia- 
tion. Sometimes  labored  respiration  resembling  that  of  spasmodic  asthma  occurs 
in  acute  pneumothorax,  but  the  physical  signs  are  so  different  that  no  difficulty 
is  experienced  in  separating  these  two  conditions. 

Prognosis. — The  prognosis  as  to  recovery  from  an  individual  attack  of  asthma 
is  very  favorable,  even  if  it  be  exceedingly  severe,  provided  that  no  acute  complica- 
tion arises.  The  prognosis  as  to  recovery  from  the  tendency  to  asthma  is  very 
bad,  for  the  history  of  the  vast  majority  of  cases  is  that  they  have  recurrences. 
It  is  only  in  those  cases  in  which  tliere  is  a  manifest  exciting  cause,  external  or 
internal,  which  can  be  removed,  that  a  favorable  prognosis  as  to  the  future  can  be 
advanced.  The  tendency  of  spasmodic  asthma  to  produce  bronchopneumonia, 
emphj^sema,  dilatation  of  the  right  side  of  the  heart,  and  secondary  circulator}' 
feebleness  must  never  be  forgotten;  but,  on  the  other  hand,  it  is  remarkable  that 
very  many  asthmatics  live  to  moderate  old  age  without  being  in\alided. 

Treatment. — The  treatment  of  spasmodic  asthma  may  be  di\-ided  into  three 
parts:  that  devoted  to  the  prevention  of  the  attack,  the  relief  of  a  paroxysm  which 
is  present,  the  removal  of  the  underlying  causes  and  of  the  sequeki?  which  are  pro- 
duced by  the  attack.  It  has  already  been  pointed  out  that  certain  conditions  of 
the  atmosphere  and  the  presence  of  certain  kinds  of  dust  in  the  air  strongly  pre- 
dispose certain  individuals  to  attacks  of  asthma.  On  the  principle  tliat  an  ounce 
of  prevention  is  worth  a  pound  of  cure,  it  is  evident  that  asthmatic  patients  should 
be  exposed  as  little  as  possible  to  such  provoking  causes,  and  if  they  must  of  neces- 
sity sleep  in  a  room  the  air  of  which  has  been  heated  by  a  furnace,  steam  should 
be  disengaged  in  the  air  of  this  room,  so  that  it  will  not  be  unduly  dry.  Such 
patients  should  be  subjected  to  a  careful  examination  of  the  nasal,  pharjmgeal, 
and  tracheal  mucous  membranes,  with  the  object  of  discovering  whether  they 
suffer  from  any  localized  spot  of  hyperesthesia  in  these  mucous  membranes,  for 
it  not  infrequently  happens  that  foreign  bodies  or  dry  air  may  irritate  these  spots 
and  so  reflexly  produce  an  attack.  Indeed,  in  some  cases  of  so-called  "nasal 
asthma"  it  is  possible  by  touching  a  hyperesthetic  spot  on  the  nasal  mucous  mem- 
brane to  precipitate  an  attack  of  spasmodic  asthma.  .Such  hyperesthetic  spots 
should  be  removed  by  the  application  of  the  cautery  where  it  can  be  employed. 
Often  permanent  relief  is  obtained  by  change  of  residence. 

For  the  relief  of  the  attack  of  asthma  itself  when  it  is  threatened,  nothing  com- 
pares in  efficiency  to  the  hypodermic  use  of  5  or  10  drops  of  adrenalin  solution 
1 :  1000,  or  a  hypodermic  injection  of  morphine  and  atropine  may  be  given. 

When  the  attack  is  developed,  an  innimierable  number  of  drugs  ha\'e  been 
recommended  by  \'arious  practitioners  and  by  a  still  greater  number  of  sufferers. 
Among  the  older  remedies,  without  doubt,  belladonna  and  its  sister  drugs  possess 
the  confidence  of  a  large  number  of  the  profession;  but  none  really  exercise  a  power- 
ful curative  influence,  unless  they  are  given  in  doses  which  are  so  large  as  to  be 
almost  capable  of  producing  moderate  poisoning.  These  drugs  probably  act  by 
their  depressant  influence  upon  the  vagus  nerve,  and  by  altering  the  circulation 
in  the  capillaries  supplying  the  bronchial  mucous  membrane.     They  are  particularly 


BRONCHIAL  ASTHMA  385 

useful  in  those  cases  of  asthma  in  which,  during  the  attack,  there  is  formed  a 
considerable  quantity  of  bronchial  secretion,  and  they  are  the  cliief  ingredients, 
with  nitrate  of  potassium,  of  most  of  the  proprietary  cigarettes  and  powders  which 
are  burned  in  the  patient's  room. 

Of  the  so-called  depressant  remedies  for  asthma,  we  have  lobelia,  which  is  very 
highly  thought  of  by  many  practitioners,  particularly  in  England.  On  the  other 
hand,  some  physicians  are  afraid  of  this  drug,  because  of  the  depressant  influence 
upon  the  heart.  It  is  not  to  be  employed  when  the  heart  is  feeble.  When  the 
heart  is  strong,  it  should  be  given  in  full  doses,  if  given  at  all.  As  much  as  ^  to  1 
drachm  of  the  tincture  should  be  given  in  one  dose,  and  repeated  in  the  dose  of  10 
minims  every  half-hour  or  hour  until  the  patient's  circulation  is  markedly  depressed 
and  the  skin  is  relaxed  and  perspiring.  These  doses  may  produce  nausea  and  even 
vomiting,  but  the  associated  relaxation  often  will  abort  an  attack,  whereas  smaller 
doses  which  do  not  produce  vomiting  may  produce  more  profound  circulatory 
symptoms,  since  all  of  the  drug  is  absorbed  and  none  lost  by  emesis.  Pilocarpine 
may  also  be  employed  in  those  cases  of  spasmodic  asthma  in  which  there  seems  to 
be  an  excessive  dryness  of  the  bronchial  mucous  membranes.  But  the  fact  that 
this  drug  in  some  cases  seems  to  depress  the  heart  seriously,  and  in  others  cause  an 
excessively  profuse  outpouring  of  bronchial  secretion,  has  properly  prevented  its 
general  employment.  Many  patients  experience  great  relief  in  the  early  stages 
of  an  attack  if  they  receive  a  hypodermic  injection  of  \  grain  of  morphine  with 
Y^Tj  grain  of  atropine.  In  a  disease  which  recurs  frequently,  as  does  asthma,  this 
use  of  morphine  is  always  dangerous,  in  view  of  the  possibility  of  establishing  the 
morphine  habit.  Furthermore,  the '  after-depressant  effect  of  the  drug  upon  the 
following  day  often  renders  the  remedy  almost  as  bad  as  the  disease. 

For  internal  administration  in  the  treatment  of  asthma,  there  is  no  drug  which 
meets  as  many  indications  in  as  many  cases  as  nitroglycerin.  If  the  attack  is 
threatened  y^ts  or  even  Jjj  of  a  grain  may  be  given  hypodermically,  and  the  same 
dose  may  be  repeated  every  hoiu-  or  two,  particularly  if  the  patient  is  one  of  ad- 
vanced years  and  has  a  somewhat  high  arterial  tension.  In  some  cases  the  inhala- 
tion of  a  few  minims  of  nitrite  of  amyl,  poured  upon  a  handkerchief,  will  serve  to 
abort  a  threatened  attack  or  to  modify  the  severity  of  one  which  is  already  well 
developed. 

In  those  cases  where  there  is  great  irritability  of  the  nervous  system  underyling 
the  asthmatic  attack,  the  occasional  use  of  the  bromides  may  be  advantageous, 
but  they  are  of  little  value  for  the  prevention  of  an  individual  attack,  and  their 
continued  use  between  attacks  is  obviously  unwise.  The  same  opinion  may  be 
expressed  in  regard  to  the  employment  of  chloral,  which  has  the  additional  disad- 
vantage that  the  chloral  habit  may  be  instituted,  or  that  the  heart  may  be  depressed 
to  an  undue  degree. 

For  many  years  the  author  has  employed  a  compound  in  tablet  or  elixir  in  the 
treatment  of  asthma,  both  as  a  preventive  remedy  and  as  a  cure  for  individual 
attacks,  and  has  gotten  results  from  it  which  cause  him  to  regard  this  formula 
with  considerable  favor.  It  is  now  placed  on  the  market  by  all  large  manufacturing 
druggists. 


gr.  ij. 
gr-  iJ- 
miij- 
gr.  zlo- 

mij.— M. 


I^ — Sodii  iodidi 

Potas.  bromidi    .... 

Ext.  euphorbife  piluliferae    . 

Nitroglycerini      .... 

Tinct.'lobeliae 

Ft.  in  tabel,  vel  capsul.  No.  i. 
S. — One  every  four  to  six  hours. 

It  must  never  be  forgotten,  however,  that  asthma  is  a  symptom  rather  than  a 
disease,  and  that  the  remedies  which  prove  useful  in  one  case  may  in  another 
25 


380  DISEASES  OF  THE  LfXaS 

prove  entirely  useless,  because  in  each  instance  the  underlying  cause  of  the  malady 
is  quite  diflerent.  It  is  this  fact  which  has  prol)al)ly  caused  some  physicians  to 
speak  in  high  praise  of  certain  remedies  in  the  treatment  of  spasmodic  asthma, 
while  others  with  equal  experience  assert  that  they  have  gotten  no  good  results 
from  the  employment  of  such  drugs. 

Reference  has  already  been  made  to  the  value  of  supplying  asthmatic  patients 
with  moist  air,  particularly  when  they  live  in  furnace-heated  houses.  It  is  the 
author's  constant  habit,  when  cases  of  astluna  come  under  his  care  to  place  them 
in  a  bronchitis  tent.  To  the  air  of  this  tent  is  supplied  a  small  quantity  of  steam, 
with  the  result  that  the  patient  has  a  great  diminution  in  the  degree  of  dyspnea, 
and  frequently  gets  some  hours  of  refreshing  sleep.  An  additional  advantage 
in  putting  these  patients  in  a  bronchitis  tent  is  that  it  requires  them  to  remain 
in  bed,  and  so  gives  rest  to  the  heart,  which  organ  is  often  sadly  in  need  of  relief, 
since  the  difficulty  of  breathing  and  the  lack  of  sleep  throws  upon  it,  day  after  day, 
in  some  patients,  a  very  severe  strain.  In  some  instances  the  addition  of  a  few 
grains  of  menthol  to  the  boiling  water  seems  to  increase  the  efficiency  of  the  bron- 
chitis tent.  In  still  others  equal  parts  of  oil  of  pine,  oil  of  eucalyptus,  and  com- 
pound tincture  of  benzoin  may  be  added,  in  the  quantity  of  a  tablespoonful  or 
two  to  the  boiling  water,  with  benefit  to  the  patient.  In  cases  in  which  the  bron- 
chial tubes  are  full  of  liquid  this  tent  is  often  not  well  borne. 

In  all  cases  of  asthma  the  physician  should  carefully  examine  the  heart,  and  if 
there  are  any  evidences  of  feebleness  and  dilatation  of  the  right  side  of  the  heart, 
as  manifested  by  venous  engorgement,  and  the  extension  of  cardiac  dulness  down- 
ward and  to  the  right,  small  doses  of  strophanthus  or  digitalis  should  be  given. 
In  some  cases  in  which  the  cardiac  difficulty  is  marked  during  the  attack,  full 
doses  of  Hoffmann's  anodyne  are  advisable.  These  drugs  may  be  assisted  in 
their  stimulating  influence  by  one  or  two  hypodermic  injections  of  strychnine. 

It  is  also  the  duty  of  the  physician  in  all  these  cases  to  carefully  and  repeatedly 
examine  the  urine,  since  renal  disease  sometimes  produces  true  asthmatic  seizures, 
and  still  more  commonly  produces  attacks  of  dyspnea,  which  the  patient  may  call 
asthma,  but  which  are  really  those  of  true  uremic  poisoning.  Then,  too,  if  asthma 
is  present  with  a  moderate  degree  of  albuminuria  without  casts,  this  albuminuria 
may  aid  the  physician  in  determining  that  the  heart  is  yielding  under  the  strain, 
since  this  albuminuria  is  frequently  due  to  renal  congestion,  resulting  from  a  feeble 
circulation.  The  albuminuria  disappears,  the  lu-inary  flow  becomes  more  profuse, 
and  the  heart's  action  gets  better  under  the  administration  of  digitalis  or  stro- 
phanthus, combined  with  rest,  as  already  indicated.  It  is  an  interesting  fact  that 
persons  who  are  susceptible  to  asthma  seem  to  be  very  sensitive  to  antidiphtheritic 
serum.  On  the  other  hand  it  is  luidoubtedly  a  fact  that  certain  asthmatics  are  fre- 
quently almost  immediately  relieved  of  their  attack  by  the  injection  of  diphtheritic 
antitoxin.  So  far  we  have  no  means  of  determining  beforehand  in  which  cases 
it  will  do  good  and  in  which  it  will  do  harm,  but  it  is  in  any  event  a  dangerous 
remedy  for  asthmatics,  particularly  when  a  second  dose  is  given  ten  days  after 
the  first. 


DISEASES  OF  THE  LUNGS. 


BRONCHOPNEUMONIA. 


Definition. — Catarrhal  pneumonia,  lobular  pneumonia,  or  bronchopneumonia 
is  an  acute  inflammation  of  the  small  bronchioles  and  of  the  tissues  immediately 
surrounding  them  and  their  attached  lobules,  and  primarily  involves  the  lobules, 


BRONCHOPNEUMONIA  387 

rather  than  the  lobes  as  does  the  croupous  type  of  pulmonary  consolidation.  It 
is  called  bronchopneumonia  because  of  this  primary  inflammation  of  the  smaller 
bronchi,  and  it  is  called  lobular  pneumonia  because  it  affects  the  lung  by  lobules 
rather  than  by  lobes.  More  commonly  still  it  is  designated  catarrhal  pneumonia, 
since  it  usually  follows  inflammatory  changes  in  the  mucous  membrane  of  the 
bronchial  tubes.  No  single  or  specific  micro-organism  is  the  cause  of  broncho- 
pneumonia, but  it  is  due  to  infection  of  the  bronchi  and  adjacent  tissues  by  many 
pathogenic  germs. 

As  with  typhoid  fever,  so  with  bronchopneumoma :  Gerhard,  a  Philadelphia 
student  of  Louis,  in  Paris,  was  the  first  person  to  clearly  differentiate  broncho- 
pneumonia from  croupous  pneimionia  (1834),  although  as  early  as  1823  Seger 
had  separated  the  croupous  pneumonia  of  adults  from  this  form,  which  is  that  which 
commonly  affects  children. 

Distribution. — Bronchopneumonia,  because  of  its  various  causes,  is  found  every- 
where tliroughout  the  world. 

Etiology. — Frequently  bronchopneumonia  is  due  to  the  micrococcus  of  croupous 
pneumonia,  which  for  some  unknown  reason  fails  to  produce  a  croupous  exudate 
in  a  single  lobe  or  in  several  lobes,  as  is  usual  when  that  organism  enters  the  lung 
in  an  adult.  In  other  instances  pyogenic  organisms  such  as  the  streptococcus  or 
staphylococcus  are  responsible  for  the  disease.  Thus,  in  103  cases  of  broncho- 
pneumonia examined  by  Netter,  Weichselbaum,  and  Pearce,  the  streptococcus 
was  found  in  about  30  and  the  pneumococcus  in  29.  When  associated  with  other 
organisms  the  number  of  instances  in  which  these  cocci  were  found  was  much 
greater.  Primary  bronchopneiunonia  is  usually  due  to  the  pneumococcus,  and 
secondary  bronchopneumonia  to  the  streptococcus. 

When  such  a  specific  malady  as  diphtheria  is  the  primary  cause  of  the  illness 
the  Klebs-LoefHer  bacillus  is  the  most  frequent  cause  of  the  pneiunonic  lesions. 
Thus,  in  62  cases  of  bronchopneumonia  following  diphtheria  examined  by  Pearce, 
this  organism  was  found  52  times  and  the  streptococcus  27  times.  In  still  others 
the  bacillus  of  Pfeiffer  (that  of  epidemic  influenza)  brings  on  an  attack.  The 
tubercle  bacillus  not  rarely  is  responsible  for  the  inflammatory  process,  and  almost 
any  pathogenic  organism  entering  the  lower  bronchial  tubes  may  act  as  an  exciting 
cause.  Doubtless  these  organisms  often  gain  access  to  the  bronchioles  in  periods 
of  good  health  without  producing  evil  efl'ects,  but  if  by  chance  there  is  present  a 
general  or  local  impairment  of  vital  resistance  pathological  changes  ensue. 

Bronchopneiunonia  is  usually  said  to  be  capable  of  division  into  two  types,  namely, 
the  primary  and  secondary.  The  primary  form  is  met  with  in  cliildren  and  adults 
who  are  usually  in  poor  health  with  diminished  vitality,  and  seems  to  have  its 
onset  with  the  development  of  an  acute  "cold."  It  is  most  commonly  met  with 
in  infants,  and  in  them,  as  has  just  been  stated,  is  usually  a  pneumococcus  infection, 
although  true  croupous  pneumonia  at  this  age  is  not  common.  The  secondary 
t}ipe  is  much  the  more  frequent  of  the  two;  indeed,  it  may  be  considered  the  rule 
that  bronchopneumonia  occurs  as  a  secondary  affection  in  the  vast  majority  of 
cases,  for  nearly  always  there  is  a  historj^  of  a  previous  acute  or  subacute  bronchitis, 
or  of  some  disease  which  predisposes  to  such  a  condition,  as  whooping-cough, 
measles,  or  influenza. 

In  adults  there  is  usually  the  history  of  a  severe  cold  affecting  the  upper  respi- 
ratory tract,  or  of  the  use  of  an  anesthetic  drug  by  inhalation,  which  has  at  one 
and  the  same  time  irritated  the  air-passages  and  permitted  the  entrance  of  saliva 
or  particles  of  mucus  or  food  containing  many  micro-organisms  which  produce 
infection.  A  similar  result  may  accrue  in  instances  in  which  no  such  drug  is 
employed.  Thus,  in  some  asthmatics  during  the  progress  of  an  attack  there 
may  be  drawn  into  the  air-passages  micro-organisms  from  the  mouth  or  tiny 
particles  of  food.     In  individuals  suffering  from  the  coma  of  alcoholism,  cerebral 


388  DISEASES  OF  THE  LUNGS- 

congestion,  uremia,  or  apoplexy,  witli  stertorous  breathing,  tiie  same  accident 
may  ensue.  Sucli  a  form  of  infection  may  occur  in  the  coma  following  an  epileptic 
seizure.  In  some  instances  the  presence  of  an  ulcerative  laryngitis,  due  to  syphilis, 
tuberculosis,  or  malignant  disease  produces  an  infection  in  this  manner.  Bulbar 
paralysis,  or  that  due  to  diphtheria,  may  also  provoke  this  type  of  pneumonia. 
In  many  cases  of  severe  illness,  as  in  typhoid  fever,  with  foul  secretions  in  the 
nose  and  mouth,  this  method  of  infection  ensues  because  the  ordinary  sensitiveness 
of  the  glottic  mucous  membrane,  and  that  of  the  trachea,  is  obtunded  by  the  drj'ne.ss 
of  these  parts  or  by  the  benumbing  efi'ects  of  the  disease.  This  form  of  the  disease 
is  called  aspiration  pneumonia,  or  the  "  Schluck-pneumonie"  of  the  Germans. 
Old  age  and  debility  are  also  predisposing  causes. 

Prevention. — From  what  has  been  said  it  is  e\'ident  that  the  secondary  forms 
of  bronchopneumonia  are  capable  of  prevention,  at  least  to  some  extent.  Perfect 
cleanliness  of  the  mouth  is  one  of  the  methods  of  prophylaxis,  in  that  it  prevents 
the  inhalation  from  the  oral  cavity  of  infecting  micro-organisms.  So,  too,  during 
the  course  of  measles  and  whooping-cough  carefid  a\'oidance  of  exposure  and  the 
use  of  a  bronchitis  tent  to  allay  bronchial  irritation  is  preventive  in  its  influence. 
If  local  lesions  in  the  upper  respiratory  tract  exist,  they  should  be  modified  or 
removed  by  proper  treatment. 

Frequency. — Bronchopneumonia  is  an  exceedingly  common  disease,  certainly 
outranking  in  frequency  its  sister  malady,  croupous  pneumonia.  As  a  terminal 
infection  it  causes  death  in  many  maladies  otherwise  almost  ne^'er  fatal  in  them- 
selves, such,  for  example,  as  whooping-cough  and  measles,  both  of  which  have  a 
high  mortality  in  very  yoimg  children  from  this  very  cause.  Thus,  out  of  446 
cases  of  bronchopneimionia  in  children  cited  by  Holt,  it  followed  or  comi)licated 
whooping-cough  66  times  and  measles  89  times.  It  is  a  noteworthy  fact  that 
bronchopneumonia  is  the  type  which  is  particularly  common  in  infancy,  while 
croupous  pneumonia  is  generally  a  disease  of  later  life.  In  the  child  under  five 
years  it  is  very  common,  and  fatal  in  direct  proportion  to  the  youth  of  the  patient, 
whereas  croupous  pneumonia  is  rare  in  this  period  of  life,  and  \-ery  rarely  is  fatal 
at  this  time.  Out  of  Holt's  446  cases,  53  per  cent,  occurred  in  the  first  year  of 
life  and  33  per  cent,  in  the  second  year. 

Pathology  and  Morbid  Anatomy. — This  form  of  pneumonia,  at  least  in  its  earlier 
stages,  occurs  in  patches  which  cause  the  lung  to  present  during  life  physical  signs, 
and,  after  death,  macroscopic  appearances,  ordinarily  quite  distinct  from  those 
of  the  solidified  or  hepatized  lung  of  croupous  pneumonia.  ]\Iacroscopically 
the  limg  presents  a  mottled  appearance  because  its  surface  represents  three  con- 
ditions of  the  pulmonary  parench^-ma,  namely,  (a)  areas  of  consolidation,  (b) 
areas  of  atelectasis  or  collapse,  and  (c)  areas  of  emphysema,  or  enlargement,  of 
groups  of  vesicles  due  to  overdistention,  resulting  from  collapse  of  adjacent  lobules. 
The  consolidatetl  areas  are  pinkish,  reddish,  or  grayish-yellow  in  hue,  the  emphyse- 
matous patches  are  paler  and  crepitate  when  touched,  while  the  collapsed  portions 
arc  bluish  or  mahogany  in  color  and  depressed  below  the  rest  of  the  cut  surface  of 
the  lung. 

The  inflammatory  process  usually  begins  in  the  smaller  bronchi  and  extends 
from  them  to  the  tissues  immediately  adjoining,  forming  patches  of  consolidation, 
which  arc  deep  red  in  hue,  and  which  extend  farther  and  farther  from  their  original 
site,  until  perchance  they  coalesce  and  form  fairly  large  airless  consolidations. 
As  the  margin  of  the  inilammatory  zone  extends,  the  primary  area  of  inflammation 
undergoes  necrotic  degcnerati\c  changes,  loses  its  red  appearance,  and  may  become 
grayish,  through  granular  and  fatty  degeneration  of  the  exudate.  This  inflam- 
matory exudate  not  only  invades  the  peribronchial  tissues,  but  the  vesicles  as 
well,  so  that  they  are  rendered  airless.  If  the  lung  be  cut  across  these  patches  of 
consolidation  will  project  slightly,  and  in  the  centre  of  each  can  he  seen  the  cross- 


BRONCHOPNEUMONIA  389 

section  of  the  primarily  involved  bronchus,  which  looks  whitish,  and  from  which 
mucopus  may  exude.  In  some  instances  in  which  the  infec-tion  is  severe  and  the 
inflammatory  process  rapid,  the  mucopurulent  character  of  the  exudate  into  the 
bronchial  tubes  is  very  well  developed,  and  this  purulent  process  may  extend 
into  the  peribronchial  spaces  and,  in  septic  cases,  cause  small  pyogenic  foci.  The 
exudate  itself  is  composed,  as  would  be  expected  from  the  character  of  the  lesions, 
of  serum,  red  cells,  epithelial  cells  which  have  separated  from  the  bronchial  and 
vesicular  walls,  and  a  large  number  of  leukocytes,  and  in  varying  numbers  the 
associated  bacteria. 

The  exudate  contains  much  less  fibrin  than  it  does  in  croupous  pneumonia, 
often  none  at  all,  and  a  copious  fibrinous  deposit  on  the  pleura  is  exceptional. 

If  the  inflammation  of  the  walls  of  the  bronchial  tubes  is  severe  they  become 
thickened  and  swollen,  and  therefore  their  lumen  is  greatly  decreased  or  even 
occluded.  This  result  is  greatly  aided  by  their  becoming  plugged  with  the  mucus 
and  dead  cells,  and  so  it  not  infrequently  happens  that  a  certain  area,  or  several 
areas  of  the  vesicular  portion  of  the  lung  is  deprived  of  air  and  undergoes  collapse 
or  atelectasis.  A  marked  polymorphonuclear  leukocytosis  and  lymphocytosis 
is  usually  preseiat. 

It  is  worthy  of  note  that  catarrhal  pneumonia  is  in  the  great  majority  of  instances 
present  in  both  lungs,  and  that  it  is  usually  conspicuous  in  the  bases  posteriorly. 
The  anterior  portions  of  the  lungs  and  particularly  the  apices,  except  in  tuberculous 
cases,  show  little  involvement  unless  the  lesions  are  well  developed  elsewhere. 

The  exudate  in  bronchopneumonia  undergoes  resolution,  as  do  most  inflammatory 
exudates,  by  the  degeneration  of  the  extravasated  and  desquamated  elements 
and  their  speedy  absorption  or  expectoration.  With  this  process  the  material 
plugging  the  bronchial  tubes  disappears  and  the  collapsed  vesicles,  upon  receiving 
their  normal  supply  of  air,  expand  so  that  complete  recovery  ensues. 

When  this  does  not  take  place  we  find  the  development  of  dense  connective 
tissue  about  the  air  tubes  and  between  the  air  spaces,  which,  as  it  increases  in 
degree,  causes  thickening  and  induration.  As  this  process  increases  the  connective 
tissue  distorts  the  lung  so  that  the  bronchi  are  twisted  or  bent,  patches  of  vesicular 
tissue  collapse,  secretion  is  retained  in  the  bronchial  tubes,  and  as  a  result  chronic 
bronchial  inflammation,  dilatation,  or  sacculation  of  these  tubes  occm-s,  and  the 
patient  becomes  a  sufferer  from  chronic  bronchitis,  with  bronchiectasis  or  a  clironic 
bronchopneumonia. 

In  other  instances  old  tuberculous  lesions  are  rendered  active  by  the  acute 
bronchopneumonia,  or  a  new  tuberculous  infection  is  superadded,  so  that  the  case 
speedily  passes  into  a  well-developed  pulmonary  tuberculosis.  In  still  other 
instances  the  whole  process  from  the  very  beginning  is  really  due  to  the  Bacillus 
tubemilosis,  and  the  patient  rapidly  develops  unmistakable  evidences  of  tuberculous 
infection,  the  microscope  showing,  sooner  or  later,  the  presence  of  these  organisms 
in  the  sputum.  In  such  cases  the  exudate  in  the  air  cells  goes  on  to  caseation, 
and  may  become  encapsulated  or  disseminated,  depending  upon  the  virulence 
of  the  organism  and  the  resistance  of  the  patient. 

Symptoms. — The  symptomatology  of  bronchopneumonia  varies  with  the  primary 
cause.  If  it  be  primary  it  naturally  presents  sjTiiptoms  which  difi^er  somewhat 
from  those  which  it  presents  when  it  is  secondary,  and  follows  some  more  or  less 
prolonged  and  exhausting  malady.  Then,  too,  the  symptoms  naturally  vary  with 
the  age  of  the  patient  attacked,  with  the  areas  of  the  lungs  which  are  involved, 
and  with  the  severity  of  the  illness  which  has  preceded  it. 

For  the  ready  study  of  the  symptoms  of  bronchopneumonia  we  may  therefore 
form  at  least  three  classes  of  cases:  those  which  are  distinctly  primary,  those  that 
are  clearly  secondary,  and  those  which  involve  the  small  bronchioles  very  early 
in  the  attack,  producing  what  is  known  as  acute,  suffocative  catarrh. 


390 


DISEASES  OF  THE  LUNGS 


When  the  child  is  attacked  with  the  privmry  form  of  hronchopneuvionia  there 
is  usually  a  chill  at  onset,  which  varies  greatly  in  its  severity,  in  some  cases  being 
so  slight  that  it  is  scarcely  noted,  and  in  others  amounting  to  a  true  rigor.  Com- 
monly there  is  a  history  that  the  child  has  been  exposed  to  cold  and  wet.  As  in 
all  inflammatory  conditions  in  childhood,  there  is  a  sharp  rise  in  temijerahire, 
almost  from  the  very  first  an  increase  in  the  respiratory  rate,  and,  it  may  be,  very 
considerable  evidence  of  resjjiratory  difficulty. 

It  is  ciu-ious  to  note  how  the  se\erity  of  the  sAinptoms  of  catarrhal  pneumonia 
vary  in  different  children.  Some  become  dynpneic  very  early,  and  others  suft'er 
very  little  respiratory  embarrassment  through  the  whole  course  of  the  malady. 

So  sudden  may  be  the  onset  in  this  primary  form  of  bronchopneumonia  that 
it  may  be  practically  impossible  for  the  physician  to  separate  it  from  croupous 
pneumonia,  particularly  as  children  suffering  from  the  latter  disease  rarely  bring 
up  rusty  sputum,  and  also  because  they  frequently  have  a  pulse  rate  which  is 


Lung  of  a  child.  Oatairhal  pneumonia  following  measles.  In  the  upper  left  quadrant  is  part  of  the 
wall  of  a  small  bronchus,  the  epithelium  of  which  is  desquamating  {A):  several  air  vesicles  containing 
catarrhal  exudate  are  shown  (B).  The  connective  tissue  of  the  bronchus  and  the  intervesicular  structure 
are  slightly  edematous  and  the  seat  of  considerable  leukocytic  infiltration  (C). 


higher  in  proportion  to  the  respirations  than  that  ratio  which  is  common  in  croupous 
pneumonia  in  adults.  Cerebral  symptoms  may  also  be  present,  just  as  they  arc  in 
croupous  pneimionia;  and  this  is  not  surprising  in  view  of  the  fact  already  pointed 
out,  that  the  pneumococcus  is  the  micro-organism  most  frequently  responsible 
for  both  forms  of  pneumonia  in  children.  For  this  reason,  probably,  primary 
catarrhal  pneumonia  in  children  not  infrequently  ends  by  crisis,  and  recovery 
may  speedily  take  place  after  a  very  few  days  of  illness.  Indeed,  the  outlook  in  a 
case  of  this  kind  in  an  otherwise  healthy  child,  which  is  not  very  young,  is  usually 
favorable. 

The  symptoms  of  the  onset  of  secondary  bronchopneumonia  ^■ary  greatly  from 
those  just  described.  Instead  of  having  a  sharp  onset  the  onset  is  insidious.  A 
child  having  been  ailing  from  some  other  malady  for  a  number  of  days  or  weeks, 
is  found  to  ha-\e  an  accession  of  fever,  to  be  languid,  to  ha\e  a  rapid  pulse,  to  have 
a  very  marked  increase  in  respiratory  rate,  and  the  skin  is  found  to  be  hot  and  dry. 
The  speed  of  the  pulse  is  often  excessive,  reaching  150  to  200  a  minute;  but  in 


BRONCHOPNEUMONIA  391 

this  disease,  as  in  all  others,  its  quality  is  of  as  great  importance  as  its  speed.  An 
irregular  pulse  is  of  evil  import.  The  cough  is  fairly  constant  and  sometimes 
produces  'pain,  and  if  the  area  involved  is  at  all  large  respiratory  embarrassment 
is  early  manifested.  This  is  shown  by  the  increased  number  of  respirations,  by 
the  fact  that  they  are  somewhat  labored,  and  also  by  the  fact  that  the  intercostal 
spaces  are  frequently  drawn  in  by  the  suddenness  of  the  inspiratory  movement. 
Auscultation  will  probably  reveal  in  the  smaller  bronchial  tubes  some  fine  rales,  with 
exaggerated  inspiratory  and  soviewhai  prolonged  expiratory  sounds.  The  breathing 
is  of  the  exaggerated,  puerile  type;  the  cough  is  unproductive.  Percussion  for 
the  first  twenty-four  hours  of  the  attack  may  reveal  practically  nothing.  This 
is  in  part  due  in  children  to  the  resiliency  of  the  entire  chest,  so  that,  unless  very 
gentle  percussion  is  exercised,  the  resonance  of  neighboring  parts  may  cover  the 
impaired  resonance  of  the  consolidated  area.  Again,  those  areas  which  have 
undergone  compensatory  dilatation  possess  a  hj'perresonance  which  may  cover 
the  impairment.  If,  however,  the  pathological  lesion  is  well  developed,  at  the 
end  of  twenty-four  or  forty-eight  hours  careful  percussion  will  usually  reveal 
distinct  impairment  of  resonance,  particularly  if  the  lesions  are,  as  is  common, 
chiefly  at  the  bases  posteriorly. 

If  the  disease  is  severe  the  symptoms  of  dyspnea  may  become  distressingly 
well  marked,  and  cyanosis  may  become  constant,  the  child  being  so  short  of  breath 
that  it  ceases  to  cry,  and,  indeed,  may  have  difficulty  in  taking  liquids  because 
of  its  dyspnea;  that  is  to  say,  it  is  so  short  of  breath  that  it  cannot  take  time  to 
swallow.  Usually  at  this  time  the  expression  is  somewhat  anxious.  If  the  dyspnea 
has  been  prolonged  enough  to  exhaust  the  child,  and  the  accumulation  of  carbon 
dioxide  in  the  blood  has  been  sufficient  to  benumb  its  sensibilities,  it  is  markedly 
apathetic.  These  symptoms  last  a  variable  number  of  days,  but  usually  a  change 
for  the  better  in  a  mild  case  begins  to  be  noted  by  the  end  of  the  fifth,  sixth,  or 
seventh  day,  and  with  the  beginning  of  improvement  in  the  general  symptoms 
auscultation  will  reveal  that  the  rales  in  the  chest  are  more  moist,  that  on  coughing 
they  alter  in  quality  more  than  before,  and,  further,  air  will  be  fomid  passing  through 
portions  of  the  lung  which  heretofore  have  seemed  devoid  of  it. 

In  other  instances  the  disease  runs  a  much  longer  course,  and  the  child,  after 
hovering  between  life  and  death  for  a  number  of  days,  slowly  emerges  from  its 
illness,  and  the  physical  signs  in  the  lungs  equally  slowly  disappear. 

In  young  children  it  is  by  no  means  an  uncommon  occurrence  for  the  disease  to 
spread  in  a  violent  form  into  the  smaller  bronchioles,  and  by  the  swelling  of  the 
mucous  membrane,  the  copiousness  of  the  exudate,  and  the  wide  area  involved, 
produce  what  is  known  as  acute  suffocative  catarrh,  a  condition  which  at  one  time 
was  considered  as  a  separate  entity  from  bronchopneiunonia,  but  which  is  now 
recognized  as  being  simply  a  malignant  form  of  the  disease  involving  a  large  number 
of  the  smaller  bronchioles,  and  so  greatly  interfering  with  respiration.  Another 
term  which  has  also  been  used  to  describe  this  condition  is  "capillary  bronchitis;" 
in  other  words,  this  name  is  meant  to  bring  out  the  fact  that  the  finer  bronchioles 
are  involved.  A  very  excellent  term  to  describe  this  form  of  the  disease  is  "  acute 
disseminated  bronchopneumonia." 

Capillary  bronchitis,  or  acute  suffocative  catarrh,  is  one  of  the  most  distressing 
acute  maladies  which  affect  young  children.  Its  onset  is  usually  very  rapid,  and 
within  twelve  or  twenty-four  hours  the  child  may  be  suffering  intensely  from 
dyspnea.  At  first,  the  dyspnea  and  inability  to  get  a  sufficient  quantity  of  oxygen 
render  it  fretful  and  restless;  but  very  soon  it  becomes  loeary,  and  with  weariness 
of  the  general  system  there  develops  a  weariness  of  the  respiratory  centre,  which 
fails  to  send  out  sufficiently  powerful  influences  to  cause  the  remaining  healthy 
portion  of  the  lung  to  be  completely  filled  at  each  inspiration.  Very  speedily, 
too,  carbonic  acid  gas  accumulates  in  the  blood  and  benumbs  the  respiratory 


392  DISEASES  OF  THE  LUNGS 

centre,  so  that  within  twenty-four  or  tlilrty-six  hours  after  the  hegiiuiing  of  the 
malady  the  child  may  lie  in  its  mother's  arms  limp  and  motionless  except  for  the 
rapid  respirations  which  are  required  to  maintain  life.  I  Jiave  not  infrequently 
seen  a  child  in  this  condition  as  limp  as  it  is  when  unfler  the  influence  of  ether  or 
chloroform,  and  only  semiconscious.  The  finger-nails  are  livid,  the  lips  much 
darker  than  normal.  The  mouth  is  apt  to  be  excessi\'ely  dry,  owing  to  rapid 
evaporation  of  moisture  from  the  high  fe\'er  and  rapid  breathing. 

During  a  portion  of  the  attack  the  respiratory  rate  may  become  as  high  as  60 
or  even  70  a  minute,  and  not  infrequently  death  comes  on  as  a  combined  result 
of  the  infection,  of  the  dilatation  of  the  right  side  of  the  heart,  of  the  accumulalidii 
of  carbon  dioxide  in  the  blood,  and  of  general  nervous  exfiaustion. 

Probably  the  most  characteristic  symptom  of  capillary  l)ronchitis  is  the  intense 
dyspnea,  which  is  quite  as  acute  in  some  cases  as  it  is  in  dii)htheria  with  laryngeal 
obstruction.  Indeed,  I  have  known  intubation  to  be  done  in  a  case  of  capillary 
bronchitis,  it  being  thought  that  the  child  had  laryngeal  trouble  in  addition  to 
its  pulmonary  difficulties,  although  no  laryngeal  lesion  was  actually  present. 

The  teinperature  in  cases  of  capillary  branchitis  varies  \'ery  greatly.  At  the 
time  of  death  the  temperature  may,  superficially  at  least,  be  subnormal,  although 
the  rectal  temperature  may  be  high.  The  general  run  of  the  temperature  pursues 
no  definite  course  as  it  is  wont  to  do  in  croupous  pneumonia,  but  progresses  very 
irregularly. 

The  degree  of  fever  in  bronchopneumonia  of  the  secondary  t^'pe  is  of  little  value 
for  the  purpose  of  determining  the  severity  of  the  disease.  Sometimes  when  the 
infection  is  quite  se\'ere  the  temperature  may  not  rise  above  101°  or  102°,  whereas 
in  other  cases  which  are  really  less  ill,  it  may  reach  105°  or  106°. 

Duration. — ^The  duration  of  bronchopneumonia  varies  very  greatly  with  the 
condition  of  the  child  at  the  onset  of  the  disease.  In  primary  bronchopneumonia, 
occurring  in  an  otherwise  healthy  child,  the  malady  may  last  for  but  a  few  days, 
and  it  is  a  noteworthy  fact  that  it  may  be  arrested  in  any  stage  of  its  development, 
so  that  recovery  may  speedily  take  place. 

In  secondary  bronchopneumonia  the  duration  is  apt  to  be  very  much  longer 
than  in  the  primary  form.  Under  these  circumstances  it  commonly  runs  a  course 
of  from  ten  days  to  two  weeks,  and  if  the  condition  of  the  patient  is  seriously 
impaired  at  the  time  of  its  onset,  it  may  last  for  three  or  foiu-  weeks.  Usually, 
however,  during  the  last  ten  days  or  two  weeks  of  a  prolonged  attack  of  this  char- 
acter, the  symptoms  are  much  modified  and  the  temperature  is  but  a  little  above 
normal.  Whooping-cough,  which  is  a  very  frequent  cause  of  bronchopneumonia, 
runs  a  course  of  from  six  to  twelve  weeks,  and  if  bronhcopneumonia  develops 
early  in  the  attack  of  whooping-cough  the  persistency  of  the  spasmodic  seizures, 
with  their  accompanying  bronchitis,  naturally  prolongs  the  duration  of  the  pul- 
monary disorder;  whereas,  in  another  disease  like  measles,  which  runs  a  much 
shorter  course,  the  pulmonary  disorder  may  disappear  almost  as  soon  as  the  erup- 
tive disease,  although  very  often  it  persists  for  a  week  or  ten  days,  and  convalescence 
from  measles  is  well  established.  Much  depends,  too,  as  to  the  duration  of  the 
malady,  upon  the  size  of  the  areas  of  consolidation  and  the  presence  of  more  slowly 
liquidated  exudates.  Commonly,  the  greater  the  area  infected,  the  greater  the 
length  of  the  disease. 

Complications. — The  complications  of  bronchopneumonia  are  not  numerous. 
As  already  pointed  out,  it  occasionally  happens  that  tuberculosis  develops  in  the 
area  which  is  diseased.  More  rarely  still  the  infection  of  the  peribronchial  tissues 
is  so  severe  that  pulmonary  abscess  results.  Pleuritis  is  rare  unless  there  happens 
to  be  a  patch  of  consolidation  close  to  the  pleura,  in  which  case  a  small  area 
may  be  involved.  This  rarely  spreads  and  still  more  rarely  is  accompanied  by 
marked  effusion,  but  it  sometimes  results  in  empyema. 


BRONCHOPNEUMONIA  393 

Diagnosis. — Bronchopneumonia  is  to  be  differentiated  from  ordinarj'  severe 
bronchitis  by  the  presence  of  patches  of  impaired  resonance  on  percussion,  and 
by  the  fact  that  during  the  course  of  an  acute  bronchitis  an  exacerbation  of  tem- 
perature and  of  the  general  symptoms  of  severe  illness  ensue.  Beyond  these  points 
it  may  be  practically  impossible  to  separate  the  two  maladies.  It  is  not  to  be 
forgotten  that  bronchitis  is  not  associated  with  hyperresonance  in  any  portion 
of  the  chest  as  a  rule,  but  catarrhal  pneumonia  is  frequenth'  associated  with  this 
physical  sign.  Percussion  in  capillary  bronchitis  may  therefore  give  exaggerated 
resonance  owing  to  the  emphysematous  state  of  the  vesicular  parts  of  the  lung, 
for,  as  in  asthma,  the  difficulty,  which  often  exists,  is  an  inability  to  expire  some 
of  the  air  which  has  been  taken  in  by  forced  inspiration.  As  has  already  been 
stated,  hyperresonance  may  completely  take  the  place  of  impaired  resonance  due 
to  consolidation. 

From  croupous  pneumonia  bronchopneumonia  is  to  be  separated  by  the  fact 
that  its  onset  is  more  gradual  or  insidious,  by  the  intermittent  character  of  the 
fever,  and  by  the  irregular  distribution  of  the  physical  signs  in  the  chest.  Another 
important  differential  point  is  the  fact  that  catarrhal  pneumonia  is  usually  bilateral 
and  joined  at  the  bases,  whereas  croupous  pneumonia  is  not;  that  bronchopneu- 
monia is  usually  well  diffused,  and  in  both  lungs,  whereas  the  croupous  t.-s-pe  is 
usually  but  not  always  unilateral,  and  commonly  limited  to  one  lobe.  Croupous 
pneumonia  usually  ends  by  crisis,  whereas  bronchopneiunonia  may  end  by  lysis. 
The  predominance  of  severe  cerebral  or  meningeal  symptoms  is  rather  in  favor  of 
the  croupous  type  of  the  disease. 

In  many  cases  it  is  impossible  to  determine  whether  the  bronchopneimionia 
is  due  to  the  pneumococcus  or  some  other  coccus,  or  is  the  result  of  the  infection 
by  the  tubercle  bacilli.  In  the  absence  of  enlargement  of  the  mesenteric  glands 
and  of  other  signs  of  tuberculous  infection,  the  differential  diagnosis  between 
bronchopneumonia  of  tubercidous  origin  and  that  due  to  ordinary  causes  is  prac- 
tically impossible,  until  the  disease  has  advanced  so  far  that  other  systemic  mani- 
festations of  tuberculous  infection  are  evident. 

Sometimes  the  intermittent  and  irregular  temperature  curves  of  bronchopneu- 
monia suggest  the  possibility  of  malarial  infection.  The  differential  diagnosis 
in  a  case  of  malarial  infection,  with  bronchial  symptoms  like  those  of  bronchopneu- 
monia, can  of  course  only  be  made  by  careful  examination  of  the  blood,  and  by  a 
more  careful  study  of  the  temperature  chart  than  is  usual  in  the  ordinary  case. 
Then,  too,  in  the  malarial  forms  of  the  disease  the  symptoms  will  be  modified 
or  arrested  by  the  use  of  quinine. 

As  already  pointed  out,  the  sjTnptoms  of  bronchopneumonia,  in  children  in 
particular,  vary  to  an  extraordinary  degree  with  the  primary  illness  from  which 
the  patient  has  been  suffering.  Thus,  in  whooping-cough  the  onset  of  the  disease 
is  often  so  insidious  as  to  be  easily  overlooked  because  the  rales  are  mistaken  for 
those  of  the  usual  mild  bronchitis.  In  other  instances  the  sjTnptoms  may  be 
those  of  tuberculous  or  acute  meningitis,  particularly  in  rachitic  infants. 

Not  rarely  an  acute  diarrhea  may  be  present,  the  stools  being  green  and  containing 
much  mucus,  some  of  which  is  due  to  a  coincident  gastro-intestinal  catarrh,  and 
some  of  it  being  from  the  bronchial  tubes,  for  a  child  rarely  expectorates,  and 
usually  swallows  what  he  coughs  up  from  the  chest.  Because  of  the  associated 
indigestion  there  may  be  vomiting  and  distention  of  the  abdomen  by  gas,  which 
factors  all  aid  in  increasing  the  adynamia,  and  in  interfering  with  the  cardiac 
and  pulmonary  activity.  These  facts  emphasize  a  fact  too  frequently  overlooked, 
namely,  that  the  condition  of  the  lungs  should  always  be  carefully  investigated 
in  all  cases  which  present  signs  of  illness  elsewhere,  since  it  may  be  found,  to  the 
physician's  surprise,  that   the   pulmonary  condition  is  the  primary  underlying 


394  DISEASES  OF  THE  LUNGS 

Prognosis. — The  prognosis  of  bronchopiieunioiiia  varies  very  greatly  with  the 
underlying  cause  of  the  disease  and  with  the  age  of  the  patient.  In  young  infants 
it  is  an  exceedingly  fatal  malady,  whether  it  is  primary  or  secondary,  and  during 
the  first  year  of  life,  if  the  disease  is  well  marked,  the  prognosis  is  always  imfavor- 
ahle.  The  favorableness  of  the  prognosis  increases  with  each  year  of  age.  Another 
im]5ortant  factor  in  the  prognosis  of  these  cases  is  the  general  vitality  of  the  patient. 
Children  who  are  naturally  strong  and  healthy,  and  are  provided  with  good  air 
and  sunshine,  have  a  better  opportunity  than  those  who  live  in  poorly  constructed 
dwellings  with  bad  ventilation,  and  whose  primary  vitality  is  necessarily  limited. 
This  question  of  the  vitality  of  the  patient  is  a  most  important  factor  from  a  prog- 
nostic stand-point,  and  therefore  if  the  child  has  been  much  weakened  and  devi- 
talized by  prolonged  illness,  or  has  had  its  heart  seriously  weakened  by  the 
prolonged  strain  of  severe  whooping-cough,  the  outlook  is  much  less  favorable 
than  if  the  disease  attacks  the  child  who  is  suffering  from  a  mild  attack  of 
measles. 

The  mortality  of  bronchopneumonia  in  very  young  children  in  private  practice 
is  probably  about  30  per  cent. ;  whereas  in  asylum  practice,  where  it  is  impossible 
to  provide  them  with  the  same  amount  of  fresh  air  and  careful  nursing,  and  where 
the  health  is  often  previously  unpaired,  it  is  not  infrequently  as  high  as  65  or  70 
per  cent.  While  it  is  true  that  poorly  nourished,  rachitic  children  are  very  apt 
to  fall  victims  to  the  disease,  it  is  also  a  fact  that  well-nourished,  stout,  fat  children 
sometimes  have  marked  difficulty  in  surviving  its  attack;  and  this  is  particularly 
true  if  they  are  "condensed-milk  babies,"  for  such  children  usually  have  low  vital 
resistance.  The  complicating  maladies,  as,  for  example,  active  diarrhea  and 
indigestion  or  vomiting,  of  course  make  the  prognosis  very  uncertain,  and  if  they 
resist  treatment  are  still  more  cause  for  anxiety. 

Treatment. — In  the  treatment  of  bronchopneumonia  it  is  of  the  greatest  impor- 
tance that  the  child  should  be  in  a  well-ventilated  room  which  recei\-es  as  much 
sunshine  as  possible,  for  bronchopneiunonia  is  essentially  a  disease  of  bad  ventila- 
tion. The  temperature  of  the  room  should  be  kept  constant,  and  every  care 
should  be  exercised  that  it  is  not  damp.  If  possible,  it  should  be  heated  by  a  stove, 
or  by  an  open  fire,  rather  than  by  furnace-heated  air,  and  if  it  is  necessary  to  heat 
it  by  means  of  a  furnace,  care  should  be  taken  that  the  air  of  the  room  should  not 
be  allowed  to  become  unduly  dry.  This  may  be  prevented  by  having  the  air  from 
the  furnace  flue  pass  over  the  surface  of  a  pan  of  water,  and  if  the  air  is  very  hot 
and  thoroughly  clried  it  is  better  to  set  free  in  the  air  of  the  room  a  certain  amount 
of  steam  from  a  tea-kettle,  a  pan  of  boiling  water,  or  by  occasionally  inunersing 
a  large  piece  of  quicklime  in  a  bucket  of  water. 

There  can  be  no  doubt  that  the  influence  of  dusty,  impure,  or  dry  air  upon  the 
bronchial  mucous  membrane  in  cases  of  this  disease  is  most  deleterious,  and  I 
believe  that  in  many  instances  much  better  results  can  be  olitained  if  it  is  possible 
to  place  the  child  in  a  bronchitis  tent,  or  to  provide  the  air  of  the  room  with  a 
sufficient  degree  of  moisture  to  make  the  apartment  the  equivalent  of  a  bronchitis 
tent.  This  can  readily  be  accomplished  in  the  way  just  suggested,  or  by  the  use 
of  what  is  known  as  a  "croup  kettle,"  which  continually  sets  free  a  small  quantity 
of  steam.  To  the  water  which  is  placed  in  the  croup  kettle  1  or  2  grains  of  menthol 
may  be  added  every  two  or  tliree  hours,  and  in  some  instances,  for  their  soothing 
influence,  a  few  drops  of  oil  of  eucalyptus  and  compound  tincture  of  benzoin  may 
be  so  employed.  As  far  as  possible  the  patient  should  be  kept  quiet  in  bed,  or, 
in  the  case  of  little  children,  should  be  moved  as  little  as  is  consistent  with  com- 
fort; but  if  the  child  is  very  ill,  it  should  not  be  allowed  to  lie  in  one  posture  hour 
after  hour,  but  occasionally  be  changed,  lest  h.vpostatic  congestion  occur.  Easily 
digested,  nutritious  food  should  be  given  in  small  quantities  every  two  hours.  No 
medicine  wliicli  may  disturb  digestion  should  be  given. 


BRONCHOPNEUMONIA  395 

In  the  way  of  external  applications  to  the  chest,  the  child's  back,  sides,  and 
front  may  be  rubbed  with  a  mLxture  of  a  teaspoonful  of  turpentine  and  three 
tablespoonfuls  of  sweet  oil.  In  other  instances  a  weak  ammonia  liniment  may  be 
used,  or  in  still  other  cases  oil  of  amber,  in  the  strength  of  a  teaspoonful  to  two 
tablespoonfuls  of  sweet  oil.  These  methods  of  treatment  provide  sufficient  counter- 
irritation  and  do  not  maintain  the  febrile  temperature  as  do  the  poultice  or  cotton 
jacket,  both  of  which  forms  of  application  have  now  deservedly  gone  out  of  use, 
as  it  is  inconceivable  that  they  can  favorably  affect  the  lesion  in  the  lung,  and  they 
certainly  increase  the  discomfort,  the  fever,  and  the  irritation  of  the  child's  nervous 
system. 

Stimulants  are  not  needed  in  all  cases  of  bronchopneumonia,  but  are  used  wisely 
in  a  larger  proportion  of  patients  than  in  those  who  suffer  from  the  croupous  variety 
of  the  disease,  because  bronchopneumonia,  as  has  already  been  pointed  out,  usually 
attacks  the  feeble  and  therefore  those  who  commonly  need  stimulation.  The 
quantity  of  stimulant  which  is  given  varies  of  course  with  the  feebleness  of  the 
heart  sounds,  the  condition  of  arterial  tension,  and  the  degree  of  general  nervous 
prostration.  One  of  the  best  stimulants  which  can  be  used  is  the  carbonate  of 
ammonium  in  the  dose  of  2  or  3  grains  every  tliree  or  four  hours  to  a  child  of  a 
year  or  two,  usually  giving  it  in  the  syrup  of  acacia  and  water.  Carbonate  of 
ammonium,  however,  acts  best  when  it  is  given  for  comparatively  short  periods 
of  time,  and  for  a  constant  stimulant  during  the  greater  portion  of  the  disease 
it  is  probable  that  brandy  occupies  the  first  place.  Care  should  be  exercised  that 
the  brandy  is  at  least  five  years  old,  and  that  it  is  as  bland  as  possible.  It  should 
be  given  very  well  diluted  by  water,  and  a  child  of  a  year  may  take  as  much  as  half 
an  ounce  to  an  ounce  in  twenty-four  hours  with  advantage,  30  drops  being  given 
every  two  or  three  hours. 

As  a  rapidly  acting  diffusible  stimulant  to  meet  critical  periods  of  depression  Hoff- 
mann's anodyne  in  the  dose  of  5, 10,  or  15  drops  may  be  employed  in  young  children. 
In  other  instances  y^-^  grain  of  strychnine  may  be  used,  or  a  larger  dose  than  this, 
it  being  always  borne  in  mind  that  the  nervous  system  of  a  child  is  exceedingly 
susceptible  to  this  drug.  Like  the  carbonate  of  ammonium,  strychnine  is  only  to 
be  used  when  it  is  necessary  to  bridge  an  exceedingly  critical  period.  If  the  dose 
of  strychnine  is  to  be  repeated,  3^73-  of  a  grain  is  a  sufficiently  large  amount.  Tliis 
quantity  may  be  given  twice,  thrice,  or  four  times  in  twenty-four  hours,  but,  as  a 
rule,  it  is  unwise  to  continue  its  use  for  a  longer  period  than  this. 

Where  the  quantity  of  bronchial  secretion  is  considerable,  particularly  in  many 
cases  of  suffocative  bronchitis,  a  critical  period  may  be  weathered  by  the  use  of 
small  doses  of  atropine;  from  yijVij  to  5-5- q-  of  a  grain  may  be  given  every  two  or 
three  hours  by  the  mouth,  or,  if  need  be,  g^  to  -^^  may  be  given  hypodermically, 
if  there  seems  to  be  danger  of  the  child  drowning  in  its  own  secretions.  Oxygen 
may  be  taken  by  inlialation  in  some  cases  with  advantage. 

'The  use  of  antipjTetic  drugs  is  to  be  absolutely  condemned.  They  are  even 
more  dangerous  in  this  disease  than  in  croupous  pneumonia.  If  the  temperature 
is  so  high  as  to  be  dangerous  in  itself,  it  may  be  controlled  by  cool  or  tepid  spongings, 
with  gentle  friction;  by  the  use  of  cool  cloths  to  the  forehead,  or  an  ice-bag  applied 
to  the  head  if  cerebral  sjTiiptoms  are  marked. 

When  the  symptoms  of  respiratory  oppression  are  marked  and  the  fever  is 
high,  it  is  often  advantageous  at  a  critical  period  to  dip  the  child  alternately  in 
cool  and  hot  water,  the  water  being  hot  enough  to  produce  distinct  counter-irritation 
on  the  skin,  and,  reflexly,  to  arouse  the  dormant  nervous  system.  Under  these 
circumstances  the  child  often  rallies,  takes  deep  inspirations,  dislodges  the  mucus 
which  is  otherwise  obstructing  its  breathing,  and  at  the  same  time  has  a  reduction 
in  its  temperature.  Such  an  alternate  hot  and  cold  plunge  bath  should  only  be 
resorted  to  when  conditions  are  desperate,  and  should  not  be  repeated  too  fre- 


396  DISEASES  OF  THE  LUNGS 

quently.  A  tepid  bath,  the  patient  being  immersed  or  simply  sponged,  will  also 
very  frequently  allay  restlessness  and  permit  quiet  sleep. 

In  the  protracted  cases  it  is  exceedingly  important  that  pure  air  and  good  food 
should  be  provided.  Not  infrequently  the  child  whicli  fails  to  improve  in  the  city 
may,  when  carried  in  its  nurse's  arms  to  the  sea-shore  or  the  mountains,  change 
for  the  better  to  a  remarkable  degree  within  a  very  short  period  of  tune.  This  is 
particularly  true  if  the  weather  is  oppressively  hot.  Such  patients  also  may 
be  benefited  in  some  instances,  particularly  during  the  winter  months,  liy  cod-liver 
oil  inunctions,  and,  if  the  digestion  will  stand  it,  by  the  administration  of  small 
quantities  of  cod-liver  oil  or  the  syrup  of  iodide  of  iron  by  the  mouth.  Sometimes 
such  patients  are  also  greatly  benefited  by  the  administration  of  the  hj'pophosphites. 

During  tlie  acute  stage  of  bronchopneumonia  there  is  little  use  in  employing 
the  ordinary  expectorants.  During  the  stage  of  resolution,  if  the  secretion  is 
profuse,  small  doses,  such  as  1  or  2  grains  of  chloride  of  ammonium,  with  fluid- 
extract  of  licorice  and  water,  may  be  given  twice  or  thrice  a  day.  Rarely  in  young 
children  is  there  much  expectoration,  either  in  the  sense  of  expelling  mucus  from 
the  mouth  or  coughing  it  up  into  the  pharynx.  The  younger  the  child  the  less 
chance  there  is  of  freeing  its  bronchial  tubes  of  secretion  by  coughing,  and  care 
should  always  be  taken  that  the  administration  of  an  expectorant,  which  is  not 
of  very  great  importance,  does  not  disorder  the  digestion,  which  is  of  far  greater 
importance  to  the  maintenance  of  the  child's  health  and  strength  than  any  medicine 
can  be. 

The  bronchopneumonia  of  adults  usually  follows  astlima  or  the  inspiration 
of  irritant  materials,  and  must  be  treated  in  much  the  same  manner  as  that  just 
described  for  bronchopneumonia  in  children,  except  that  the  doses  should  be 
larger  in  proportion  to  the  age  and  size  of  the  individual.  In  nearly  all  cases 
active  stimulation  is  required,  and  digitalis  and  strychnine  are  particularly  useful. 
Counter-irritation,  freely  applied  to  the  chest,  seems  to  be  of  advantage  in  some 
instances,  but  here  again  the  cotton  jacket  or  the  poultice  ought  not  be  resorted 
to,  as  they  simply  oppress  the  patient  and  do  little  good. 

METASTATIC  PNEUMONIA. 

Definition. — By  the  term  metastatic  pneumonia  is  meant  a  condition  of  consolida- 
tion of  part  of  one  lung,  or  more  rarely  parts  of  both  lungs,  as  the  result  of  the  plug- 
ging of  one  or  more  of  the  pulmonary  vessels  by  an  embolus  ^^■hich  is  of  septic 
origin. 

Etiology  and  Pathology. — As  elsewhere,  emboli  reaching  the  lung  may  be  (1) 
simple  or  bland,  (2)  septic  or  infective;  either  of  these  may  be  massive  or  small. 
A  large  mass  thrown  into  the  pulmonary  artery  at  once  arrests  the  flow  of  blood, 
the  patient  gives  a  few  gasps,  possibly  has  a  convulsion,  or  at  least  convulsive 
movements,  and  dies.  Smaller  emboli,  if  numerous  (an  embolic  shower),  may 
induce  similar  phenomena.  The  simple  or  bland  embolus  occludes  one  or  more 
vessels,  and  leads  to  the  formation  of  a  hemorrhagic  infarct.  These  irregularly 
shaped  or  conical  areas  vary  in  size,  depending  upon  the  magnitude  of  the  occluded 
vessel  and  the  efficiency  of  the  collateral  circulation.  They  may  be  central  or 
peripheral,  massive  or  small,  single  or  multiple. 

The  question  of  autochthonous  embolism  is  of  pathological  rather  than  clinical 
niterest. 

The  affected  area  is  airless,  denser  than  the  uninvolved  pulmonary  tissues,  and 
near  the  centre  it  is  dark  purple  or  almost  black  in  recent  infarcts,  black  or  brownish- 
black  in  older  areas,  and  it  may  be  surrounded  by  a  zone  of  reactionary  inflannna- 
tion.  If  the  lesion  is  peripheral  the  indurated  area  rises  above  the  level  of  the 
j)lcura  and  is  frequently  covered  by  a  delicate  stratum  of  fibrin.     Certain  pleurisies. 


BRONCHOPNEUMONIA  397 

particularly  those  following  operations,  have  been  attributed  to  pulmonary  infarc- 
tion. Histologically  such  areas  when  recent  show  air  vesicles  occupied  by  blood 
cells  and  fibrin  and  more  or  less  interstitial  extravasation.  Later  the  erythrocytes 
are  fragmented,  the  leukocytes  increased,  phagocytes  abundant,  and  evident 
reparative  processes  in  progress. 

The  sputum  is  more  or  less  blood-stained,  and  when  the  infarcts  are  large  or 
numerous  it  may  be  intensely  so.  In  fat  embolism,  such  as  may  accompany 
fractures  of  the  long  bones,  oil  globules  may  be  demonstrable  in  the  sputum. 

Whether  the  process  arises  to  the  dignity  of  a  pneumonia  depends,  of  course, 
upon  the  amount  of  accompanying  inflammation.  It  is  evident  that  a  few  small 
infarcts  irregularly  distributed  may  give  rise  to  no  symptoms  because  of  the  insig- 
nificant lesions  induced;  or,  on  the  other  hand,  large,  or  multiple,  areas  may  be 
accompanied  by  evident  lung  symptoms.  Whether  inflammation  be  marked 
or  slight  is  so  largely  dependent  upon  the  presence  of  infection  that  in  the  absence 
of  bacteria  the  name  metastatic  pneumonia  is  scarcely  applicable. 

Embolism  due  to  fragments  of  neoplasms  entering  the  lungs  usually  escapes 
notice  until  the  proliferating  cells  give  rise  to  metastatic  tumors. 

The  most  important  and  gravest  type  of  metastatic  pneiunonia  is  that  seen 
in  pyemia. 

During  the  course  of  a  septic  process  in  any  part  of  the  body,  even  though  it 
may  be  so  minute  as  to  escape  notice  unless  carefully  sought,  it  is  possible  for  a 
small  clot  (embolus)  infected  by  micro-organisms  to  enter  the  circulation  and, 
being  carried  to  the  lung,  to  plug  one  of  the  vessels.  The  difference  between  the 
infarct  resulting  from  an  ordinary  embolus  and  the  lesion  ensuing  from  one  of 
septic  origin  is  very  marked,  for  in  the  latter  condition  there  speedily  develops 
an  acute  local  process  due  to  the  rapid  extension  of  the  infection  from  the  embolus. 
In  this  way  the  immediate  neighborhood  of  the  closed  vessel  becomes  engorged; 
polymorphonuclear  leukocytes  accumulate  in  the  infected  area,  which  rapidly 
undergoes  liquefaction,  necrosis,  and  an  abscess  is  formed.  As  such  emboli  are 
rarely  solitary,  multiple  foci  are  prone  to  develop;  these  may,  by  extension, 
become  confluent,  or  successive  embolic  showers  may  cause  closely  approximated 
lesions  of  different  ages. 

As  the  quantity  of  infective  material  and  its  distribution  constantly  vary, 
the  anatomical  result  of  such  conditions  can  rarely  be  the  same  in  any  two  cases. 
There  may  be  a  single  area  of  infection,  or  the  lung  may  be  riddled  by  abscesses, 
the  "  pyemic  pneumonia"  of  old  writers. 

The  area  of  solidification  in  the  lung  may  resemble  the  patchy  state  seen  in 
bronchopneumonia  or  the  hepatized  appearance  of  croupous  pneumonia.  There 
is,  however,  this  important  difference  in  the  further  progress  of  the  local  lesions 
between  the  two  diseases  named  and  that  under  discussion,  for  in  metastatic 
pneumonia  the  inflammatory  process  usually  goes  on  to  suppuration,  the  entire 
infected  area  becoming  crowded  with  pus  cells  and  cocci,  the  walls  of  the  vesicles 
and  the  connective  tissue  of  the  lung  breaking  down  instead  of  remaining  intact 
as  in  most  cases  of  ordinary  pneumonia.  As  a  result  we  find  one  or  more  abscesses 
of  the  lung  which  may  rupture  into  a  bronchus,  into  the  pleural  cavity,  or  even 
through  the  diaphragm,  and  are  practically  always  accompanied  by  marked  septic 
fever. 

The  pleura  rarely  escapes,  and  empyema,  in  patients  surviving  sufficiently 
long,  is  not  uncommon.  As  the  abscesses  open  into  the  bronchi  and  eroded  vessels 
give  way,  pulmonary  hemorrhage  is  prone  to  occur.  Large  areas  of  pulmonary 
tissue  may  undergo  necrosis  and  further  complicate  the  case  by  the  addition  of 
pulmonary  gangrene. 

Symptoms. — The  symptoms  of  metastatic  or  septic  pneumonia  present  so  little 
that  is  characteristic  that  they  are  often  overlooked.    This  is  because  the  lesion 


398  DISEASES  OF  THE  LUNGS 

in  the  lung  is  secondary  to  some  inflammatory  process  already  present,  which 
is  responsible  for  much  of  the  fever  and  other  signs  of  an  infection.  In  the  midst 
of  these  symptoms,  if  they  are  severe,  the  slight  exacerbation  produced  by  the 
embolism  is  not  recognized.  It  is  only  in  those  cases  in  which  the  area  of  the  lung 
involved  is  very  considerable  that  pulmonary  signs  are  forced  upon  the  physician, 
projecting  themselves,  as  it  were,  above  those  already  present.  When  tlie  pulmo- 
nary symptoms  are  marked  they  so  closely  resemble  those  of  an  acute  pneumonia 
that  not  infrequently  the  diagnosis  of  an  intercurrent  pneumonia  is  made,  only  to 
be  modified  when  repeafcd  chills,  sweats,  and  a  temperature  chart  indicative  of 
sepsis  show  that  the  process  in  the  lung  is  septic.     (See  Pyemia.) 

When  the  embolus  is  a  large  one  and  plugs  the  pulmonary  artery  at  its  bifurca- 
tion, death  suddenly  ensues. 

The  physical  signs  of  metastatic  pneumonia  are  practically  identical  in  the 
early  stages  of  the  affection  with  those  of  bronchopneumonia  or  croupous  pneu- 
monia, for  the  consolidated  portion  of  the  lung  produces  dulness  on  percussion, 
bronchial  breathing,  and  increased  vocal  fremitus  and  resonance.  Later,  when 
the  consolidated  area  breaks  down  and  begins  to  undergo  suppuration,  the  physical 
signs  may  be  those  met  with  in  beginning  resolution  in  ordinary  croupous  pneumonia. 

Prognosis. — The  prognosis  in  metastatic  pneumonia  is  bad  because  it  is  a  septic 
process  and  also  because  it  is  a  serious  complication  added  to  a  process  which  is 
already  more  or  less  severe.  It  usually  ends  in  abscess  or  gangrene,  and  these 
affections,  particularly  the  latter,  are  fatal  in  the  great  majority  of  cases.  In  the 
rare  instances  in  which  recovery  takes  place  the  health  of  the  patient  is,  as  a  rule, 
permanently  impaired.  I  have,  however,  seen  two  instances  followed  by  abscess 
end  in  complete  restoration  to  health. 

Treatment. — There  is  no  specific  treatment  of  this  condition  unless  it  be  know-n 
that  the  streptococcus  is  the  cause  of  the  infection,  in  which  case  antistreptococcic 
serum  may  be  employed.  Even  in  these  instances,  however,  it  cannot  do  much 
good  because,  after  the  pulmonary  vessel  is  mechanically  closed  by  an  embolus, 
no  treatment  can  bring  about  its  relief.  The  most  that  the  serum  can  do  is  to 
limit  the  degree  of  general  toxemia. 

Ordinarily  the  treatment  must  consist  in  the  use  of  as  much  easily  assimilated 
food  as  the  patient  can  take  without  disordering  his  digestion,  the  administration 
of  proper  quantities  of  stimulants,  and  the  careful  control  of  such  symjitoms  as 
may  become  excessive,  as,  for  example,  the  reduction  of  high  temperature,  if  it  is 
persistent. 

PNEUMONOCONIOSIS. 

Definition. — This  term  is  applied  to  a  state  of  the  lungs  in  which,  l)y  reason  of 
exposure  to,  and  inhalation  of,  various  kinds  of  dust,  a  deposit  of  the  foreign  body 
takes  place  in  the  pulmonary  tissues  and  produces  secondary  changes.  When  the 
individual  is  exposed  to  coal-dust  in  sufficient  amount  and  for  a  long-enough  period 
to  cause  its  accumulation  in  the  lung,  the  state  of  the  lung  is  called  "  anfliracosis;" 
when  the  dust  is  derived  from  the  grinding  of  iron  or  steel,  it  is  called  "sidcrosis;" 
when  the  dust  arises  from  stones,  the  term  "lithkisis"  or  "  chalicosis"  is  employed. 
Still  another  type  of  foreign  body  capable  of  causing  pneumonoconiosis  affects 
those  who  work  in  large  textile  industries  and  shoddy  mills.  The  minute  particles 
of  wool  and  cotton,  and  of  the  clay  used  for  "sizing,"  often  cause  bronchitis  and 
favor  the  occurrence  of  phthisis.  The  dust  can  often  be  found  in  the  sputum  of 
such  patients.  Reference  to  this  type  of  the  disease  is  made  in  the  author's  Fiske 
Fund  Prize  Essay  for  1885.  Still  another  form  of  exposure  gives  rise  to  "grain- 
shovellers'  disease,"  and  to  "potters'  rot." 

Etiology. — Under  ordinary  circumstances  the  respiratory  tract  is  able  to  get 
rid  of  niiiuite  foreign  bodies  which  mav  enter  it.     This  is  accomplished  by  the 


PNEUMONOCONIOSIS  399 

arrest  of  the  dust  in  the  nasal  and  pharyngeal  mucus,  and  by  the  action  of  ciliated 
epithelium  lining  the  larynx,  trachea,  and  bronchial  tubes,  which  continually 
passes  along  toward  the  mouth  for  expectoration  any  dust  particles  which  may 
enter.  If  these  protective  measures  are  insufficient  because  of  the  great  quantity 
of  dust  inhaled,  or  where  after  a  time  this  ciliated  epithelium  is  destroyed,  some  of 
the  particles  are  carried  through  the  mucous  membrane  and  are  arrested  in  the 
nearby  connective  tissue;  but  if  the  amount  of  dust  is  so  large  that  even  this  third 
barrier  is  passed,  then  the  dust  particles  are  taken  up  by  the  lymphatics  and  carried 
to  the  bronchial  lymph  nodes,  or  to  the  interlobular  pulmonary  septa  under  the 
visceral  layer  of  the  pleura,  or  to  the  substernal  lymph  glands,  where  they  are 
deposited  and  remain  fixed.  Very  rarely  the  fine  particles  may  enter  the  circula- 
tion and  be  deposited  in  the  liver  and  spleen,  as  in  a  case  reported  by  Welch,  or 
they  may  be  even  excreted  in  the  urine. 

Pathology. — Up  to  this  stage  these  results  may  possess  no  pathological  signifi- 
cance, but  in  some  instances  the  presence  of  large  quantities  of  these  foreign  bodies 
produces  a  low-grade  inflammatory  process  in  the  lung  tissues  which  results  in 
overgrowth  of  connective  tissue ;  that  is,  a  chronic  productive  interstitial  pneumonia 
or  pulmonary  sclerosis.  Occurring  independently  of  the  interstitial  change,  or 
associated  with  it,  there  is  quite  constantly  a  subacute  or  chronic  bronchitis  and 
emphysema,  and  finally  areas  of  softening  take  place,  in  the  fibroid  portions  of  the 
lungs,  which  are  small  in  size  and  filled  with  dust-stained  fluid.  Sometimes  these 
communicate  with  a  bronchial  tube  and  may  then  become  infected  and  ulcerate. 
These  ulcerated  patches  or  spots  of  softening  may  or  may  not  be  due  to  infection 
by  the  Bacillus  tuberculosis.  It  is  by  this  process  that  we  have  established  "  miners' 
phthisis"  or  "  grindstone  consumption"  and  "  gold-dnst  complaint"  of  the  lung.  So 
common  is  this  condition  in  Sheffield,  England,  that  it  has  been  called  "knife- 
grinders'  rot." 

Symptoms. — ^As  a  rule  symptoms  of  pulmonary  trouble  do  not  come  on  in  serious 
form  until  the  individual  has  been  exposed  for  some  months  or  years,  when  chronic 
cough,  dyspnea,  and  loss  offiesh  call  attention  to  the  insidious  changes  in  the  lungs. 
A  macroscopic  or,  when  this  fails,  a  microscopic  examination  will  usually  reveal 
the  dust  in  the  sputum,  and  the  history  of  the  case  renders  the  diagnosis  easy. 

Prognosis. — In  an  investigation  carried  on  at  Solingen,  Germany,  by  Moritz, 
it  was  found  that  there  were  no  fork-grinders  above  forty-five  years  of  age  and  no 
sword-grinders  above  fifty.  Of  the  total  number  of  knife-grinders  employed, 
only  5.5  per  cent,  were  over  forty  years  of  age.  Of  the  scissors-grinders  there  were 
8.4  per  cent,  above  forty.  The  fork-  and  sword-grinders  work  with  dry  grinding 
stones,  while  the  knife-  and  scissors-grinders  work  with  grinding  stones  which  are 
constantly  kept  moist.  The  relatively  greater  number  of  scissors-grinders  who  live 
to  be  over  forty  is  explained  by  the  fact  that  the  knife-grinders  sit  closer  to  their 
machines  than  the  scissors-grinders,  and  thus  inhale  more  dust. 

Peabody,  in  some  investigations  made  at  Sheffield,  England,  found  that  the 
average  period  of  knife-grinders  who  are  able  to  continue  their  work  is  thirteen 
years.  In  South  Africa,  Fox  states  that  the  duration  of  life  in  gold  mines  where 
there  is  much  dust  from  blasting  is  only  four  years.  Out  of  1377  rock-drill  miners, 
225,  or  16.34  per  cent.,  died  in  two  and  a  half  years. 

Treatment. — The  treatment  is  removal  from  exposure  and  the  use  of  the  medicinal 
measures  advised  in  the  articles  on  Chronic  Bronchitis  and  Emphysema.  It  is 
the  duty  of  all  employers  of  labor  in  dusty  places  to  provide  free  ventilation,  both 
to  dissipate  the  dust  and  to  diminish  the  chance  of  tuberculous  infection.  In 
many  industries  the  employers  should  use  moist  respirators  to  catch  the  dust  in 
the  respired  air.  Moist  or  wet  grinding  should  be  used  instead  of  dry  grinding 
to  prevent  dust,  and  workmen  known  to  be  tuberculous  should  be  excluded  from 
the  workshop. 


400  DISEASES  OF  THE  LUNGS 


EMPHYSEMA  OF  THE  LUNGS. 


Definition. — The  tcrui  emphysema,  as  aj)phe(l  to  disease  of  tlie  hmg,  sijjnifics 
a  condition  in  which  the  air  content  of  the  organ,  in  a  large  or  small  area,  is  in 
excess  of  the  normal.  Systematic  writers  ordinarily  make  it  include  (\)  essential 
hypertrophic  or  large-lunged  emphysema;  (2)  atrophic  or  senile  emphysema; 
(3)  compensatory  emphysema,  a  form  of  vesicular  overdistention  due  to  inexpan- 
sion,  or  absence,  of  pulmonary  parenchyma  in  some  juxtaposed  or,  less  commonly, 
a  distant  area,  and  (4)  a  form  of  what  occurring  elsewhere  is  ordinarily  termed 
"surgical  emphysema,"  but  in  the  lung  is  called  "interstitial,"  "interlobular," 
or  "  intervesicular" — names  that  indicate  the  location  of  the  air  and  difi'erentiate 
the  condition  from  the  first-named  states  or  those  forms  in  which  the  abnormal 
air  content  is  intravesicular. 

Emphysema  has  also  been  divided  into  an  acute  and  chronic  form.  In  point 
of  time  the  interstitial  is  always  acute,  the  essential  and  atrophic  always  chronic, 
while  the  compensatory  may  be  either.  Some  writers  apply  the  term  "acute" 
to  that  condition  in  which  rapid  overdistention  of  relatively  large  areas  occurs  as  a 
result  of  violent  inspiratory  efforts,  or  obstructed  expiration,  such  as  occurs  in 
cardiac  asthma,  bronchial  obstruction,  and  allied  conditions. 

Briefly  described,  vesicular  emphysema  is  a  state  in  which  there  is  atrophy  of 
the  septa  between  the  air  cells  so  that  a  number  of  vesicles  coalesce.  As  a  result 
we  find  in  the  lung  many  small,  bladder-like  spaces  containing  air.  Associated 
with  this  minute  change  the  entire  lung  increases  in  bulk  and  the  thoracic  cavity 
is  usually  much  increased  in  all  its  diameters,  especially  the  anteroposterior  and 
the  vertical,  producing  the  so-called  "barrel-shaped  chest." 

Etiology. — Much  difference  of  opinion  exists  as  to  the  primary  cause  of  pulmonary 
emphj'sema.  It  is  universally  acknowledged  that  the  condition  develops  as  a 
result  of  inadequacy,  either  congenital  or  acquired,  of  the  supporting  elastic  tissue 
between  the  vesicles,  but  one  school  of  pathologists  maintains  that  the  gi\ing  way 
of  the  vesicular  walls  depends  upon  mechanical  stress,  while  another  school  asserts 
that  such  a  result  ensues  only  when  the  normal  support  is  removed  through  failure 
of  nutrition  in  these  parts  so  that  atrophy  results.  The  author  is  convinced  of 
the  correctness  of  the  latter  view,  namely,  that  the  coalescence  of  the  vesicles 
takes  place  only  after  the  elastic  connective  tissue  has  become  wasted  as  the  result 
of  impaired  circulatory  supply.  It  is  perfectly  true  that  great  pulmonary  stress 
tends  to  produce  emphysema  of  the  lung,  but  it  only  produces  this  state  when  the 
connective  tissue  is  unable  to  provide  proper  vesicular  support. 

Probably  in  a  large  proportion  of  cases  the  tendency  is  hereditary,  the  defect 
is  congenital,  and  the  tissues  succumb  as  soon  as  any  great  stress  is  put  upon  them. 
If  this  primary  nutritional  feebleness  be  admitted  as  the  fundamental  cause  of 
the  condition,  it  is  easy  to  understand  how  it  is  that  persons  so  aflected  fall  victims 
to  emphysema  when  attacked  by  spasmodic  asthma,  or  when  following  occupations 
which  produce  pulmonary  stress,  and  it  also  makes  manifest  why  it  is  that  other 
persons  exposed  to  equally  severe  exciting  causes  escape. 

Frequency. — The  frequency  of  true  pulmonary  emphysema  is  difficult  to  deter- 
mine because  many  of  the  mild  cases  are  overlooked,  and  patients  do  not  present 
themselves  for  treatment  until  the  disease  is  far  advanced.  To  show  how  widely 
statistics  may  vary  according  to  the  method  of  their  collection,  it  is  interesting 
to  note  that  Lebert  states  that  pulmonary  emphysema  forms  about  5  per  cent, 
of  all  diseases,  while  Virchow  found  in  nearly  200,000  cases,  admitted  to  the  Charite 
in  Berlin,  that  the  percentage  of  emphysema  was  only  0.3,  a  result  confirmed  by 
West  at  St.  Bartholomew's  in  London.  The  disease  is  met  with  three  times  as 
frequently  in  men  as  in  women,  probably  because  they  are  exposed  to  its  secondary 
causes  more  constantly,  and  it  occurs  chiefly  between^the  ages  of  thirty  and  sixty 


EMPHYSEMA   OF  THE  LUNGS  401 

years.  It  occurs  in  children,  but  rarely  before  tiiey  are  ten  years  of  age,  although 
cases  as  young  as  two  years  of  age  have  been  recorded. 

Pathology  and  Morbid  Anatomy.— It  has  already  been  stated  that  the  essential 
characteristic  of  ]Hilmonary  emphysema  is  the  wasting  of  the  interalveolar  tissues 
so  that  coalescence  of  the  vesicles  takes  place.  As  a  result  small,  bladder-like 
spaces  are  formed,  the  lung  loses  its  elasticity,  and  so  fails  to  expel  the  air  on  expira- 
tion, with  the  result  that  the  quantity  of  residual  air  is  greatly  increased.  This 
results  in  dyspnea  in  two  ways:  first,  there  is  an  impaired  circulation  of  fresh  air 
in  the  lung,  and,  second,  there  is  a  decrease  in  the  area  of  the  vesicular  tissues,  so 
that  a  much  smaller  surface  is  afforded  for  the  absorption  of  oxygen. 

When  the  thorax  of  a  case  of  essential  emphysema  is  opened  the  lungs  do  not 
retract  as  do  healthy  lungs.  Indeed,  they  may  project  into  the  opening  which  has 
been  made.  The  left  lung  extends  so  far  forward  as  to  cover  the  heart,  and  the 
right  lung  may  overlap  the  edge  of  the  left.  Often  the  epiclavicular  spaces  are 
distended  by  lung  tissue,  and  if  the  disease  be  marked  the  convexity  of  the  dia- 
phragm is  reduced,  with  consequent  displacement  downward  of  the  adjacent 
abdominal  viscera,  particularly  the  liver. 

The  chest  is  changed  in  appearance  because  with  the  increase  in  the  size  of  the 
lungs  the  ribs  become  more  horizontal  and  the  intercostal  spaces  more  bulging, 
the  sternum  and  costal  cartilages  are  projected  forward,  and  the  normal  dorsal 
curvature  of  the  spine  is  exaggerated. 

When  the  lungs  are  removed  from  the  chest  it  is  found  that  they  possess  four 
peculiarities  aside  from  their  great  size:  they  are  pale  gray  in  color,  unusually 
free  from  blood,  dry,  and  when  pressed  between  the  fingers  they  lack  the  crepitation 
met  with  in  normal  lung  tissue.  A  noteworthy  change  is  the  presence  of  dilated 
pouches  or  bladder-like  protuberances  on  the  surface  of  the  lung,  and  particularly 
at  its  margins.  If  the  lung  be  cut,  somewhat  smaller  spaces  will  be  found  scattered 
through  it.  It  is  noteworthy  that  in  emphysema  these  open  spaces  are  surrounded 
by  thin  walls  which  readily  collapse,  whereas  the  sacculations  of  saccular  bronchi- 
ectasis are  surrounded  by  areas  of  thickening  and  inflammatory  change. 

With  the  coalescence  of  the  air  spaces  the  capillaries  which  usually  pass  between 
the  vesicular  walls  disappear,  and  this  in  turn  diminishes  the  number  of  pathways 
by  which  the  blood  can  pass  from  the  right  to  the  left  side  of  the  heart.  As  a 
result  three  chief  circulatory  changes  ensue.  Some  of  the  blood  finds  its  way  by 
large  anastomotic  channels  from  one  side  to  the  other,  and  so  is  imperfectly  oxidized. 
The  increased  obstruction  to  the  flow  results  in  distention  and  arteriosclerotic 
changes  in  the  pulmonary  artery,  in  dilatation,  with  more  or  less  hypertrophy,  of 
the  right  ventricle  and  finally  in  dilatation  of  the  right  auricle.  Eventually, 
when  the  pathological  process  is  far  advanced  we  find  that  the  liver  is  greatly 
engorged  with  blood,  ascites  may  develop,  the  cardiac  failure  rapidly  progresses, 
and  death  results  from  the  various  sequences  of  the  primary  lesions. 

Associated  with  emphysema  there  is  usually  more  or  less  well-developed  chronic 
bronchitis. 

Symptoms.— The  symptoms  of  emphysema  may  be  best  divided  into  the  objective, 
or  those  that  can  be  seen  by  the  physician,  and  the  subjective,  or  those  described 
by  the  patient. 

Physical  Signs.— The  most  noteworthy  objective  signs  are  the  increase  in 
the  diameter  of  the  chest,  so  that  the  anteroposterior  diameter  equals  the  lateral; 
the  fulness  or  bulging  of  the  intercostal  spaces;  the  impaired  respiratory  movement 
of  the  thorax,  which  may  seem  quite  fixed;  the  well-filled  or  distended  cervical  vessels, 
and  the  presence  in  the  epigastrium  of  the  apex  beat  of  the  heart.  If  the  case 
is  severe  we  see  in  addition  to  these  signs  pulsations  of  the  jugular  veins,  labored 
breathing,  cyanosis  of  the  lips,  fulness  of  the  abdomen,  due  to  the  displaced  and 
engorged  liver,  and  the  accumulation  of  fluid  in  the  peritoneum.  Not  infrequently 
26 


402 


DISEASES  OF  THE  LUNGS 


inspection  of  the  upper  part  of  the  epigastrium  reveals  a  network  of  enlarged  capil- 
laries in  the  skin.     These  are  the  chief  signs  on  inspection. 

On  further  careful  physical  examination  we  find  on  palpation  that  the  apex 
beat  cannot  be  felt  at  the  normal  area  near  the  nipple  because  it  is  displaced  and 
covered  by  the  enlarged  lung.  The  lower  margin  of  the  liver  may  be  felt  as  low 
as  the  navel.  Palpation  of  the  chest  while  the  patient  speaks  reveals  a  marked 
decrease  in  vocal  fremitus.   Percussion  gives 

a  high-pitched  resonant  note  all  over  the  Fig.  74 

chest,  particularly  over  the  upper  lobes; 
reveals  a  decrease  of  the  normal  area  of 
cardiac  dulness;  shows  the  liver  to  be  as 
low  as  palpation  indicated  it  to  be,  and 
gives  flatness  in  the  flanks  and  in  the 
suprapubic  area  if  ascites  is  present. 
Avscultation  reveals  a  feeble  vesicular 
murmur,  marked  prolongation  of  expir- 
ation because  of  the  inelastic  state  of  the 


Section  of  anterior  margin  of  the  lung  from  a  case 
of  essential  emphysema,  showing  the  wasting  and 
absorption  of  the  vesicular  walls. 


Lung,  anterior  aspect,  from  a  case  of  essen- 
tial emphysema.  The  large  bulla)  on  the 
anterior  margin  of  the  middle  lobe  are  nearly 
two  centimeters  in  diameter.  Smaller  vesicles 
are  present  on  the  anterior  margin  of  the  upper 
lolie  and  along  the  diaphragmatic  border  of  the 
lower  lobe.  The  apex  is  but  slightly  involved, 
but  in  some  cases  it  is  markedly  affected. 


lung,  and  sometimes  there  can  be  heard  rales,  which  are  due  to  the  associated 
bronchitis.  A  curious  crackling  sound,  the  cause  of  which  is  not  certain,  is  also 
heard  sometimes.  It  is  not  due  to  pleurisy  and  is  probably  produced  by  the  air 
in  the  bladder-like  dilatations  in  the  margins  of  the  lungs.  This  sound  is  usually 
best  heard  at  the  apices. 

Subjective  Signs. — The  symptoms  from  which  the  patient  complains  are 
chiefly  those  connected  with  respiration.  The  shortness  of  breath  varies  greatly 
in  different  cases.  In  some  it  is  constant.  In  others  it  is  only  developed  when 
exercise  is  taken,  and  the  difference  in  its  degree  on  exertion  varies  widely  in  different 
individuals.  Often  dyspnea  is  only  felt  on  warm,  oppressive,  or  humid  days, 
while  iji  other  casgs  any  exertion  whatever  produces  such  severe  dyspnea  that  the 


EMPHYSEMA  OF  THE  LUNGS  403 

patient  is  forced  to  rest.  This  dyspnea,  as  already  stated,  depends  upon  deficient 
oxygenation  of  the  blood,  upon  the  interference  with  the  action  of  the  right  side 
of  the  heart,  and  upon  the  inability  of  patient  to  take  fresh  air  into  his  lungs  in 
large  quantity  because  of  the  excess  of  residual  air  which  is  present. 

The  cough  in  some  cases  is  so  constant  as  to  greatly  annoy  the  patient.  In 
other  instances  it  is  almost  entirely  absent.  The  development  of  this  symptom 
largely  depends  upon  the  degree  of  bronchitis  which  is  associated  with  the  emphy- 
sematous change.  If  marked  bronchial  irritation  is  present,  the  cough  is  not 
only  annoying  because  of  its  persistency,  but  also  exhausts  the  patient,  and  aids 
in  the  dilatation  and  fatigue  of  the  right  side  of  the  heart.  The  sputum  which 
results  from  the  cough  varies  in  quantity  with  the  se\'erity  of  the  bronchitis  which 
is  present,  and  is  not  peculiar  in  appearance  unless  by  chance  the  patient  is  also 
a  sufferer  from  asthma,  when  the  characteristics  of  asthmatic  sputum  may  be 
manifest.  The  digestive  disorders  sometimes  complained  of  by  the  patient  depend 
chiefly  upon  the  impairment  of  the  circulation  in  the  liver,  stomach,  and  intestines, 
produced  by  the  secondary  cardiac  lesions.  Sometimes,  too,  the  urine  is  scanty, 
owing  to  congestion  of  the  kidneys  from  the  same  cause. 

Diagnosis. — From  what  has  just  been  said  of  the  symptoms  and  tj-pical  signs 
of  pulmonary  emphysema  it  is  evident  that  the  diagnosis  is  not  difficult.  ^  Indeed, 
in  a  well-developed  case  there  is  probably  no  pulmonary  condition  so  easily  recog- 
nized. The  bilateral  increase  in  the  size  of  the  chest,  the  narrowing  of  the  inter- 
costal spaces,  the  dyspnea,  the  cyanosis,  the  prolongation  of  expiration,  the  hyper- 
resonance  on  percussion  are  all  to  be  noted  in  forming  a  positive  conclusion  as  to 
the  character  of  a  case.  It  is  not  necessary  for  the  diagnosis  of  emphysema  that 
deformity  of  the  chest  be  present.  Sometimes  a  marked  degree  of  pulmonary 
change  exists  without  any  change  in  the  shape  of  the  thorax. 

Emphysema  of  one  lung  is  practically  never  seen,  and  therefore  pneumothorax 
can  be  easily  separated  from  emphysema. 

Prognosis. — The  prognosis  of  emphysema  is  always  unfavorable;  at  least,  so  far 
as  complete  recovery  is  concerned.  In  many  cases,  however,  the  progress  of  the 
disease  is  so  slow  that  the  patient  may  live  for  years  with  a  fair  degree  of  comfort. 
Indeed,  in  some  instances  the  pathological  process  becomes  stationary.  Patients 
with  well-developed  emphysema  are,  however,  rarely  fortunate  enough  to  develop 
this  arrest  of  the  disease,  and  equally  rarely  live  until  advanced  old  age,  usually 
because  with  advancing  years  the  muscle  fibre  of  the  right  side  of  the  heart 
becomes  less  and  less  able  to  stand  the  strain  which  is  tlirown  upon  it. 

It  is  vitally  important,  so  far  as  prognosis  is  concerned,  for  patients  suffering 
from  pulmonary  emphysema,  to  avoid  exposure  to  sudden  changes  of  temperature; 
for  such  changes  may  produce  a  severe  bronchitis  or  pneumonia,  conditions  which 
the  patient  is  111  able  to  withstand.  The  presence  of  a  persistent  chronic  bronchitis 
renders  the  prognosis  more  grave  than  if  this  complication  does  not  exist.  Death 
rarely  comes  on  suddenly  in  these  patients,  but  slowly,  as  a  result  of  constantly 
increasing  circulatory  failure.  Lebert  asserts  that  one-third  of  these  cases  die 
from  cardiac  dropsy,  and  the  rest  from  pulmonary  congestion  and  gradual 
feebleness,  with  slow  suffocation,  increasing  cyanosis,  and  constantly  developing 
bronchitis. 

Treatment. — The  treatment  of  pulmonary  emphysema  is,  unfortunately,  very 
limited.  There  is  no  curative  treatment.  The  most  that  the  physician  can  do 
is  to  improve  the  condition  of  the  circulation  and  the  nutrition  of  the  patient,  and 
to  prevent  him  from  throwing  severe  strain  upon  his  pulmonary  tissues  and  his 
circulatory  apparatus .  Where  the  patient  follows  an  occupation  which  is  manifestly 
injurious,  he  must  be  advised  to  give  it  up,  and,  for  that  matter,  to  avoid  all  violent 
muscular  effort  which  will  throw  a  strain  upon  his  heart  and  lungs.  Incipient 
attacks  of  acute  bronchitis  should  be  treated  at  the  earliest  possible  moment,  and 


404  DISEASES  OF  THE  LUNGS 

if  c'lironic  bronchitis  is  present,  the  remedies  whicli  are  commonly  given  for  that 
disorder  should  he  employed,  care  being  taken,  however,  that  no  drug  is  given 
which  tends,  on  the  one  hand,  to  act  as  a  circulatory  depressant,  and,  on  the  other, 
to  i)romote  too  free  bronchial  secretion,  for  it  must  always  be  borne  in  mind  that 
drugs  of  this  character  may  precipitate  an  attack  of  profuse  bronchial  secretion, 
in  which  the  patient  may  drown  in  his  own  fluids. 

Many  of  these  patients  will  be  benefited  by  the  administration  of  5  grains  of 
carbonate  of  ammonium  and  5  grains  of  chloride  of  ammonium  given  in  a  cachet, 
or  capsule,  or  in  fluidextract  of  licorice  and  water,  three  or  four  times  a  day.  In 
other  instances,  if  the  bronchitis  is  chronic  and  well  marked,  creosote  or  guaiacol 
may  be  used;  but  care  must  be  exercised  that  they  do  not  disorder  the  stomach. 
If  the  secretion  is  thick  and  tenacious,  iodide  of  ammonium,  or  iodide  of  sodium, 
in  the  dose  of  5  grains  three  times  a  day,  is  useful,  care  being  taken,  however 
that  the  administration  of  this  remedy  does  not  produce  too  free  bronchial  secretion. 
It  must  also  be  borne  in  mind  that  bronchitis  complicating  emphysema  is  not 
infreriuently  the  result  of  impaired  cardiac  action,  and,  therefore,  that  the  best 
treatment  for  the  bronchitis  is  the  administration  of  cardiac  tonics,  such  as  small 
doses  of  digitalis,  3  to  5  minims  twice  or  thrice  a  day,  or  the  tincture  of  strophan- 
thus,  or,  in  other  cases,  the  administration,  for  a  few  days,  of  moderately  large 
doses  of  strychnine  or  nux  vomica. 

When  the  patient's  means  permit  him,  it  is  important  that  he  should  avoid 
extreme  climatic  changes.  High  altitudes  are,  of  course,  not  only  disadvantageous, 
but  even  dangerous  to  patients  suffering  from  pulmonary  emphysema,  because  of 
the  dyspnea  which  such  altitudes  produce  and  because  of  the  strain  which  is  thrown 
upon  the  dilated  right  heart. 

In  cases  of  emphysema  suffering  from  an  unusually  severe  attack  of  dyspnea, 
with  great  congestion  and  engorgement  of  the  venous  system,  it  is  often  ad^•an- 
tageous  to  resort  to  venesection,  removing  as  much  as  20  to  30  ounces  of  blood; 
but  it  is  manifest  that  this  method  of  treatment  can  only  be  resorted  to  on  a  few- 
occasions,  and  when  the  symptoms  of  dilatation  and  distention  of  the  right  side 
of  the  heart  and  of  the  liver  are  very  well  developed.  Sometimes  in  these  ca.ses, 
if  there  is  evidence  of  hypostatic  congestion  of  the  lungs,  the  application  of  wet 
or  dry  cups,  posteriorly,  near  the  bases  is  advantageous. 

For  many  years  various  text-books  have  recommended  the  employment  of 
the  iodides  in  their  various  forms  in  the  treatment  of  pulmonary  emphysema, 
with  the  idea  that  they  distinctly  modify  the  pathological  jirocess  going  on  in 
the  lungs,  and  to  a  certain  extent  arrest  the  destruction  of  the  elastic  tissue  whicli, 
by  its  failure,  results  in  the  coalescence  of  the  vesicles.  It  must  be  manifest  that 
even  that  wonderful  drug,  iodide  of  potassium,  must  be  quite  useless  for  this 
purpose  in  many  instances.  Any  advantage  which  follows  its  employment  probal)ly 
depends  upon  its  influence  upon  the  associated  bronchitis,  or  upon  the  efl'ect  which 
it  produces  upon  the  vascular  system  by  diminishing  the  tendency  to  atheromatous 
change,  and  by  reducing  high  arterial  tension  if  it  is  present,  and  so  relieving 
the  heart  of  unnecessary  burden.  Still  another  advantage  in  the  iodides  may  be 
that  in  some  cases  they  act  as  a  diuretic  and  so  help  to  relieve  the  tissues  of  an 
undue  (juantity  of  fluid  if  dropsy  be  threatened. 

Compensatory  or  Acute  Emphysema. — This  is  an  unfortvuiate  use  of  the  word 
eui])hyscma,  as  the  condition  is  not  a  true  emphysema,  but  simply  an  abnormal 
distention  of  each  individual  air  Acsicle  by  active  efl'orts  at  forced  respiration, 
so  that  the  entire  lung  may  be  increased  in  size  and  the  areas  of  pulmonary  resonance 
greatly  increased.  Usually  in  this  state  some  high-pitched  rales  arc  audible  in 
the  chest.  The  condition  may  be  seen  in  cases  which  have  suffered  from  stridor 
due  to  laryngeal  obstruction,  or  more  commonly  in  those  who  are  recovering 
from  an  acute  asthmatic  attack.     It  is  also  found  in  those  parts  of  the  lungs 


GANGRENE  OF  THE  LUNG  405 

which  have  endeavored  to  compensate  for  other  parts  afl'ected,  as,  for  example, 
by  pneumonia. 

Small-lunged  Emphysema. — Smail-kinged  emphysema  is  sometimes  called  senile 
or  atrophic  erapiiysema,  or  senile  atrophy  of  the  lung.  It  resembles  ordinary 
emphysema,  as  just  described,  in  the  fact  that  there  is  a  wasting  of  the  walls  of 
the  air  vesicles,  so  that  several  vesicles  form  a  larger  cavity;  but  instead  of  the 
lung  being  larger  and  more  voluminous  than  normal,  it  is  shrunken  and  small, 
so  that  the  heart  is  uncovered,  the  diaphragm  raised  in  well-marked  cases,  and  the 
whole  thorax  distinctly  decreased  in  size.  The  expansion  of  the  vesicles,  as  in 
large-lunged  emphysema,  is  most  marked  at  the  apices  and  the  edges  of  the  lung. 
Inspection  of  the  chest  in  such  a  case  shows  the  intercostal  spaces  obliterated  by 
the  drawing  together  of  the  ribs,  while  the  epiclavicular  and  episternal  spaces  are 
exaggerated  and  the  respiratory  movement  is  feeble  and  very  shallow.  On  percus- 
sion the  chest  is  found  to  be  hyperresonant  e\-erywhere,  but  there  is  a  great  increase 
in  the  area  of  cardiac  dulness,  due  to  the  retraction  of  the  lung.  On  auscultation 
little  that  is  abnormal  is  heard,  save  that  expiration  may  be  prolonged. 

Except  there  be  an  associated  bronchitis,  the  patient  with  this  type  of  emphysema 
rarely  suffers  from  much  inconvenience  as  a  result  of  the  pulmonary  disease,  and 
life  is  not  materially  shortened. 

Treatment. — There  is  no  curative  treatment  for  this  type.  The  physician  can 
only  order  rest,  good  food,  proper  clothing,  and  the  avoidance  of  exposure. 

Interstitial  Emphysema.— In  interstitial  emphysema  the  pathological  condition 
is  not  like  that  of  ordinary  pulmonary  emphysema,  for  the  lung  is  riddled  with 
'tiny  globules  of  air  which  find  their  way  between  the  lobules  and  underneath  the 
visceral  layer  of  the  pleura,  where  they  may  form  quite  large  blebs.  The  condition 
arises  whenever  air  escapes  into  the  pulmonary  tissues,  as  after  tracheotomy, 
when  it  extends  down  along  the  trachea  into  the  lung  itself;  fractures  of  the  ribs 
with  puncture  of  the  lung;  other  wounds  of  the  lung;  rupture  of  air  vesicles  by 
great  thoracic  compression,  as  in  sand  crushes,  even  without  injury  to  the  skeleton, 
and  occasionally  results  from  violent  abnormal  respiratory  action,  as  in  whooping- 
cough,  strangling,  and  sneezing.  It  has  been  observed  after  severe  convulsions 
in  epileptics  and  eclamptics. 

GANGRENE  OF  THE  LUNG. 

Etiology. — This  condition  arises  in  individuals  whose  general  vitality  is  greatly 
impaired  by  some  primary  disease,  with  the  result  that  various  micro-organisms, 
putrefactive  and  otherwise,  produce  death  of  part  of  the  pulmonary  parenchyma, 
and  so  a  slough  is  formed.  Manifestly,  the  causes  of  gangrene  and  abscess  must 
be  nearly  related,  and  why  gangrene  rather  than  abscess  should  develop  in  any 
particular  case  is  difficult  to  determine.  Infarction  of  the  lung,  or  pulmonary 
hemorrhage,  may,  by  affording  a  nidus  for  the  development  of  putrefactive  germs, 
result  in  this  state,  and  so  may  croupous  pneumonia;  yet  it  is  a  curious  fact  that 
bronchopneumonia,  which  is  often  due  to  profound  debility  and  secondary  infection, 
rarely  so  results.  Equally  curious  is  it  to  note  that  pulmonary  tuberculosis  in 
all  its  forms  is  rarely  complicated  in  this  manner. 

The  most  common  cause  of  pulmonary  gangrene  is  embolism  and  thrombosis, 
after  this  croupous  pneumonia,  and,  thirdly,  injuries  to  the  lung  through  the  chest 
wall,  as  in  gunshot  injuries.  It  may  also  arise  from  foreign  bodies  in  the  bronchi. 
It  may  also  be  due  to  pressure  produced  by  an  aneurysm,  or  tumor,  or  by  an  exten- 
sion of  an  infective  process  to  the  lung  from  the  esophagus,  pleura,  vertebrae, 
mediastinum,  or  ribs.  It  may  also  follow  the  inspiration  of  particles  of  food. 
Rarely  it  is  due  to  pressure  of  an  aneurysm  or  to  perforation  of  the  esophagus 
when  that  tube  is  affected  by  cancer. 


406  DISEASES  OF  THE  LUNGS 

Frequency. — Pulmonary  gangrene  most  frequently  attacks  males  in  middle 
life — that  is,  from  twenty  to  forty  years  of  age — and  is  undouljtedly  a  very  rare 
affection.  In  a  large  hospital  service  only  a  single  case  may  he  met  with  in  many 
years. 

Pathology  and  Morbid  Anatomy. — Xo  description  of  pulmonary  gangrene  is 
better  than  that  gi^■cn  by  Laenncc,  wlio,  ne\ertlieless,  in  an  experience  of  twenty- 
four  years,  saw  only  2  cases.  He  divides  the  condition  into  three  stages:  (1) 
that  of  early  mortification,  in  which  the  pulmonary  tissue  is  edematous  and  of 
dark  brown  or  greenish  hue,  the  sloughing  area  looking  shreddy  and  water-soaked; 
(2)  that  of  deliquescence  or  liciuefaction,  the  part  of  the  lung  affected  becoming 
still  more  soft  and  flabby;  and  (3)  that  of  excavation  or  abscess  formation,  in  which 
the  lung  undergoes  the  separation  of  the  slough  and  the  formation  of  a  line  of 
demarcation  to  limit  the  pathological  process.  At  this  line  of  separation  a  con- 
solidation takes  place,  the  sphacelus  breaks  down,  and  suppuration  rapidly  results 
in  the  coughing  up  of  the  dead  tissues.  As  a  matter  of  fact,  it  is  incorrect  to  si)eak 
of  a  single  sphacelus,  for  the  cavity  usually  contains  separate  masses  of  shred-like 
tissue. 

Finally  the  limiting  wall  may  undergo  fibroid  contraction,  as  it  does  in  abscess, 
and  the  area  be  more  or  less  closed,  a  focus  usually  remaining,  from  which  more 
or  less  foul  pus  is  constantly  discharged.  In  the  majority  of  cases  this  reparative 
process  does  not  occur,  and  the  patient  dies.  OA'er  the  seat  of  the  process  the 
pleural  membrane  is  usually  thickened  and  may  be  covered  by  a  fibrinopurulent 
exudate,  while  if  the  pleura  be  perforated  a  putrid  empyema  may  develop.  In 
such  cases  pyopneumothorax  may  also  manifest  itself.  Extensive  suppuration 
of  the  bronchial  glands  may  occur. 

Pulmonary  gangrene  affects  the  lower  lobes  oftener  than  the  upper. 

Symptoms. — The  symptoms  of  pulmonary  gangrene  in  the  early  stages  are  not 
very  definite.  They  depend,  to  some  extent,  upon  the  se\erity  of  the  lesions  and 
upon  the  micro-organisms  which  produce  it.  Ihe  patient  is  markedly  prostrated, 
the  heart's  action  is  feeble  and  rapid,  the  skin  leaky,  the/«ft'  anxious  and  thin,  and 
the  tongue  dry  and  coated.  The  temperature  runs  the  typical  course  of  hectic 
fever,  and  it  is  a  noteworthy  fact  that  the  exhaustion  seems  out  of  proportion  in 
its  severity  to  the  febrile  movement.  Sometimes  these  symptoms  are  ushered 
in  with  severe  chills,  which  recur  at  irregular  intervals.  The  respirations  are 
quickened,  and  there  may  be  covgh  and  expectoration,  but  until  the  break-down 
goes  on  so  far  as  to  result  in  suppuration  there  may  be  but  little  material  expec- 
torated. If  a  cavity  forms,  the  ordinary  signs  of  excavation,  with  those  of  sur- 
rounding consolidation,  may  be  developed  upon  auscultation  and  percussion. 

One  of  the  most  characteristic  symptoms  of  pulmonary  gangrene  is  the  odor 
of  the  patient's  breath  and  of  the  materials  which  he  expectorates.  There  is 
probably  no  discharge  from  the  human  body  the  odor  of  which  is  so  penetrating 
and  disgusting  as  is  that  of  pulmonary  gangrene.  Not  only  docs  it  render  the 
patient  disgusting  to  everyone  who  comes  near  him,  but  it  penetrates  every  part 
of  the  room  in  which  he  exists,  and  often  can  be  smelled  throughout  the  whole 
house.  On  some  days  it  is  worse  than  others,  but  the  variation  of  the  quantity 
of  expectoration  does  not  necessarily  mean  a  variation  in  its  fetid  character.  The 
quantity  of  material  which  is  expectorated  docs  not  gi\e  an\-  \ery  definite  concep- 
tion of  the  size  of  the  lesion  of  the  lungs.  West  quotes  a  case  of  Godlee  and  Williams 
in  which  the  patient  expectorated  a  cjuart  daily,  and  yet  the  autopsy  revealed  a 
gangrenous  cavitv  which  was  not  large  enough  to  contain  more  than  an  ounce  of 
fluid. 

The  sputum  is  peculiar,  in  that  on  standing  it  separates  into  three  layers.  The 
upper  layer  is  apt  to  be  yellowish-green  and  opaque;  the  middle  layer  is  opalescent 
and  turbid,  and  resembles  saliva  when  a  cousiderable  quantity  is  gathered  in  a 


PULMONARY  ABSCESS  407 

glass.  The  lowest  layer  consists  in  a  mass  of  greenish  or  brown-looking  material, 
which  constains  considerable  quantities  of  pus,  altered  red  blood  cells,  and  fragments 
of  connective  tissue.  A  careful  microscopic  examination  of  this  sputum  will 
show  that  it  is  filled  with  an  immense  number  of  micro-organisms,  and  crystals 
of  leucin  and  tyrosin  can  be  seen  in  large  numbers.  Various  fatty  acid  crystals 
are  also  present.  The  sputum,  at  first  alkaline,  becomes  acid,  and  seems  to  exercise 
a  peculiar  digestant  or  disintegrating  influence  upon  the  shreds  of  connective  tissue 
which  it  contains. 

The  cough  in  a  case  of  pulmonary  gangrene  varies  greatly  according  to  the 
amount  of  material  which  is  expectorated,  and  also  with  the  degree  of  bronchial 
irritation  which  coexists.  Sometimes,  after  a  prolonged  spell  of  coughing,  a  con- 
siderable amount  of  material  from  the  gangrenous  area  comes  away  in  a  gush. 
Sometimes,  too,  the  fluid  which  is  expectorated  is  distinctly  blood-tinged,  due  to 
the  ulceration  of  small  bloodvessels  in  the  part  surrounding  the  affected  part. 
Not  only  may  free  hemoptysis  develop,  but  septic  emboli  may  be  carried  elsewhere, 
as,  for  example,  to  the  brain  or  liver,  and  so  cause  secondary  abscess. 

If  by  chance  the  patient  swallows  any  of  the  sputum,  septic  diarrhea  may 
be  established  and  the  stools  may  also  become  excessively  offensi^■e.  The  degree 
of  exhaustion  gradually  increases,  the  heart  becomes  more  and  more  feeble,  the 
patient  more  and  more  emaciated,  and,  finally,  dies  of  asthenia. 

Diagnosis. — The  diagnosis  between  a  moderate  degree  of  pulmonary  gangrene, 
pulmonary  abscess,  and  bronchiectasis  may  be  almost  impossible,  since,  if  bronchiec- 
tasis exists,  the  fetor  of  the  sputum  may  be  very  marked.  If  the  sputum  under 
the  microscope  shows  a  large  amount  of  connective  tissue,  the  diagnosis  is  largely 
in  favor  of  gangrene.  The  absence  of  tubercle  bacilli  in  the  sputum  and  the  presence 
of  the  various  bodies  already  named  as  appearing  in  this  fluid  will  also  aid  in  differ- 
entiation of  the  case.  When  the  grangrene  cavity  is  small,  a  positive  antemortem 
diagnosis  may  not  be  possible,  the  more  so  because  of  the  presence  of  acid-resisting 
bacilli,  which  may  be  mistaken  by  the  novice  for  tubercle  bacilli. 

Treatment. — The  treatment  of  pulmonary  gangrene  is  not  promising.  It  is 
the  duty  of  the  physician  to  maintain  the  strength  of  the  patient,  as  far  as  possible, 
by  the  administration  of  nutritious  food  given  at  frecpient  intervals,  in  small 
quantities,  so  that  the  digestion  will  not  be  overloaded;  to  give  stimulants,  as 
alcohol;  and  occasionally,  if  the  circulation  becomes  feeble,  to  administer  strychnine 
hypodermically,  or  by  the  mouth.  Bitter  tonics  may  also  be  prescribed  for  the 
purpose  of  maintaining  digestive  activity.  The  employment  of  antiseptic  inhala- 
tions, as  suggested  in  the  treatment  of  pulmonary  abscess,  may  also  be  resorted 
to,  but  at  most  only  do  good  by  soothing  the  irritation  of  the  bronchial  mucous 
membranes  and  cannot,  of  course,  influence  the  pulmonary  parenchyma  where 
the  disease  exists. 

If  the  evidences  of  sepsis  are  marked  and  anemia  is  present,  the  tincture  of 
chloride  of  iron  is  to  be  administered,  and  the  heart  supported  by  alcohol,  digitalis, 
and  occasionally  by  caffeine.  The  internal  use  of  creosote,  carbolic  acid,  and 
similar  substances,  with  the  idea  that  they  exercise  a  beneficial  influence  upon  the 
gangrenous  portion  of  the  lung,  is  futile. 

A  few  cases  of  gangrene  of  the  lung  have  been  treated  surgically,  with  success, 
by  incision  and  drainage.  For  these  methods  the  reader  is  referred  to  surgical 
treatises. 

PULMONARY  ABSCESS. 

Etiology. — Abscess  of  the  lung  is  always  due  to  invasion  of  its  tissues  by  one  or 
more  forms  of  pyogenic  micro-organisms.  Single  large  abscess  occurs  very  rarely, 
but  it  is  met  with  as  a  sequel  of  lobar  pneumonia,  bronchopneumonia,  and  as  a 
result  of  injury  to  the  lung  by  the  entrance  of  foreign  bodies  through  the  chest 


408  DISEASES  OF  THE  LUXGS 

wall  or  by  the  respiratory  passages.  Most  commonly  small  abscesses  are  the 
result  of  septic  emboli.  Abscess  may  be  due  to  the  extension  of  a  septic  process 
from  the  mediastinal  tissues  or  of  the  liver.  So,  too,  a  suppurative  process  in 
the  deep  tissues  of  the  neck  may  result  in  secondary  infection  of  the  lung. 

When  pulmonary  abscess  ensues  after  an  attack  of  croupous  pneumonia  or 
bronchopneumonia,  it  is  usually  not  single,  but  multiple,  the  area  of  consolidation 
being  the  seat  of  several'  foci  of  purulent  material.  These  formations  are  not  by 
any  means  so  rare  as  in  the  larger  variety.  Holt  states  that  he  found  them  in 
about  7  per  cent,  of  the  autopsies  of  young  children  dying  of  pneumonia.  Such 
foci  are  really  not  true  abscesses;  that  is  to  say,  they  have  no  true  abscess  wall. 
When  these  formations  are  numerous,  as  they  usually  are,  and  of  considerable 
size,  the  patient  may  maintain  a  high  temperature  for  a  long  time  after  the  acute 
primary  disease  has  passed  away,  and  may,  by  causing  septic  absorption,  ultimately 
produce  the  patient's  death.  It  may  be  difficult,  even  at  autopsy,  to  state  positively 
whether  the  purulent  infiltration  of  the  later  stages  of  both  forms  of  pneumonia 
is  present,  or  if  there  is  a  true  suppurative  abscess  in  the  lung.  In  both  cases  the 
areas  of  softening  are  found  to  be  infected  by  the  streptococcus,  staphylococcus, 
or  other  pyogenic  organism. 

When  the  foci  are  of  large  size,  and  are  multiple,  the  prognosis  is  bad,  for  wide- 
spread suppuration  in  the  lung  is  always  fatal  when  the  breaking-down  process 
involves  the  exudation  of  pneumonia.  If  there  be  a  single,  large,  localized  abscess 
involving  the  area  of  pneumonic  exudate,  the  prognosis  is  less  grave,  but  it  is 
exceedingly  bad,  nevertheless.  To  sum  up,  therefore,  we  find  that  suppuration 
takes  place  in  the  lung  in  three  degrees  or  forms  after  pneumonia:  (1)  as  a  mild 
suppurative  process,  which  is  reallj'  nothing  more  than  a  rapid  breaking  down  of 
the  exudate  of  the  disease;  (2)  as  a  more  severe  process,  partaking  more  of  the 
character  of  true  suppuration,  in  which  multiple  and  large  foci  of  pus  form;  and 
(3)  of  a  single  large  suppurative  process;  in  other  words,  a  single  abscess  of  the  lung. 
As  already  stated,  these  so-called  "abscesses"  rarely  have  a  true  abscess  wall. 

Abscess,  multiple  or  single,  when  it  arises  from  the  entrance  of  a  foreign  body, 
occurs  only  if  that  body  enables  infecting  micro-organisms  to  enter  the  surrounding 
tissues.  Thus,  a  marble,  or  small  stone,  entering  a  bronchus  may  be  there  for  a 
long  time  without  causing  abscess;  whereas,  the  entrance  of  a  piece  of  food,  a  straw, 
or  a  fragment  of  cork,  or  other  organic  matter  may  speedily  cause  a  septic  suppura- 
tive pneumonia  and  death.     An  abscess  may  follow  a  gunshot  injury. 

If  by  chance  the  patient  recovers  from  the  acute  illness,  there  may  be  left  a 
constantly  discharging  focus  of  pus. 

Again,  we  find  pulmonary  abscess  forming  as  the  result  of  a  septic  embolus 
entering  the  lung.  About  the  site  of  its  lodgement  an  inflammatory  exudate 
rapidly  forms,  and  this  speedily  proceeds  to  suppuration.  Pus  and  yellow  elastic 
tissue  are  expectorated,  and  the  patient  dies  of  septic  poisoning  and  exhaustion, 
or  if  recovery  takes  place  there  is  formed  around  the  zone  of  necrotic  tissue  a  wall 
of  inflammatory  exudate,  which  prevents  further  destruction  of  the  parts,  and,  with 
recovery,  proceeds  to  organization,  finally  developing  into  more  or  less  well-formed 
fibrous  tissue,  which  gradually  contracts  until  the  (•a\ity  disai)pears  or  is  greatly 
decreased  in  size.  We  have  in  this  type  what  may  be  called  the  true  form  of  abscess 
as  it  occurs  in  other  tissues;  whereas,  the  ordinary  suppurative  foci  hitherto  de- 
scribed are  hardly  to  be  regarded  as  true  abscesses.  Occasionally  the  abscess 
cavity  persists  for  months,  and  we  have  then  a  chronic  pulmonary  abscess. 

When  abscesses  elsewhere  than  in  the  lung  break  into  its  tissues  the  result  is 
not  always  a  pulmonary  abscess  by  any  means.  It  is  often  extraordinary  how 
much  foul  pus  may  pass  from  an  empyema  or  hepatic  abscess  through  the  lung, 
and  be  expectorated,  without  causing  any  severe  lesions  in  these  organs. 

Sometimes  suppuration  takes  place  in  an  echinococcus  cyst  in  the  lung. 


CONGESTION  OF  THE  LUNGS  409 

Symptoms  and  Diagnosis. — The  diagnosis  of  pulmonary  abscess  in  its  early 
stages  may  be  practically  impossible,  for  there  may  be  present  no  other  signs  than 
cough,  fever,  and  scanty  expectoration,  with  patches  of  impaired  resonance  on  ycrcus- 
sion.  In  unresolved  pneumonia  the  physical  signs  may  be  identical,  but  the 
leukocyte  count  is  rarely  above  15,000  or  20,000,  whereas  in  abscess  from  30,000 
to  50,000  white  cells  may  be  present.  As  the  pus  is  freely  formed,  much  aid  may 
be  gained  from  the  temperature  chart,  which  may  show  the  long  sweeps  of  septic 
absorption.  There  may  be  sweats,  chills,  and  some  hectic  flushing;  but  these  do 
not  necessarily  point  to  abscess  of  the  lung,  for  they  may  be  due  to  empyema 
or  an  abscess  elsewhere,  or  be  a  result  of  tuberculosis.  If  the  sputum  becomes 
distinctly  purulent,  and  the  microscope  shows  abundant  pus  and  masses  of  connec- 
tive tissue  without  tubercle  bacilli,  the  diagnosis  is  readily  made.  About  this 
time  it  may  be  possible,  too,  to  discover  the  physical  signs  of  cavity. 

When  a  single  large  abscess  is  present  the  positive  diagnosis  may  be  made  evident 
by  the  sudden  rupture  of  its  contents  into  a  bronchus,  and  the  expelling  through 
the  mouth  of  a  considerable  quantity  of  pus.  I  had  under  my  care  recently  a 
young  woman,  aged  twenty  years,  who,  after  an  attack  of  tj-pical  croupous  pneu- 
monia, developed  a  more  and  more  septic  temperature,  and,  finally,  expelled  at 
one  time  nearly  a  pint  of  pus  from  the  right  lung.  Constant  expectoration  of  pus 
persisted  for  several  days,  and  then  an  equally  large  amount  was  expelled,  nearly 
causing  death  by  strangulation.  After  a  long  convalescence  she  reached  perfect 
health.  In  this  case  the  fluoroscope  revealed  the  site  of  the  abscess  very  clearly. 
Care  must  be  taken  that  the  purulent  expectoration  and  fetid  breath  of  a  case  of 
bronchiectasis  is  not  considered  an  indication  of  true  pulmonary  abscess. 

Prognosis. — The  prognosis  in  these  cases  is  always  very  grave.  Death  may 
ensue,  not  only  from  septic  absorption,  but  from  the  gradual  exhaustion  due  to 
prolonged  suppuration  or  from  the  ulceration  of  the  wall  of  a  bloodvessel  with 
consequent  severe  hemoptysis.  Again,  a  secondary  pneumonia  may  develop 
from  the  primary  suppurative  process. 

Treatment. — The  treatment  of  abscess  of  the  lung  divides  itself  into  three  parts : 
the  support  of  the  patient's  strength  by  good  food  and  the  moderate  use  of  stimu- 
lants; the  resort  to  as  much  fresh  air  and  sjanshine  as  possible;  the  inhalation  of 
gentle  antiseptic  balsams  which  do  not  really  influence  the  abscess,  but  perhaps 
benefit  the  associated  bronchitis;  and,  lastly,  by  the  use  of  the  knife,  bone  forceps, 
and  the  actual  cautery,  to  open  the  abscess  through  the  chest  wall  and  lung. 

As  supporting  drugs,  iron  and  arsenic,  whiskey  and  port  wine,  are  particularly 
valuable.  Easily  digested  semiliquid  foods,  with  digestants  to  aid  their  speedy 
absorption,  are  valuable,  and  in  the  way  of  an  inhalation  equal  parts  of  oil  of 
eucalyptus,  oil  of  pine,  and  compound  tinctiu-e  of  benzoin  may  be  added  to  the 
water  in  a  croup  kettle,  and  so  dissipated  through  the  air  of  the  room.  Codeine 
and  cannabis  indica  may  be  used  to  relieve  excessive,  painful  cough;  but  large 
doses  of  these  drugs  should  not  be  used,  because  they  prevent  the  expectoration 
of  the  pus,  and  if  the  patient  sleeps  soundly  while  under  their  effects,  rupture  of 
the  abscess  may  cause  fatal  asphyxia. 

CONGESTION  OF  THE  LUNGS. 

Definition. — Strictly  speaking,  there  is  a  congestion  of  the  lungs  whenever  severe 
exercise  is  taken,  but  this,  of  course,  is  not  referred  to  here;  nor  is  it  the  intention 
to  consider  that  form  which  constitutes  the  early  stage  of  croupous  pneumonia, 
and  w'hich  ends  in  the  formation  of  a  croupous  exudate.  The  form  of  congestion 
here  referred  to  is  that  due  to  mechanical  causes  which  interfere  with  the  proper 
passage  of  blood  through  the  pulmonary  vessels  (passive  congestion),  or  that  due 
to  intense  irritation  caused  by  inhaling  irritant  vapors  or  fimaes. 


410  DISEASES  OF  THE  LUNGS 

Etiology  and  Pathology. — The  most  common  cause  of  pulmonary  congestion 
is  progressive  vahular  inadequacy  at  the  left  auriculoventricular  orifice,  or,  in 
other  words,  mitral  disease,  cither  obstructive  or  regurgitant.  These  lesions  dam 
the  blood  back  into  the  lungs,  and  the  right  ventricle  undergoes  hypertroiihy  in 
an  endea\or  to  drive  it  onward.  As  a  result  the  pulmonary  capillaries  arc  placed 
under  abnormal  strain,  increased  hemolysis  occurs,  and  when  the  condition  becomes 
chronic  there  is  produced  what  is  known  as  brown  induration  of  the  lungs.  At 
autopsy  they  appear  of  a  dull  reddish-brown  hue,  the  incised  surfaces  becoming 
brighter  red  after  exposure  to  the  air.  The  supporting  tissue  of  the  lung  is  thickened 
and  less  elastic  than  normal,  and  the  organ  is  heavy,  as  shown  by  the  fact  that  when 
placed  in  water  it  does  not  float  so  high  as  normal  lung  tissue.  Microscopically 
the  connective  tissue  and  the  alveolar  epithelium,  some  of  which  is  desquamated, 
contain  granules  of  brownish  pigment  derived  from  the  hemoglobin  content  of  the 
disintegrated  red  blood  cells. 

The  bloodvessels  are  tortuous,  and  the  capillaries  which  line  the  walls  of  the 
alveoli  project  in  loops  or  tufts  into  the  air  spaces.  Sometimes  hemoptysis  of 
moderate  degree  arises  from  rupture  of  these  vessels  or  those  which  are  in  the 
bronchial  tubes.  It  can  be  readily  understood  why  it  is  that  a  person  with 
these  lesions  is  a  ready  victim  for  pneumonia,  hypostatic  congestion,  and  infarc- 
tion. 

Acute  pulmonary  congestion  resulting  from  sudden  failure  of  the  left  ventricle 
is  often  the  cause  of  sudden  death  in  the  course  of  an  attack  of  sunstroke  or  after 
the  inhalation  of  irritant  gases. 

Closely  connected  with  this  form  of  congestion  from  an  etiological  stand-point 
is  hypostatic  congestion  of  the  lungs.  In  this  state  the  lower  portions  of  the  kings 
are  commonly  aft'ected  because  the  patient  is  usually  in  the  dorsal  decubitus  and 
the  blood  accumulates  in  the  most  dependent  part  of  the  organs.  Associated  with 
this  accumulation  of  blood  in  the  vessels  of  the  lung,  an  excess  of  serum  collects 
in  the  intervesicular  structures,  producing  edema,  or,  passing  into  the  vesicles, 
causes  the  aft'ected  part  to  become  essentially  airless. 

The  causes  of  hypostatic  congestion  are  not  very  difl'erent  from  those  of  ordinary 
congestion  as  just  described,  save  that  the  failure  of  the  right  side  of  the  heart 
is  more  marked  and  the  condition  is  more  freciuently  met  with  as  the  result  of 
profound  asthenia  occurring  in  the  course  of  some  malady  like  se\-ere  typhoid 
fever  or  advanced  renal  disease.  That  the  dorsal  decubitus  is  not  the  chief  cause 
is  proved  by  the  fact  that  many  persons  suft'ering  from  certain  maladies  which 
require  the  maintenance  of  this  posture  do  not  suil'er  from  hypostatic  congestion. 
That  posture  exercises  some  influence,  however,  is  shown  by  the  fact  that  if  the 
patient  remains  on  one  side  the  stasis  is  often  unilateral. 

Autopsy  in  cases  of  hypostatic  congestion  reveals  the  involved  area  as  darkened 
in  color,  often  black  or  purj)lish-black  in  hue.  They  may  be  airless,  with  frothy 
accumulations  in  the  bronchial  tubes,  loss  of  crepitation  on  pressure,  and  a  doughy 
condition  when  one  finger  is  pressed  upon  the  lung,  resembling  the  sensation 
produced  by  edema  elsewhere.  In  some  cases,  not  only  a  serous  exudation  takes 
place  into  the  vesicles,  but  red  and  white  blood  cells  are  extruded,  which  may 
render  the  lung  so  red  that  it  looks  somewhat  as  if  true  croupous  pneumonia  were 
present.  To  this  state  has  been  applied  the  term  "splenization,"  or  "hypostatic 
pneumonia,"  in  distinction  from  the  red  solidification  in  true  pneumonia  called 
"hepatization."  Still  less  frecjuently  actual  hemorrhage  into  the  lung  occurs  as 
the  result  of  giving  way  of  the  walls  of  small  vessels. 

The  causes  being  identical  on  both  sides  of  the  chest,  it  is  natural  that  hypostatic 
congestion  should  usually  be  found  to  be  bilateral.  It  begins  at  the  bases  and 
slowly  creeps  upward,  until  it  may  invohe  the  lower  lobes  of  each  side,  and  even 
the  middle  lobe  on  the  right  side  and  part  of  the  upper  on  the  left. 


CONGESTION  OF  THE  LUNGS  411 

Symptoms. — The  symptoms  of  that  form  which  is  due  to  valvular  disease  at 
first  are  those  of  shortness  of  breath,  with  repeated  attacks  of  bronchitis,  which 
may  become  chronic.  The  mucus  expectorated  may  contain  tiny  clots  of  blood 
arising  from  the  dilated  vessels  just  described.  An  infarct  of  the  lung  may  develop 
into  an  area  of  consolidation  and  hemoptysis  may  occur.  Sometimes  this  accident 
follows  an  improvement  in  the  condition  of  the  heart,  ^\hich  is  produced  by  rest 
and  tonics,  because  the  renewed  strength  of  the  right  ventricle  ruptures  a  weak 
and  tortuous  vessel. 

The  symptoms  of  hypostatic  congestion  differ  greatly  with  the  rapidity  with 
which  the  condition  develops,  and  the  underlying  cause.  When  the  exudation 
rapidly  takes  place  evidences  of  respiratory  embarrassment  develop  and  dysynea 
and  cyanosis  are  often  marked.  If  the  condition  is  slow  in  onset  as  in  most 
instances  when  it  complicates  some  state  of  adynamia,  no  symptoms  may  be 
present  until  a  large  area  of  lung  tissue  is  affected.  Cases  of  the  acute  type  are 
seen  chiefly  as  the  result  of  renal  disease  and  cardiac  failure. 

The  physical  signs  of  hypostatic  congestion  are  not  well  marked  in  the  early 
stages.  Careful  light  percussion  may  reveal  slight  imjjairment  of  resonance,  and 
auscultation  may  discover  a  few  moist  rales,  which  are  chiefly  bronchial,  forming 
small  rhonchi  or  sibilant  sounds.  These  are  the  signs  which  it  is  important  to 
recognize,  since  it  is  at  this  time  that  the  physician  can  do  much,  in  many  cases, 
to  limit  or  even  prevent  the  spread  of  the  condition  which  is  beginning  to  develop. 
Later  on  the  condition  is  so  well  marked  that  the  merest  tyro  can  recognize  it  by 
reason  of  the  bronchial  breathing,  the  moist  rales,  and  the  absence  of  vesicular 
sounds  which  have  been  put  aside  by  exudation.  The  only  thing  to  be  done  at  such 
a  late  hour  is  to  endeavor  to  support  the  circulation,  so  that  the  lesions  will  not 
spread  and  so  that  the  patient  may  be  kept  going  till  absorption  or  resolution 
occurs. 

The  presence  of  hypostatic  congestion  is  often  not  recognized,  because  the 
physician  does  not  carefully  examine  the  lungs.  In  many  cases,  too,  it  is  agonal, 
particularly  if  death  comes  slowly. 

Diagnosis. — Hypostatic  congestion  must  be  separated  from  catarrhal  and  crowpoiis 
-pneumonia,  and  from  pleural  effusion,  serous  or  purulent.  An  important  point 
in  the  differentiation  is  the  fact  that  in  both  forms  of  pneumonia  the  temperature 
is  usually  febrile,  and  if  they  complicate  some  pre-existing  state  the  fever  is  usually 
exacerbated  wheii  the  pulmonary  condition  develops,  whereas  distinct  febrile 
movement  is  unusual  in  hypostatic  congestion  unless  it  is  in  turn  associated  with  a 
true  pneumonic  process.  The  sputum,  if  any  is  raised,  is  frothy  in  cases  of  con- 
gestion, but  is  sticky  and  rusty  in  croupous  pneumonia,  and  perhaps  mucopurulent 
in  the  catarrhal  form.  The  cough  is  loose  and  productive  (juicy)  and  not  hard 
and  difficult  as  in  pneumonia.  Then,  too,  the  onset  of  congestion  is  not  character- 
ized by  a  chill  nor  by  pain  in  the  chest.  Pleural  effusion  may  be  separated  from 
hypostatic  congestion  by  a  change  in  the  level  of  dulness  on  percussion  when  the 
patient  changes  his  posture,  by  the  fact  that  the  percussion  note  in  congestion 
is  rarely  as  flat  as  in  effusion,  by  the  fact  that  pleural  effusion  is  rarely  bilateral, 
and  if  at  all  profuse  usually  displaces  the  heart  to  the  left  if  it  be  on  the  right  side 
and  downward  if  it  be  on  the  left. 

Prognosis. — This  depends  largely  on  the  promptness  with  which  hypostasis 
is  discovered  and  treated,  the  cause  of  the  condition,  and  the  vitality  of  the  patient. 
When  due  to  renal  disease  and  associated  with  a  general  tendency  to  edema,  the 
prognosis  is  bad.  So,  too,  if  it  ensues  in  a  prolonged  exhausting  fever  the  prognosis 
is  bad  because  it  indicates  great  feebleness.  In  old  persons  and  in  young  children 
it  is  vevy  often  the  cause  of  death  during  the  course  of  other  diseases. 

Treatment. — This  consists  in  preventive  measures,  such  as  changing  the  posture 
of  the  patient  every  hour,  in  the  use  of  cold  sponging  if  fever  is  present,  to  readjust 


412  DISEASES  OF  THE  LUNGS 

the  circulation,  and  in  tlic  proper  use  of  stimulants.  As  soon  as  any  signs  of  the 
malady  api)ear,  the  patient  should  be  made  to  lie  on  one  side  and  then  on  the 
other  and  not  upon  the  hack.  Two  or  three  dry  cups  should  be  applied  to  the 
chest  over  the  base  of  each  lung  posteriorly,  or  in  their  i)lace  a  mustard  plaster 
may  be  used.  If  the  heart  is  feeble,  strychnine,  digitalis,  and  Ix'liadonna  are 
useful.  It  may  be  wise  in  urgent  cases  to  give  strychnine  and  atroi)ine  hypodcr- 
mically  and  to  use  Hoffmann's  anodyne  in  the  dose  of  a  drachm  every  hour  for 
several  doses.  Sometimes  if  the  patient  is  strong  enough  to  stand  active  purga- 
tion, colocynth  or  elaterium  are  valuable  cathartics,  the  latter  being  given  in  the 
dose  of  I  grain,  but  when  the  symptoms  are  urgent  and  the  venous  system  is 
engorged  free  venesection  should  be  practised. 

Manifestly  it  is  the  physician's  duty  in  all  these  cases  of  exliausting  disease  to 
carefully  listen  to  the  chest  at  every  visit  during  an  illness,  to  note  the  first  sign 
of  this  insidious  state. 

TUMORS  IN  THE  LUNGS. 

Tumors  in  the  lungs  are  rarely  met  with.  They  may  be  benign  or  malignant, 
but  are  usually  the  latter,  and  occur  as  primary  or  secondary  growths;  tumors 
secondary  to  growths  elsewhere  being  much  the  more  frequent.  The  lienign 
tumors  are  chondroma,  fibroma,  osteoma,  and  dermoid  cyst.  The  malignant 
tumors  are  sarcoma,  carcinoma,  and  occasionally  endothelioma.  The  sarcoma 
and  carcinoma  usually  occur  as  nodular  masses  which  as  they  grow  push  the  lung 
tissue  aside,  or  more  rarely  they  occur  as  infiltrating  growths  which  extend  along 
the  bloodvessels  or  bronchial  tubes.  If  the  tumors  are  placed  peripherally  or 
are  primary,  it  may  be  difficult  to  determine  whether  they  are  pleural  or  pulmonary. 
In  cases  of  lymphosarcoma  and  in  leukemia  typical  masses  of  lymphomatous 
tissue  are  quite  frequently  found  infiltrating  the  lung,  and  they  may  cause  consoli- 
dation throughout  considerable  areas. 

When  the  malignant  growths  are  secondary  they  are  usually  found  in  both 
lungs  unless  the  tumor  is  the  result  of  extensive  infection,  as  in  the  case  of  tumor 
in  the  chest  wall  directly  involving  the  lung  tissue  through  the  pleura.  In  such 
an  instance  the  growth  at  first  is  single,  whereas  when  it  has  spread  by  metastasis 
it  is  multiple.  Secondary  cancer  of  the  lung  is  more  frequent  in  women  than  in 
men  because  of  the  frequency  with  which  women  sufi'er  from  carcinoma  of  the  breast. 

Symptoms. — The  symptoms  are  not  characteristic.  They  depend  largely  upon 
the  situation  of  the  growth  and  upon  the  degree  of  pressure  which  it  exercises 
upon  surrounding  tissues.  If  it  presses  upon  nerve  trunks  it  causes  severe  jiain; 
if  upon  a  large  bronchus  it  produces  co7igh  and  expectoration:  and  if  a  consider- 
able area  of  lung  tissue  is  involved  it  causes  dyspnea,  particularly  if  the  growth 
or  growths  press  upon  the  bloodvessels  and  so  cause  pulmonary  congestion  or 
stasis,  so  that  as  the  disease  advances  pulmonary  edema  aids  in  decreasing  the 
area  for  the  oxygenation  of  blood.  Great  and  manifest  engorgement  of  the  super- 
ficial veins  of  tiie  neck  and  head  is  sometimes  present  as  the  result  of  pressure  on 
tlie  superior  vena  cava,  and  if  the  vagus  or  the  recurrent  laryngeal  nerves  are 
pressed  vipon  cardiac  neuroses  and  laryngeal  spasm  or  paralysis  may  ensue. 

Diagnosis. — The  diagnosis  of  tumor  of  the  lung  when  no  primary  growtli  exists 
elsewhere  is  extremely  difficult.  The  presence  of  thoracic  pain,  in  the  absence 
of  signs  of  aneurysm,  and  inability  to  discover  cardiac  disease,  aortitis,  or  disease 
of  vertebra^  should  arouse  the  suspicion  of  the  presence  of  a  growth,  which  may  be 
confirmed  by  the  presence  of  duhiess  on  percussion  in  the  area  afi'ected.  When 
these  symptoms  develop  in  a  ])atient  who  has  a  growth  elsewhere,  or  has  had  a 
growth  elsewhere  which  has  been  excised,  as  in  carcinoma  of  the  breast,  they 
possess  much  more  diagnostic  value.  Stokes  considered  that  prune-juice  sputum 
was  a  very  typical  sign  of  malignant  growth  in  the  lung.     Emaciation  may  he  a 


PLEURITIS  413 

marked  symptom,  as  it  is  so  often  in  cases  of  malignant  growth  elsewhere  in  the 
body,  but  the  maintenance  of  flesh  by  the  patient  does  not  negative  malignant 
growth,  as  sometimes  little  weight  is  lost. 

It  is  hardly  necessary  to  add  that  the  malignant  tumors  are  more  frequently 
met  with  in  middle  life  or  in  advanced  age  than  in  youth. 

No  treatment  is  of  any  avail  so  far  as  cure  is  concerned.  The  most  that  can 
be  done  is  to  support  the  system  by  good  food  and  relieve  pain  by  morphine. 


DISEASES  OF  THE  PLEURA. 


PLEURITIS. 


Defuiition. — The  term  pleuritis,  or  pleurisy,  is  applied  to  an  inflammation, 
either  acute  or  chronic,  of  the  serous  membrane  which  lines  the  thoracic  cavity 
and  in  its  reflections  co\'ers  the  lung;  the  so-called  parietal  and  \isceral  layers 
of  the  pleura.  This  inflammation  is  always  the  result  of  an  infection  by  some 
pathogenic  micro-organism.  It  occurs  in  four  forms,  namely,  as  dry  or  fibrinous, 
serofibrinous,  purulent,  when  it  is  called  empyema,  and  that  due  to  tuberculosis, 
or  tuberculous  pleurisy.  Sometimes  malignant  disease  affects  this  membrane, 
and  this  may  be  considered  a  fifth  form  of  pleural  inflammation  fFig.  75). 


A 


Carcinomatosis  of  the  costal  pleuroe.     (Kast  and  Rumpler.) 

Etiology. — As  just  stated,  pleurisy  is  practically  always  due  to  an  infection 
by  some  micro-organism.  In  a  large  number  of  cases  it  arises  as  the  result  of  an 
invasion  of  the  lung  by  the  pneumococcus,  with  or  without  an  associated  pneumonia. 
In  other  instances  it  is  due  to  the  entrance  of  pyogenic  organisms  such  as  the 


414  DISEASES  OF  THE  PLEURA 

sta])hylococcus  and  streptococcus,  and  in  still  other  cases  from  invasion  by  tnborcle 
bacilli.  Infection  of  the  pleura  may  also  take  place  through  the  periciirdiuni, 
the  mediastinal  tissues,  the  vertebrae,  and  the  diaphragm.  Sometimes,  though 
rarely,  it  is  from  the  chest  wall  itself,  after  injury  to  the  thorax  or  by  extension 
from  the  mammary  gland.  Pulmonary  abscess  may,  by  the  extension  of  the 
inflammatory  process,  produce  pleuritis,  or  a  bronchopneumonia  may  cause  a 
secondary  infection.  In  some  cases,  however,  the  inflammation  of  the  pleura  is  a 
primary  lesion  without  any  pathological  change  in  the  lung  except  as  a  secondary 
condition. 

The  relative  frequency  with  which  acute  pleurisy  is  produced  by  each  specific 
micro-organism  is  unknown,  since  recovery  takes  place  in  mild  cases  and  no  oppor- 
tunity of  determining  the  provoking  cause  presents  itself.  The  pneumococcus 
and  tubercle  bacillus,  however,  are  the  causes  in  the  majority  of  cases. 

When  empyema  follows  pleurisy  the  necessity  of  setting  free  tlie  pus  enables 
us  to  determine  the  character  of  the  infection  in  the  great  majority  of  cases,  and 
the  statistics  derived  from  this  source  give  us  some  conception  of  the  relative 
frecjuency  with  which  pleurisy  follows  infection  by  different  organisms.  (See 
Empyema.) 

Frequency. — Pleurisy  is  most  commonly  met  with  between  the  ages  of  twenty 
and  forty,  but  it  is  by  no  means  confined  to  these  decades  of  life.  On  the  contrary, 
it  is  very  frequent  in  young  children — at  least,  as  a  complication  of  pneumonia 
in  its  various  forms — and  is  also  not  rarely  met  with  in  persons  of  ad\anced  years. 
In  adults  pleurisy  occurs  more  than  twice  as  often  in  males  as  in  females,  but  in 
early  childhood  this  predominance  does  not  occur.  As  an  illustration  of  these  facts 
it  is  interesting  to  note  that  in  651  cases  in  St.  Bartholomew's  Hospital,  London, 
465  were  in  males  and  only  186  in  females.  The  distribution  of  these  cases  as 
to  age  was  as  follows:  five  years  and  under,  25;  ten  years,  59;  fifteen  years,  50; 
twenty  years,  54;  thirty  years,  179;  forty  years,  149;  fifty  years,  85;  sixty  years,  35; 
over  sixty  years,  15. 

Pleurisy  occurs  most  frequently  in  the  early  spring  and  late  autumn,  A\heii 
great  changes  in  temperature  take  place.  This  does  not  mean  that  exposure 
to  cold  produces  pleurisy  directly,  but  rather  that  the  exposure  reduces  vital 
resistance  to  such  an  extent  that  infection  takes  place. 

So,  too,  a  number  of  acute  and  chronic  diseases  result  in  pleurisy,  not  because 
they  have  any  direct  effect  on  the  pleural  membrane,  but  because  they  lower 
vital  resistance  at  the  same  time  that  they  ex-pose  the  pleura  to  infection  by  their 
specific  germ.  Thus,  pleurisy  may  be  indirectly  produced  by  the  acute  specific 
fevers  and  by  Bright's  disease,  the  first  of  which  provide  a  predisposing  cause  and 
a  specific  germ,  while  the  latter  lowers  vital  resistance  in  general.  So,  too,  it  is 
possible  for  damage  to  the  chest  wall  to  result  in  acute  pleuritis  aiul  its  conse- 
quences. 

It  is  to  be  constantly  borne  in  mind  that  of  all  specific  infections  that  liy  the 
tubercle  bacillus  is  the  most  important,  because  of  the  prognosis,  because  it  is 
often  insidious,  and  because  it  is  probably  one  of  the  most  frequent  causes  of 
pleurisy. 

The  patholog>',  morbid  anatomy,  symptomatology  and  treatment  of  tlie  \arious 
forms  of  pleurisy  are  best  considered  under  the  specific  description  of  each  type. 

Dry  Pleurisy. — Dry  pleurisy,  as  its  name  indicates,  is  an  inflammation  of  the 
pleural  memlirane  with  a  minimum  amount  of  serous  exudate.  It  may  be  circum- 
scribed or  localized,  as  over  a  tuberculous  cavity,  or  may  be  diffused  over  a  large 
area,  as  in  croupous  pneumonia.  The  pathology  and  morbid  anatomy  of  pleurisy 
of  the  dry  t^ipe  may  be  described  as  follows:  As  in  all  inflammations  of  serous 
membranes,  there  is  an  acute  h^q)eremia  followed  by  infiltration  and  exudation 
of  blood  cells,  fibrin,  and,  it  may  be,  serum.     The  pleural  membrane  is  lustreless 


PLEURITIS  415 

in  appearance,  and  roughened  or  granular,  and  is  somewhat  thickened,  partly 
because  of  infiltration,  but  chiefly  by  reason  of  the  fibrinous  exudate  on  its  surface. 
This  exudate  is  a  primary  factor  in  the  formation  of  adhesions  between  the  visceral 
and  parietal  layers  of  the  pleura.  Sometimes  the  exudate  is  remarkably  profuse 
or  perhaps  a  number  of  layers  are  formed,  so  that  the  pleura  may  exceed  a  quarter 
of  an  inch  in  thickness,  and  is  somewhat  reticulated  or  uneven  on  the  surface. 
Such  an  exudate  is  rarely  completely  absorbed  after  the  attack  has  passed,  and  it 
often  organizes  and  produces  impaired  resonance  on  percussion  and  other  mor})id 
physical  signs  during  the  lifetime  of  the  patient. 

Symptoms. — The  onset  of  acute  dry  pleurisy  is  characterized  by  a  severe  fain, 
or  "stitch,"  in  the  side  and  by  the  development  of  some  fever.  The  pain  in  the 
side  is  sharp  and  stabbing  in  character  and  the  patient  "catches  his  breath,"  to 
use  a  popular  expression,  when  he  endeavors  to  inspire.  Speaking,  coughing, 
or  any  movement  which  causes  increase  in  the  thoracic  movement,  greatly  increases 
the  pain,  which  can,  however,  be  markedly  relieved,  as  a  rule,  by  strapping  the 
side  of  the  chest  which  is  affected,  and  so  diminishing  its  freedom  of  movement. 
The  pain  which  is  developed  by  pressure  on  the  chest  wall  is  sometimes  of  two 
types,  namely,  severe  pain  produced  by  deep  pressure,  and  exquisUe  tenderness 
of  the  skin  over  that  part  of  the  pleura  which  is  inflamed.  In  the  great  majority 
of  cases  the  patient  states  that  the  greatest  pain  is  between  the  mammary  line 
and  the  posterior  axillary  line,  but  it  may  be  complained  of  in  many  other  parts 
of  the  chest,  particularly  if  the  disease  be  due  to  tuberculosis.  Young  children 
who  have  not  been  trained  in  the  localization  of  pain  often  state  that  the  suffering 
is  in  the  epigastrium,  or  in  the  left  or  right  hj'pochondrium,  and  even  in  adults 
I  have  more  than  once  seen  physicians  misled  into  a  diagnosis  of  appendicitis 
because  of  the  pain  referred  by  the  patient  to  this  region,  when  in  reality  the  cause 
was  acute  pleuritis.  In  all  cases  of  pain  below  the  diaphragm  it  is  a  good  rule 
for  the  physician  to  examine  the  condition  of  the  thoracic  viscera  before  asserting 
that  abdominal  disease  is  present.  As  severe  stabbing  pain  in  the  thorax  is  some- 
times due  to  aneurysm,  muscular  rheumatism,  or  intercostal  neuralgia,  these 
possibilities  must  be  excluded  before  we  can  decide  that  the  cause  is  pleuritis. 

The  most  important  physical  sign  which  determines  the  diagnosis  of  this 
affection  is  the  so-called  "friction  sound"  produced  by  the  rubbing  of  the  visceral 
layer  of  the  pleura  upon  the  parietal  layer,  both  layers  being  roughened  and  dried 
by  the  early  stage  of  the  inflammation.  This  friction  sound  is  usually  best  heard 
just  below  and  just  back  of  the  nipple  on  the  side  involved.  (See  Fig.  76.)  In 
persons  who  have  very  thick  chest  walls  and  who  breathe  superficially,  by  habit 
or  because  of  the  pain,  it  is  often  necessary  that  they  take  a  deep  breath  before 
a  friction  sound  is  produced.  ,  Sometimes  the  friction  sound  is  so  creaking  and  loud 
that  it  sounds  like  the  noise  made  by  a  new  leather  saddle  when  it  is  first  used; 
at  other  times  it  is  so  soft  that  only  the  most  careful  auscultation  will  reveal  it, 
and  it  may  resemble  the  fine  rales  of  croupous  pneumonia.  In  other  cases  this 
creaking  can  be  felt  by  the  hand  of  the  physician.  If  the  pleurisy  be  situated 
near  the  heart  the  action  of  that  organ  may  cause  the  pleural  friction  sound  to 
occur  as  often  as  the  heart  beats,  and  so  lead  one  to  the  diagnosis  of  pericarditis. 
This  is  called  a  -pleurofericardialfrictioyi  soimd,  and  may  also  depend  upon  a  simul- 
taneous development  of  pericarditis  and  pleuritis. 

A  second  important  physical  sign  is  the  diminished  respiratory  movement  on  the 
side  of  the  chest  which  is  afl^ected,  as  may  be  seen  by  the  eye  and  recognized  by  the 
feeble  respiratory  sounds  when  auscultation  is  performed,  the  semifixation  of  the 
chest  being  an  effort  to  decrease  the  thoracic  movement,  and  so  limit  the  degree 
of  pain.  My  colleague,  Coplin,  has  suggested  that  the  fixation  is  in  part  due  to 
changes  in  the  intercostal  muscles  themselves.  (See  article  on  Croupous  Pneu- 
monia.)    This  fixation  may  extend  to  one  side  of  the  diaphragm,  and  so  result  in 


416 


DISEASES  OF  THE  PLEURA 


decreased  abdominal  movement  on  that  side.  The  rate  of  respiration  may  be 
increased  in  order  to  compensate  for  the  shallow  breatiiiiif;,  but  it  is  never  the 
hurried  or  urgent  respiration  met  with  in  cases  of  real  dyspnea. 

There  are  two  other  signs  of  pleurisy  which  are  of  some  diagnostic  Naluo,  namely, 
the  suppressed  cvuyh,  which  the  patient  attempts  to  stifle  in  order  to  ])re\cnt  pain, 
and  the  altitude  of  fixation  of  the  body,  so  that  inad\'ertent  movement  by  the 
patient  or  change  in  his  position  made  by  his  attendant  may  not  produce  pain. 
Sometimes  if  the  skin  is  not  hyperesthetic  the  patient  lies  on  the  afl'ccted  side  to 
render  it  fixed,  or  he  may  lie  on  the  well  side  to  avoid  pressure  on  the  involved 
pleura. 

Fig.  76 


Area  in  which  a  right-sided  pleural  friction  sound  is  usually  heard  best. 


The  fever  in  acute  pleurisy  is  rarely  high  in  adults,  although  it  may  be  in  young 
persons.  Often  it  never  rises  above  102°,  and  the  pulse  is  usually  only  increased 
by  reason  of  the  fever;  so  that  it  bears  no  direct  relationsliip  to  the  disease.  There 
is  usually  marked  leukocytosis. 

Diagnosis. — Dry  pleurisy  is  separated  from  muscidar  soreness  due  to  strain  by 
the  facts  just  given  and  by  the  history  of  an  injury;  from  muscular  rheumatism 
by  the  fact  that  signs  of  this  malady  are  to  be  found  elsewhere;  from  intercostal 
neuralgia  by  the  inconstancy  of  that  affection,  and  by  the  fact  that  ordinary 
breathing  does  not  increase  the  pain  in  the  majority  of  cases,  and,  further,  that  all 
three  of  these  conditions  are  not  accompanied  by  any  febrile  movement  or  e\"idence 
of  general  systemic  disturbance.  Acute  pleurisy  of  the  dry  type  lasts  from  a 
few  days  to  two  weeks.  A  longer  attack  than  this  should  arouse  the  suspicion 
of  the  presence  of  a  more  persistent  disease,  such  as  tuberculosis. 

Prognosis. — Barring  complications  the  prognosis  is  favorable.  (See  Empyema, 
and  Pleurisy  with  EfTusion.) 

Treatment. — The  treatment  of  dry  pleurisy  consists  in  applying  adhesive  strips, 
two  inches  wide,  and  overlapping  one  another  one  inch,  from  the  middle  line  of 


PLEURITJS  417 

the  vertebrae  to  the  middle  line  of  the  sternum,  not  following  the  line  of  the  ribs, 
but  passing  from  behind  forward  horizontally.  They  should  be  applied  from  below 
upward,  and  with  a  sufficient  degree  of  pressure  to  produce  almost  complete  fixation 
of  that  side  of  the  chest.  The  pain,  if  it  is  extensive,  may  be  further  controlled 
by  the  administration  of  3-grain  doses  of  Dover's  powder  every  two  or  three  hours. 
If  necessary,  a  hypodermic  injection  of  morphine  may  be  given.  If  the  fever  is 
high  an  ice-bag  may  be  applied  to  the  head,  and  tepid  or  cold  spongings  over  the 
entire  body  may  be  employed.  An  ice-bag  may  also  be  applied  to  the  side  of  the 
chest  which  is  inflamed,  for  the  relief  of  pain. 

In  the  earliest  stages  of  an  acute  dry  pleurisy,  in  a  strong,  healthy  individual 
of  a  pleurotic  type  with  a  bounding  pulse,  there  can  be  no  doubt  that  the  adminis- 
tration of  sufficiently  large  doses  of  the  tincture  of  veratrum  \iride  or  the  tincture 
of  aconite  is  advantageous,  as  it  may  diminish  the  local  hyperemia  in  the  pleura 
and  decrease  the  action  of  the  heart  so  that  it  pumps  less  blood  into  the  inflamed 
area,  thereby  causing  determination  of  blood  to  the  peripheral  capillaries.  This 
vascular  relaxation,  associated  with  sweating,  tends  to  still  further  relie\e  the  local 
congestion,  and  altogether  exercises  a  beneficial  influence  upon  the  local  lesion. 
These  depressant  drugs,  however,  are  distinctly  contra-indicated  unless  the  patient 
is  strong  and  hearty,  and  after  the  first  twenty-four  hours  of  the  illness  they  are 
probably  useless.  Indeed,  after  this  time  they  may  do  harm.  If  they  are  used 
at  all,  they  should  be  given  freely.  Thus,  6  minims  of  the  tincture  of  veratrum 
viride  may  be  given  every  half-hour  until  the  patient  is  very  slightly  nauseated 
or  until  his  skin  becomes  moist,  when  the  drug  should  be  stopped.  A  similar 
method  of  emplojdng  aconite  may  also  be  practised. 

The  employment  of  a  poultice,  or  cotton  jacket,  in  the  treatment  of  pleurisy 
is  less  and  less  resorted  to  at  the  present  time.  There  is  no  reason  to  believe  that 
its  influence  is  advantageous,  and  it  very  greatly  increases  the  discomfort  of  the 
patient  because  of  the  heat  and  consequent  sweatings  which  are  produced.  Further 
than  this,  there  is  always  danger  of  the  patient  taking  cold  by  the  poultice  becoming 
chilled,  or  during  the  removal  of  the  poultice  or  cotton  jacket  for  cleansing  purposes. 

It  is  important  to  remember  that  the  presence  of  a  moderate  pleural  eft'usion 
does  not  require  the  physician  to  institute  measures  for  its  immediate  relief,  because 
in  a  very  considerable  proportion  of  cases  absorption  will  take  place  by  natural 
processes,  and  so  nature  will  produce  a  cure. 

Finally,  all  patients  convalescing  from  an  attack  of  dry  pleurisy  should  be 
instructed  to  present  themselves  to  the  physician  several  times  at  intervals  of  a 
few  days,  in  order  that  he  may  have  the  opportunity  of  determining  whether  the 
pathological  condition  has  entirely  disappeared.  It  happens,  all  too  frequently, 
that  such  patients  are  discharged  "cured,"  when  they  actually  have  an  insidious 
tuberculosis,  the  primary  pleurisy  having  been  due  to  this  cause. 

Pleurisy  v/ith  EfEusion. — While  a  large  proportion  of  cases  of  acute  pleurisy 
are  dry,  in  the  sense  that  no  excess  of  serum  is  poured  out  by  the  inflamed  serous 
membrane,  it  is  not  to  be  forgotten  that  a  considerable  number  of  cases  of  pleural 
inflammation  terminate  in  more  or  less  profuse  outpouring  of  fluid  into  the 
pleural  sac.  This  forms  what  is  sometimes  called  "pleurisy  with  effusion,"  or 
"pleuritic  exudation."  While  the  dry  type  often  involves  only  a  patch,  or  small 
part,  of  the  pleural  membrane,  that  form  which  is  accompanied  by  eft'usion,  unless 
limited  by  adhesions,  usually  affects  the  entire  pleura  of  one  side,  and,  indeed, 
it  may  be  bilateral,  although  this  is,  fortunately,  a  rare  occurrence.  _ 

The  exudate  is  composed  of  two  parts:  (1)  a  solid  portion,  consisting  of  fibrin 
and  ceUs,  which  is  attached  to  the  surface  of  the  pleura  and  which  constitutes 
the  basis  by  which  adhesions  binding  the  two  layers  of  the  pleura  together  may 
be  formed,  and  (2)  serum  or  fluid  exudate,  which  may  be  so  abundant  that  the 
pleural  sac  is  completely  filled.  This  fluid  is  always  turbid  or  cloudy  from  the 
27 


418  DISEASES  OF  THE  PLEURA 

presence  of  degenerated  and  exfoliated  endothelial  cells,  particles  of  fibrin  and  blood 
cells,  particularly  leukocytes.  It  is  worthy  of  note  that  the  pleura  in  cases  of 
pleuritis,  accompanied  by  serous  efi'usion,  is  usually  not  so  markedly  infiltrated 
as  in  the  dry  type. 

These  effusions  are  usually  the  result  of  infection  by  the  pneumococcus,  the 
staphylococcus  pyogenes,  and  the  tubercle  bacillus.  The  latter  infection  is  always 
to  be  suspected  in  subacute  cases  with  much  fluid  and  little  plastic  exudate. 

An  examination  of  the  literature  on  the  bacteriology  of  this  state  shows  that  a 
large  number  of  organisms  have  been  found  in  pleural  effusions  and  also  that  in 
many  cases  the  effused  fluid  is  sterile.  (See  Empyema.)  For  example,  Lemoine 
made  cultures  from  the  fluid  of  38  cases  of  serofibrinous  pleurisj',  and  found  it 
sterile  in  28  instances. 

Recovery,  which  takes  place  in  the  majority  of  cases,  occurs  by  the  absorption 
of  the  serum  and  the  partial  absorption  and  shrinkage  of  the  fibrin,  but  the  chief 
change  in  the  plastic  exudate  is  organization  brought  about  by  the  formation  of 
granulation  tissue,  which  finally  becomes  dense  and  cicatricial  in  character. 

There  is  probably  no  form  of  pleural  efi'usion  so  prone  to  confuse  the  clinician 
as  loculated  or  ensacculated  eft'usions.  These  may  form  between  lobes,  between 
the  base  of  the  lung  and  the  diaphragm,  or  on  the  mediastinal  aspect  of  the  organ. 
Their  localization  is  maintained  by  marginal  adhesions  that  prevent  the  diffusion 
of  fluid  throughout  the  pleural  cavity.  Empyema,  similarly  limited,  offers  identical 
difficulties  in  diagnosis.     (See  Interlobar  Empyema.) 

The  lung  may  be  markedly  distorted,  displaced,  or  compressed  by  the  adhesions, 
and  even  the  heart  may  be  forced  from  its  normal  position. 

Symptoms. — The  symptoms  of  pleurisy  with  effusion  are  not  very  characteristic, 
except  in  so  far  as  the  physical  signs  are  concerned,  but  these  are  typical,  and  some 
of  them  pathognomonic.  If  the  onset  of  the  attack  of  pleurisy  has  been  sharp 
the  severe  pain  already  described  passes  away  as  the  efi'usion  takes  place  and  so 
separates  the  inflamed  layers  of  the  pleura,  at  the  same  time  probably  depleting 
them.  The  fever  often  diminishes  or  disappears  when  the  stage  of  eft'usion  is 
reached.  Dyspnea  may  or  may  not  be  present,  according  to  the  size  of  effusion, 
the  spaciousness  of  the  chest,  and  the  ability  of  the  healthy  side  to  do  enough 
work  to  compensate  for  the  part  which  is  impaired  in  function.  Strong,  hearty 
individuals  often  seem  to  be  more  dyspneic  than  feeble  ones,  probably  because 
in  the  former  case  the  effusion  is  more  rapid  and  the  restricting  adhesions  are  more 
firm.  Cough  in  this  stage  of  effusion  is  usually  not  severe,  and  may  be  absent, 
except  on  exertion.     It  is  often  due  to  an  associated  bronchitis. 

The  posture  of  the  patient,  if  the  effusion  be  large,  is  usually  characteristic, 
in  that  he  persists  in  lying  on  the  affected  side,  in  order  to  permit  the  healthy  lung 
to  have  full  play.  Turning  him  on  the  affected  side  may  cause  urgent  dyspnea 
and  a  sudden  change  to  the  erect  posture  may  do  likewise,  since  the  pressure  of  the 
fluid  on  the  diaphragm  interferes  with  its  movements  or  with  the  action  of  the 
heart.     If  it  be  on  the  right  side  the  apex  beat  is  displaced  to  the  left. 

Physical  Signs. — The  physical  signs  of  pleural  eft'usion  are  as  follows:  Inspection 
shows  decrease  in  respiratory  movement  on  the  aft'ected  side,  with  increased 
activity  on  the  healthy  side;  bulging  of  the  entire  chest  on  the  diseased  side,  with 
fulness  of  the  interspaces  and  some  fulness  it  may  be  in  the  hypochondrium.  Pal- 
pation reveals  an  absence  of  vocal  fremitus  on  the  affected  side,  and  if  the  eft'usion 
be  on  the  left  side  the  apex  beat  of  the  heart  is  displaced  downward  and  to  the 
right.     If  it  be  on  the  right  side  the  apex  beat  is  displaced  to  the  left. 

Percussion  elicits  flatness,  or  marked  dulness,  except  at  the  apex  abo^•e  the 
fluid,  where  the  percussion  note  is  peculiarly  high-pitched,  and  almost  tympanitic — 
the  so-called  Skodaic  resonance.  Percussion  of  the  liver,  if  the  eft'usion  be  on  the 
right  side,  may  show  that  the  lower  margin  of  liver  dulness  is  abnormally  low. 


PLEURITIS 


419 


If  the  effusion  is  on  the  left  side,  percussion  shows  dulness  in  Traube's  semilunar 
space.     (See  Fig.  77.) 

Auscultation  discovers  that  there  is  an  absence  of  breath  sounds  in  the  area 
where  percussion  gives  flatness,  except  it  may  be  for  distant  and  transmitted 
bronchial  breathing.  Along  the  vertebral  column  and  near  the  inner  edge  of  the 
scapula  on  the  affected  side  egophony,  or  the  "bleating  voice"  sound,  may  be 
heard  if  the  patient  speaks,  while  vocal  resonance  in  the  apex  of  the  lung,  where 
Skodaic  resonance  is  present,  is  greatly  increased,  even  to  the  degree  of  pectoriloquy. 
At  this  place  above  the  effusion  bronchial  or  tubular  breathing  may  be  very  marked. 
Sometimes  the  breath  sounds  are  even  amphoric  in  character. 


Showing  at  x  mark  the  so-called  area  called  Traube's  semilunar  space,  where,  in  health,  percussion 
gives  a  tympanitic  note,  which  becomes  flat  in  left-sided  pleural  eiTusion.  The  solid  block  represents 
hepatic  and  cardiac  dulness. 


Occasionally,  as  the  result  of  the  formation  of  adhesions,  pleural  effusion  is 
circumscribed  within  narrow  limits,  and  the  presence  of  an  inflammatory  exudate 
produces  an  area  of  dulness  which  is  much  larger  than  that  space  occupied  by 
the  fluid.  The  introduction  of  an  aspirating  needle  for  diagnostic  purposes  may, 
therefore,  readily  mislead  the  physician,  since  a  dry  tap  will  often  occur  unless 
the  needle  happens  to  enter  that  portion  of  the  area  of  dulness  which  actually 
contains  the  fluid.  The  mere  introduction  of  the  needle  into  the  centre  of  the  area 
of  dulness  is  not  necessarily  followed  by  the  withdrawal  of  fluid,  since  it  not  infre- 
quently happens  that  a  considerable  mass  of  inflammatory  exudate  lies  to  one  side 
of,  or  above  or  below,  the  fluid.  These  loculated  effusions  are  more  common 
in  cases  of  empyema  than  in  ordinary  cases  of  pleurisy  with  effusion.  (See 
Empyema.) 

The  rate  at  which  effusion  takes  place  varies  very  greatly.  Rarely  the  chest 
may  become  filled  in  a  few  days;  more  commonly  it  takes  a  week  or  even  three 


420  DISEASES  OF  THE  I' LEV  It  A 

weeks.  Rapid  effusion  is  more  (Umgerous  than  the  delayed  type,  because  the 
thoracic  viscera  in  the  former  case  do  not  have  time  to  adjust  themselves  to  the 
altered  conditions.  I  have  seen  a  case  of  rapidly  forming  pleural  cfl'usion  in  which 
sudden  death  followed  the  turning  of  the  patient  on  his  well  side. 

The  duration  of  pleural  effusion  varies  very  greatly.  Small  eifusions  are  often 
absorbed  with  surprising  speed  within  a  few  days,  but  large  ones  are  often  very 
slowly  absorbed  and  may  not  be  absorbed  at  all  until  some  of  the  pressure  is  removed 
by  aspirating  the  chest. 

Diagnosis. — It  is  a  noteworthy  fact  that  while  the  diagnosis  of  pleural  effusion 
is  very  readily  made  in  some  cases,  in  other  instances  it  is  so  difficult  as  to  baffle 
the  most  experienced  clinician. 

Pleurisy  with  effusion  is  to  be  separated  from  pneumonia,  from  tuberculous 
consolidation,  from  pulmonary  edema  and  hypostatic  congestion,  from  new  growths 
in  the  lung,  pleura,  and  mediastinum,  and  from  pleurisy  with  groiit  fibrinous 
exudation  and  thickening. 

If  on  examining  one  side  of  the  chest  it  is  found  to  present  impaired  movement, 
impaired  percussion  resonance,  and  absence  of  breath  sounds,  it  is  fair  to  suppose 
that  the  cause  is  effusion,  if  in  addition  we  find,  in  disease  of  the  right  side,  displace- 
ment of  the  apex  beat  to  the  left,  or,  if  it  be  left-sided,  obliteration  of  Traube's 
semilunar  space.  This  opinion  is  still  further  confirmed  if  the  area  of  dulness  on 
percussion  varies  with  a  change  in  the  posture  of  the  patient,  and  if  Skodaic  reson- 
ance is  present  above  the  area  in  which  resonance  is  impaired.  On  the  other  hand, 
it  is  not  to  be  forgotten  that  high-pitched  resonance  is  often  met  with  in  that  part 
of  the  lung  which  is  over  an  area  consolidated  by  pneumonia.  In  many  cases  of 
pleural  eft'usion  Grocco's  sign  is  present.  This  consists  in  a  triangular  area  of 
dulness  on  the  healthy  side  of  the  chest  in  the  para\'ertebral  line.  The  base  of 
this  triangule  is  on  a  line  from  the  spine  outward;  its  side  extends  up  the  spine 
and  the  hypothenuse  of  the  triangle  from  the  outer  part  of  the  base  line  to  the 
upper  end  of  the  spinal  line.  The  hypothenuse  is  often  curved  slightly  outward. 
The  degree  of  dulness  is  not  as  great  as  that  over  the  effusion,  and  when  the  patient 
lies  on  the  affected  side  the  dulness  in  Grocco's  triangle  usually  disappears.  In 
pneumonia  distinct  bronchial  or  tubular  breathing  is  usually  heard  throughout  the 
consolidated  area,  and  this,  of  com-se,  is  not  so  markedly  the  case  in  effusion;  but 
if  the  bronchial  tubes  become  plugged  by  secretion  in  pneimionia,  this  important 
differential  point  is  destroyed.  Again,  it  sometimes  happens  that  if  the  physician 
auscults  the  chest  with  the  unaided  ear  he  can  readily  hear  bronchial  breathing 
even  if  an  eft'usion  be  present,  although  if  he  uses  a  stethoscope  bronchial  breathing 
seems  absent.  In  pneumonia,  however,  bronchial  breathing  is  usually  associated 
with  rales  which  are  absent  in  eft'usion. 

^'ery  useful  in  the  diff'erentiation  of  the  two  aft'ections  is  the  history  of  the  patient, 
in  whom  the  early  symptoms  of  the  two  diseases  are  usually  quite  at  variance, 
unless  the  case  has  been  one  of  primary  pleuropneumonia. 

In  cases  of  tuberculous  consolidation  the  ajjpearance  of  the  patient  and  the 
history  of  onset  may  be  valuable  dift'erential  points,  and  if  loss  of  flesh  or  fever  is 
present  these  facts  are  still  further  emphasized. 

When  pulmonary  edema  is  present  the  presence  of  moist  rales,  the  feeble  heart 
action,  and  the  discovery  of  some  prolonged  preceding  illness,  or  of  renal  disease 
predisposing  to  pulmonary  edema,  and  bilateral  dulness,  are  the  points  of  value  in 
making  a  diagnosis. 

In  cases  of  acute  pleurisy  with  great  thickening  of  the  pleural  membrane  there 
may  be  marked  impairment  of  resonance  on  light  percussion,  and  a  friction  sound 
may  be  heard,  but  deep  percussion  may  elicit  normal  jiulmonary  resonance. 

Growths  in  the  lung,  or  ])ulmonary  abscess,  usually  are  so  peculiarly  placed 
and  surrounded  by  healthy  tissue  that  careful  examination  of  the  chest  and  a  study 
of  the  patient's  history  will  be  sufficient  to  make  the  difterentiation. 


PLEURITIS  421 

Pneumothorax  is  separated  from  pleural  effusion  by  its  high-pitched  resonance 
on  percussion  and  the  other  physical  signs  of  that  condition  whicli  arc  only  partly 
modified  if  the  pleura  is  chronically  thickened. 

There  still  remain  two  important  diagnostic  points  in  these  cases  which  have 
to  be  studied  before  diagnosis  can  be  reached,  viz.:  Are  the  physical  signs  due 
to  the  possible  presence  of  subphrenic  abscess,  which,  pushing  the  diaiihragm 
upward,  encroaches  upon  the  thoracic  space,  or  are  they  due  to  abscess  or  hydatid 
cyst  in  the  liver?  These  conditions  become  manifest  if  the  patient  is  carefully 
examined  for  them.     Further,  their  rarity  is  a  point  against  their  presence. 

Lastly,  it  is  important  to  determine  the  size  of  the  effusion  in  order  that  the 
danger  to  the  patient  may  be  appreciated.  It  is  not  possible  to  even  approxi- 
mate the  actual  quantity,  because  the  capacity  of  the  chest  varies  greatly  in 
different  cases,  but  the  extent  of  the  effusion  can  be  decided  bj'  the  line  at  which 
percussion  dulness  first  changes  to  impaired  resonance,  and  further  up  to  high- 
pitched  resonance. 

After  a  diagnosis  of  pleural  effusion  has  been  made,  the  question  which  arises 
is  whether  the  eft'usion  is  serous  or  purulent,  and  if  serous  whether  it  is  the  result 
of  inflammation  or  transudation.  This  is  a  most  important  question,  since  the 
treatment  is  quite  different  in  each  instance. 

This  may  be  determined  by  performing  paracentesis  tlioracis  and  to  a  great 
extent  by  an  examination  of  the  fluid  after  it  is  withdrawn  by  aspiration.  Its 
specific  gravity,  if  the  cause  be  of  an  inflammatory  nature,  varies  from  1.010  to 
1.018,  and  it  contains  large  amounts  of  fibrin  and  albumin.  On  the  other  hand, 
the  fluid  due  to  transudation  in  dropsy  shows  a  specific  gravity  of  only  about 
1.008  and  contains  little  fibrin  and  albumin.  (See  Hydrothorax.)  When  the 
effusioia  is  due  to  tuberculosis  the  specific  gravity  is  very  high  (1.012  to  1.024). 
The  symptoms  and  diagnosis  of  empyema  will  be  found  discussed  below. 

Cytoscopy  in  Pleural  Effusion. — In  1900  Widal  and  Ravaut  called  attention 
to  the  cytological  examination  of  the  fluid  of  pleural  effusion,  asserting  that  the 
nature  of  the  pleurisy  can  be  determined  by  the  organized  elements  held  in  sus- 
pension in  the  exudate.  According  to  their  observations,  since  confirmed  by  others, 
the  fluid  of  tuberculous  pleurisy  is  characterized  by  the  presence  of  an  excess  of 
lymphocytes,  that  of  the  acute  infective  pleurisies  by  polymorphonuclear  leukocji;es, 
and  that  of  the  pleurisies  dependent  upon  new  growths  and  the  aseptic  pleurisies 
accompanying  renal  and  cardiac  disease,  by  slireds  of  endothelium.  These  facts 
are  not,  however  pathognomonic,  for  Naunyn  found  that  the  effusions  complicating 
Bright's  disease  often  contain  lymphocytes  instead  of  endothelium  shreds,  and 
Tarchetti  and  Rossi  found  lymphocytes  in  only  a  portion  of  the  tuberculous  effusions 
which  they  examined.  The  discovery  of  a  marked  lymphocytosis  in  the  fluid  is 
certainly  of  some  value  as  indicating  tuberculosis,  particularly  if  it  is  associated 
with  other  signs,  but  it  is  not  to  be  forgotten  that  in  certain  non-inflammatory 
exudates  a  very  extraordinary  degree  of  lymphocytosis  may  be  present.  So,  too, 
a  high  count  (60  to  90  per  cent.)  of  polymorphonuclear  cells  is  indicative  of  an 
infection  by  the  pneumococcus. 

Prognosis. — The  prognosis  in  cases  of  pleural  effusion  is  favorable,  except  in  two 
conditions.  If  the  formation  of  the  fluid  is  very  rapid  and  very  copious,  pressing 
upon  the  heart  and  lungs  and  seriously  impairing  their  action  so  that  dyspnea 
becomes  urgent,  the  prognosis  is,  of  course,  grave,  unless  relief  is  given  by  thoracen- 
tesis. Again,  if  the  effusion  is  primarily  due  to  tuberculosis,  or  to  nephritis,  which, 
by  decreasing  vitality,  has  permitted  infection  to  take  place,  the  prognosis  must 
be  correspondingly  grave  as  to  ultimate  recovery. 

Treatment. — When  the  effusion  has  formed  in  such  large  quantity  that  it  produces 
pressure  upon  a  vital  organ,  or,  again,  when  it  remains  unabsorbed  for  a  consider- 
able period  of  time,  the  physician  should  undertake  measures  for  its  removal. 


422  DISEAfiEfi  OF  THE  PLEURA 

The  onlj-  measure  of  any  value  when  tlie  pressure  is  sufficiently  great  to  be 
producing  serious  symptoms  is  "tapj)ing"  the  chest  by  means  of  an  aspirator. 
The  skin  over  the  affected  side  should  he  first  thoroughly  cleansed,  as  if  for  the 
performance  of  a  minor  surgical  operation.  A  hollow  needle  having  a  moderately 
wide  calibre,  and  attached  to  a  rubber  tube  tlu-ec  feet  long,  wliich  is  filled  with 
fluid,  is  then  pushed  into  the  pleural  cavity  in  the  sixth  or  seventh  interspace  in 
the  midaxillary  line.  Care  should  be  taken  that  the  aspirating  needle  should  be 
kept  well  down  on  the  upper  surface  of  the  nether  rib,  in  order  to  avoid  injuring 
the  intercostal  artery,  and  the  physician  should  grasp  the  needle  with  his  thumb 
and  forefinger  not  far  from  its  point,  so  that  after  it  pierces  the  skin  it  will  not 
suddenly  plunge  into  the  chest  for  several  inches,  and  so,  perhaps,  do  damage  to 
deep-lying  tissues.  No  sooner  does  the  needle  enter  the  pleural  cavity  than  the 
end  of  the  rubber  tube  is  lowered  to  a  level  with  the  floor  and  the  contents  of  the 
pleura  is  in  this  way  siphoned  out  of  the  chest.  The  advantage  claimed  for  this 
method  of  treatment  is  that  the  degree  of  suction  is  at  no  time  great,  and,  further- 
more, it  is  constant.  Again,  there  is  no  danger  of  the  fluid  being  withdrawn  with 
too  great  rapidity. 

A  very  much  more  frequently  resorted  to  measure  of  performing  yanacentesis 
thoracis  is  to  attach  a  large  needle,  or  trocar  and  cannula,  to  a  piece  of  rubber 
tubing,  which,  in  turn,  is  attached  to  a  tube  running  through  the  cork  of  a  bottle 
in  which  a  vacuum  has  been  produced  by  a  small  hand-pump.  The  entrance  to 
the  bottle  is  guarded  by  a  small  stopcock.  After  the  needle  has  been  placed  in 
the  chest,  the  trocar  is  withdrawn,  the  stopcock  is  turned,  and  the  fluid  is  drawn 
by  the  vacuum  from  the  chest  into  the  bottle.  It  is  rarely,  if  ever,  proper  to  com- 
pletely empty  the  chest  by  this  means  at  one  sitting,  particularly  if  the  effusion 
has  been  a  large  one.  Too  rapid  withdrawal  of  the  pressure  in  the  thorax  may 
cause  serious  disturbance  of  the  action  of  the  heart,  or  too  rapid  an  expansion  of 
that  portion  of  the  lung  on  the  affected  side  which  has  been  compressed  by  the 
fluid,  with  the  result  that  damage  is  done  to  the  pulmonary  tissue,  or  that  a  peculiar 
form  of  gelatinous  exudation  into  the  lungs  takes  place,  which  is  only  relieved  by 
constant  and  exhausting  cough,  and  sometimes  results  fatally. 

Should  constant  cough  develop  during  paracentesis,  it  is  best  to  discontinue 
the  operation  at  once. 

It  is  also  important  to  remember  that  not  infrequently  the  withdrawal  of  a 
small  quantity  of  the  effusion,  by  the  relief  of  pressure  and  the  establishment  of 
normal  lymphatic  and  blood  circulation  in  the  chest  wall,  may  result  in  the  natural 
absorption  of  the  remaining  fluid  with  a  very  considerable  degree  of  rapidity,  so 
that  even  if  the  chest  is  not  emptied  by  the  aspiration  it  may  become  so  in  a  few 
days  by  a  natural  process.  This  holds  true  with  particular  force  in  those  cases  of 
large  pleural  effusion  which  do  not  require  interference  because  of  pressure  symp- 
toms, but  which  do  not  undergo  absorption  by  natural  means  until  after  absorption 
has  been  stimulated  by  the  performance  of  paracentesis. 

It  is  necessary  that  the  physician  should  exercise  care  in  inspecting  his  needle 
before  he  employs  it.  Experienced  clinicians  have  frequently  been  humiliated  by  a 
dry  tap  when  they  were  skilful  enough  to  diagnose  an  effusion,  but  careless  enough 
not  to  notice  that  their  needle  was  plugged. 

A  pleural  effusion  should  not  be  permitted  to  remain  too  long  in  the  chest,  since 
its  presence  tends  to  increase  the  organization  of  the  inflammatory  process  on  the 
surface  of  the  lung,  or  results  in  the  formation  of  such  firm  adhesions  that  decortica- 
tion of  the  lung  by  the  surgeon  is  necessary  if  recovery  is  to  ensue. 

The  employment  of  purges,  diuretics,  or  diaphoretics  in  cases  of  pleurisy  with 
effusion,  with  the  object  of  causing  an  absorption  of  the  fluid,  is,  for  very  good 
reasons,  futile  in  almost  every  instance.  It  has  already  been  pointed  out  that  in 
this  disease  the  pleura  is  almost  invariably  covered  by  a  dense  fibrinous  exudate, 


PURULENT  PLEURAL  EFFUSION,  OR  EMPYEMA  423 

which  is  plastic  in  character  and  mechanically  interferes  with  the  absorption  of  the 
exudate.  Even  if  the  physician  is  able,  by  the  administration  of  powerful  hydra- 
gogue  cathartics,  to  cause  a  concentration  in  the  blood,  this  concentration  does  not 
result  in  the  absorption  of  the  pleural  effusion,  because  of  the  obstruction  just  spoken 
of,  and  also  because  absorption  takes  place  from  the  pleura  chiefly  by  the  lymphatic 
vessels,  and  not  by  the  bloodvessels.  The  only  result  of  administering  powerful 
diaphoretics  and  cathartics  to  patients  sufl'ering  with  effusion  following  pleurisy 
is  to  exhaust  their  vitality  without  materially  influencing  the  local  condition. 

The  application  of  blisters  to  the  chest,  with  the  hope  that  they  will  stimulate 
absorption,  is  probably  quite  as  futile  as  the  employment  of  purgatives,  although 
they  may  indirectly  aid  in  the  absorption  of  fluid  by  stimulating  the  removal  of 
the  film  of  plastic  exudate  which  covers  the  pleural  membrane. 

The  condition  in  pleural  transudations  following,  or  accompanying,  cardiac 
or  renal  dropsy  is  quite  a  different  one  from  that  due  to  inflammation.  In  the 
latter  condition  there  is  not  any  fibrinous  exudate,  and  the  effusion  takes  place 
by  a  process  of  transudation  from  the  vessels,  the  fluid  being  quite  dift'erent  in 
its  character  from  that  found  after  the  acute  inflammatory  process  just  discussed. 
It  usually  contains  much  less  fibrin.     Purgatives  may  therefore  do  good. 

Aside  from  the  operative  measures,  which  are  necessary  in  about  one-half  the 
cases  of  pleurisy  with  efl^usion,  the  physician  should  administer  mild  tonics,  with 
the  object  of  aiding  digestion,  and  he  should  support  the  system  by  the  administra- 
tion of  proper  quantities  of  nutritious  food.  If  after  tapping  the  fluid  it  recurs, 
it  should  be  withdrawn  a  second  time.  Such  a  recurrence  rarely  takes  place  in 
the  effusion  following  pleurisy,  although  it  is  not  infrequently  met  with  in  cases  of 
ordinary  transudation  into  the  pleural  cavity  in  other  pathological  states. 


PURULENT  PLEURAL  EFFUSION,  OR  EMPYEMA. 

Definition  and  Etiology. — By  empyema  we  mean  a  condition  in  which  pus  has 
accumulated  in  the  pleural  space  or  spaces.  It  was  taught  at  one  time  that  such 
an  effusion  might  primarily  be  serous  and  by  infection  become  piu-ulent,  but  this 
rarely  occurs.  Empyema  occurs  as  a  sequel  to  infection  from  the  lung  in  the  great 
majority  of  cases,  but  it  may  arise  from  primary  infection  of  the  pleura.  The  cour 
dition  is  far  more  common  in  children  than  in  adults  (Fig.  78).  In  children  it  is 
generally  the  result  of  the  presence  of  the  pneumococcus,  which  commonly  causes  a 
bronchopneumonia  or  a  croupous  pneumonia  first  and  empyema  afterward,  but 
in  adults  the  streptococcus  is  usually  the  exciting  cause.  The  condition  occurs 
much  more  frequently  in  boys  than  in  girls. 

In  69  cases  of  empyema  in  children,  P.  S.  Blaker  found  the  pneumococcus  in 
62  cases;  the  streptococcus  in  3;  the  pneumococcus  and  streptococcus  in  3,  and  the 
staphylococcus  in  1.  In  40  cases  in  children  reported  by  Bythell,  26  were  due  to 
the  pneumococcus  and  9  to  the  pneumococcus  and  some  other  organism  (Fig.  79). 

Empyema  is  sometimes  due  to  infection  by  the  Bacillus  tuberculosis,  and  it  is  a 
fact  worthy  of  note  that  the  pus  in  such  cases  is  usually  sterile,  only  revealing  the 
presence  of  tubercle  bacilli  when  by  chance  some  of  the  exudate  which  lines  the 
pleura  is  obtained  through  the  aspirator.  In  other  words,  sterile  pus  from  an 
empyema  raises  a  suspicion  of  tuberculous  infection.  Bacteriological  examination 
of  pus  from  311  cases  of  empyema,  occurring  in  hospitals  in  the  United  States, 
Canada,  England,  France,  Germany,  Austria,  and  Italy,  showed  that  the  pneu- 
mococcus was  the  infecting  organism  in  92  cases;  the  streptococcus  in  58;  the 
tubercle  bacillus  in  30.  In  the  remaining  cases  the  pus  was  sterile,  or  more  than 
one  micro-organism  was  found.  If  children  are  excluded  from  these  statistics,  the 
streptococcus  becomes  the  most  common  infectious  agent. 


424 


n!SE.\sr':s  of  tuk  i-lei'L'. 


When  no  pulnioiiiiry  lesion  can  be  discovered  in  a  case  of  empyema,  it  must  be 
recalled  that  a  very  small  and  insignificant  lesion  in  the  lung,  and,  therefore,  one 
which  is  easily  overlooked,  may  be  the  focus  for  a  very  severe  pleural  infection, 
and,  therefore,  the  inability  of  the  physician  to  find  a  primary  i)ulmonar>-  lesion 
does  not  prove  that  it  has  not  existed. 


Fig 

78 

z 

UNDER 
10  YEARS 
OF  AGE 

BETWEEN 
10  AND  20 

Z     o 

UJ     o 

1-   < 

BETWEEN 
30  AND40 

BETWEEN 
40  AND  50 

BETWEEN 
50  AND  60 

-10 

39 

38 

I 

37 

\ 

30 

:35 

\ 

34 

' 

33 

32 

\ 

31 

\ 

30 

\ 

1 

iU 

es 

- 

•J7 

t::::::: 

■X 

\ 

■■a 

n 

'\ 

23 

\ 

•a 

-I  - 

■<i 

.4 

■iO 

::::::i\~- 

10 

...[.  .. 

..../...\ 

18 

\ 

/    \ 

ir 

- 

_^ii : 

S,                         _         _                     -      _                 _              . 

11) 

_— L_- 

^ 

15 

/ 

14 

,  ' 

"  ui 

13 

.::.Al 

"^1^+^ 

n 
11 

rs 

V    - — r'    ^i 

10 
0 

it:i::::::::::^:::::::::::: 

s 

8 

-^       

T 

^ 

0 

:::::::::::::::::::s:':::::: 

5 

^ 

4 

^ 

3 

I  i 

■J 

1 

Chart  showing  morbidity  percentage  of  empyema  due  to  all  causes  at  different  ages,  based  on  403 
eases  occurrinc  in  five  hospitals  in  the  United  States  and  England. 


The  character  of  the  pus  found  in  cases  of  empyema  varies  considerably  in  differ- 
ent cases,  the  variation  depending  in  part  upon  the  micro-organism  which  has 
produced  the  condition,  and  upon  the  duration  of  the  malady  at  the  time  the  effusion 
is  examined.  Usually  it  is  creamy  and  homogeneous;  in  other  cases  it  is  thin 
and  separates  on  standing  into  a  thick  and  thin  layer.  When  the  efi'usion  is  an 
old  one,  the  pus  may  be  quite  thick  and  curdled  in  its  appearance,  containing  clot- 
like masses  or  shreds  of  fibrin,  which  plug  the  aspirating  needle  and  make  aspiration 
impossible.  While  the  color  is  commonly  a  creamy  yellow,  it  is  sometimes  slightly 
pinkish  in  appearance,  and  may  be  greenish  in  hue,  and  in  still  other  cases,  when  a 
considerable  amount  of  blood  has  been  extravasated  into  the  effusion,  it  is  a  dirty, 


PURULENT  PLEURAL  EFFUSION,  OR  EMPYEMA 


425 


pale  cocoa  color.  In  some  instances,  as  in  cases  due  to  infection  by  the  pneu- 
mococcus,  the  pus  is  almost  odorless,  while  in  others,  particularly  if  the  empyema 
has  ruptured  into  a  bronchus,  it  is  fetid. 

Purulent  effusion  in  the  pleural  space  is  usually  profuse.  Indeed,  it  has  been 
taught  that  as  a  class  these  collections  are  larger  than  are  serous  efi'usions,  which 
is  not,  however,  always  true  by  any  means.  On  the  other  hand,  they  are  very 
much  more  likely  than  are  serous  effusions  to  be  walled  off  and  encysted  by  reason 
of  adhesions,  thereby  forming  a  small  pocket  of  pus. 


Fig 

79 

i 

^    < 
m    ° 

z    g 

z    ° 

N 

m   ° 

z    ° 

z  g 

H 

m   ° 

z  g 
m    ° 

z  o 

33 

31 

\ 

30 

1 

29 

\ 

38 

1 

2T 

\ 

aii 

\ 

35 

\ 

24 

\ 

■a 

t 

\ 

32 

1 

\ 

I 

21 

\ 

20 

1 

19 

\ 

18 

IT 

\ 

16 

\ 

15 

\ 

14 

' 

13 

\ 

12 

' 

11 

1, 

10 

S 

0 

S 

S 

! 

K 

7 

1 

\ 

6 

\ 

5 

\ 

4 

\ 

3 

\ 

3 

\ 

1 

Chart  showing  morbidity  percentage  of  empyema  due  to  the  pneumococcus  at  different  ages,  based 
on  286  cases  collected  by  Netter.     Large  percentage  in  childhood. 

S3nnptoms. — If  after  an  attack  of  pneumonia  the  temperature  does  not  fall,  or 
if,  after  it  has  been  normal  or  near  normal,  it  begins  to  rise  again,  and  the  patient 
has  chilb  or  chilly  sensations,  empyema  should  be  sought  for. 

The  symptoms  of  empyema  in  general  are  those  of  impaired  health.  The  patient 
is,  as  a  rule,  pale  and  ill-looking,  suffers  from  loss  of  iveight,  and  sweats,  which  are 
particularly  prone  to  come  on  when  he  sleeps. 

A  vioderate  fever  may  be  present,  and  suppressed  or  even  well-developed  chills 
may  recur.  It  is  important,  however,  to  remember  that  in  some  cases  none  of 
these  constitutional  symptoms  are  manifest,  the  fever  in  particular,  being  so  mild 
that  it  fails  to  attract  attention,  so  that  the  condition  of  empyema  is  suspected 
only  when  some  shortness  of  breath  calls  attention  to  the  thorax. 

The  pus  in  cases  of  empyema  sometimes  becomes  so  completely  walled  off  from 
the  surrounding  tissues  that  it  remains  for  weeks  without  producing  any  signs  of 
its  presence,  but  in  other  cases — and  these  are  the  more  numerous— it  causes  such 


426  DISEASES  OF  THE  PLEURA 

severe  pressure  symptoms  or  so  much  evidence  of  sepsis  that  relief  is  demanded  by 
the  patient.  In  otlier  cases — and  these  are  often  those  in  wliicli  tlic  empyema 
has  not  been  recognized — the  pus  burrows  its  way  out,  rupturing  into  a  bronchus 
or  perforating  the  chest  wall.  Very  much  more  rarely  it  empties  into  the  peri- 
cardium, or  even  into  the  esophagus.  In  other  instances  it  has  perforated  the 
diaphragm,  although  this  process  is,  curiously,  much  more  rare  than  the  rupture 
of  a  subdiaphragmatic  abscess  into  the  pleural  cavity. 

Statistics  as  to  the  relative  frequency  with  which  rupture  into  a  bronchus  takes 
place  are  not  in  accord.  Thus,  of  195  cases  of  empyema  occurring  in  St.  Thomas' 
Hospital,  London,  and  in  the  Leeds  General  Infirmary,  11  ruptured  into  the 
lung,  a  percentage  of  5.64;  while  an  analysis  of  a  large  niunber  of  cases  of  empyema 
collected  by  Netter  gave  a  percentage  of  26.2  rupturing  into  the  lung.  These 
latter  figures  certainly  must  be  far  too  high. 

The  physical  signs  of  empyema  have  already  been  discussed  when  describing 
those  of  serous  effusion,  for  in  both  states  they  are  practically  the  same.  Sometimes 
the  presence  of  pus  may  be  shown  by  an  edema  of  the  superficial  tissues,  which  is 
often  met  with  over  deep-seated  suppurations.  Empyema  is  also  apt  to  produce 
more  bulging  of  the  intercostal  spaces  than  is  serous  effusion,  perhaps  because 
there  is  more  wasting,  and  so  the  bulging  is  more  readily  observed.  In  some 
instances  of  empyema,  however,  the  contraction  of  the  thickened  pleura  draws 
the  edges  of  the  ribs  so  closely  to  one  another  that  bulging  of  the  interspaces  is 
obliterated. 

When  pulsation  is  transmitted  to  the  purulent  effusion,  so  that  the  impulse 
is  manifest  through  the  interspaces,  it  is  called  "empyema  necessitatis." 

Complications. — The  chief  complications  of  empyema  ha\e  already  been  named, 
viz.,  sepsis  and  perforation.  The  signs  of  sepsis  are  similar  in  this  state  to  those 
produced  by  accumulations  of  pus  elsewhere,  and  require  no  further  discussion. 
The  symptoms  of  perforation  into  a  bronchus  consist  of  an  attack  of  violent  cough- 
ing, during  which  the  patient  expels,  in  large,  or  sometimes  in  small  amount,  a 
quantity  of  almost  pure  pus.  After  the  pus  first  appears,  it  is  commonly  brought 
up  in  mouthfuls  several  times  a  day,  and  more  rarely  in  such  large  quantities  as 
to  threaten  the  patient  with  suffocation.  This  drainage  of  pus  tln-ough  the  lung, 
curiously  enough,  rarely  causes  serious  permanent  damage  to  the  lung,  which  may 
ultimately  entirely'  recover  if  the  physician  will  but  provide  an  opening  in  the  chest 
wall  for  proper  drainage. 

When  the  pus  escapes  externally  by  burrowing,  it  most  frequently  does  so  about 
the  sixth  intercostal  space  in  the  axillary  area,  but  it  sometimes  burrows  a  great 
distance  and  escapes  by  way  of  niunerous  openings.  In  other  instances  it  burrows 
far  down  the  trunk  and  discharges  as  low  down  as  the  pelvis.  Indeed,  Barton 
has  reported  a  pulsating  empyema  in  the  left  lumbar  region.  These  openings  may 
persist  for  many  years,  and  if  the  suppurative  process  persist,  amyloid  disease  of 
the  liver  and  kidneys  may  ensue. 

Diagnosis. — The  differentiation  of  empyema  from  serous  eft'usion  is  to  be  made 
by  the  presence  of  the  septic  symptoms  just  named,  and  by  the  use  of  an  aspirating 
needle  to  determine  the  character  of  the  fluid.  The  localized  types  of  empyema 
are  those  which  offer  real  difficulty  in  diagnosis,  since  the  pus  may  be  between  two 
lobes  of  the  lung,  or  at  the  base  of  the  lung  next  the  diaphragm,  or  be  extended 
over  a  considerable  area  although  very  shallow,  or,  again,  the  inflammatory  process 
in  the  adjacent  lung  tissue  causes  the  presence  of  the  physical  signs  of  consolidation 
of  the  lung  or  of  large  eft'usion,  when  in  reality  the  pm-ulent  collection  is  a  small  one. 
In  these  cases  the  introduction  of  the  aspirating  needle  may  fail  to  reveal  the  pres- 
ence of  pus,  because  the  instrument  does  not  happen  to  strike  the  purulent  focus. 

When  the  pus  is  localized  by  adhesions  in  the  neighborhood  of  the  heart,  this 
organ  may  be  displaced  by  the  pressure  and  transmit  its  impulse  to  the  eft'usion. 


CHRONIC  PLEURISY  427 

so  giving  rise  to  the  belief  that  a  purulent  pericarditis  is  present;  the  absence  of 
this  more  serious  state  being  revealed  only  when  the  pus  is  set  free. 

A  still  more  difficult  condition  to  discover  is  interlobar  pleurisy  with  effusion. 
In  such  cases  if  the  accumulation  is  pus,  it  may  rupture  into  the  bronchi  and  give 
rise  to  the  belief  that  the  patient  has  true  pulmonary  abscess. 

Prognosis. — The  prognosis  in  empyema  in  children,  over  three  years  of  age, 
if  the  condition  is  due  to  the  pneumococcus,  and  if  the  pus  is  allowed  to  escape 
before  it  has  done  much  damage,  is  surprisingly  good,  both  as  to  rapid  and  complete 
recovery.  Not  only  do  many  of  these  cases  soon  cease  to  form  any  more  pus,  but 
the  compressed  lung  expands  with  remarkable  rapidity,  and  may,  in  the  course 
of  a  few  months,  fill  the  pleural  cavity  so  well  that  nearly  all  traces  of  the  disease 
may  disappear.  ^Vhen  the  disease  affects  infants  the  outlook  is  bad,  because 
of  their  susceptibility  to  wasting  processes  and  their  low  vital  resistance. 

In  streptococcus  infection  the  prognosis  is  not  so  favorable,  nor  is  it  good  in 
tuberculous  empyema,  for  in  the  first  type  the  formation  of  pus  is  persistent  and 
the  deformity  of  the  chest  is  very  apt  to  be  great,  while  in  the  second  type  a  primary 
infection  elsewhere  is  usually  present. 

It  has  been  stated  by  some  authors  that  an  empyema  may  undergo  absorption. 
While  a  decrease  in  the  size  of  the  effusion  may  result  from  the  absorption  of  some 
of  its  fluid  constituents,  true  disappearance  of  pus  from  the  thorax  does  not  take 
place  unless  it  is  let  out  or  escapes  spontaneously.  It  may,  however,  become 
inspissated  and  encysted. 

Treatment. — There  is  but  one  thing  to  be  done  in  cases  of  empyema,  and  that 
is  to  let  out  the  pus,  treating  the  case  as  one  of  ordinary  abscess.  If  the  quantity 
of  the  fluid  is  sufficiently  large  to  compress  and  displace  adjacent  organs,  particularly 
the  heart,  it  is  better  to  first  relieve  some  of  this  pressure  by  aspiration,  as  in  a 
case  of  serous  effusion,  removing  enough  of  the  pus  to  permit  the  heart  and  vessels 
to  slowly  regain  their  normal  position.  As  the  pus  in  these  cases  is  often  under 
great  pressure,  so  that  it  squirts  several  feet  when  an  incision  is  made,  I  am  con- 
fident that  this  preliminary  modification  of  the  pressure  is  wise  in  most  cases.  On 
the  following  day  or,  if  need  be,  immediately  after  aspiration,  an  incision  should 
be  made  between  the  sixth  and  seventh,  or  seventh  and  eighth,  ribs  in  the  posterior 
axUlary  line,  and  this  opening  should  be  maintained  by  the  insertion  of  a  doubled, 
or  extra  large,  drainage  tube  or  by  a  gauze  drain.  If  the  ribs  have  been  drawn  so 
closely  together  by  the  contraction  of  the  parietal  pleura  that  free  drainage  cannot 
be  obtained,  then  the  upper  sm-face  of  the  lower  rib  should  be  cut  away  until 
drainage  is  free,  or,  if  need  be,  several  inches  of  the  rib  or  of  several  ribs  should  be 
resected.  This  is  usually  necessary  in  streptococcus  infection.  As  a  rule,  in 
children  all  that  is  necessary  is  to  introduce  a  large  drainage  tube  by  means  of  a 
large  cannula  and  keep  it  in  place  with  a  safety-pin  and  adhesive  strip.  This  tube 
is  connected  by  means  of  a  short  glass  tube,  whereby  the  flow  can  be  watched, 
with  a  piece  of  rubber  tubing  long  enough  to  reach  a  bottle  placed  below  the  bed. 
In  this  manner  adequate  drainage  can  be  maintained  without  subjecting  the  child 
to  the  hardship  of  an  incision  and  the  excision  of  a  piece  of  rib,  but  if  the  formation 
of  pus  persists  resection  should  always  be  performed.  For  the  details  as  to  the 
exact  technique  of  these  operative  procedures  reference  should  be  made  to  a  surgical 
work. 

CHRONIC  PLEURISY. 

Definition. — Chronic  inflammation  of  the  pleura  may  be  nothing  more  than  a 
sequence  of  some  of  the  acute  conditions  already  discussed.  If  a  fluid  accumulation, 
serofibrinous  or  purulent,  be  allowed  to  remain  within  the  chest  cavity,  important 
alterations  take  place  in  the  serous  membrane.  With  the  subsidence  of  infection 
reparative  efforts  lead  to  the  production  of  fibrous  tissue,  which  greatly  thickens 


428  DISEASES  OF  THE  I'LEI'RA 

botli  parietal  and  visceral  layers  and  cnslicatlis  the  collapsed  lung,  eventually 
forming  such  a  dense  investing  mcinhrane  tliat  re-exi)ansion  Ijcconics  impossible. 
In  other  cases  the  fluid  is  absorljed  ami  the  pleural  surfaces  coated  by  iuHannnatory 
products  come  in  contact,  coalesce,  and  become  fused  by  permanent  organization 
of  the  exudate.  In  the  latter  group  of  cases  the  pleural  cavity  may  be  obliterated, 
or  partial  adhesions  only  may  form.  In  some  cases  unattended  by  frankly  expressed 
acute  inflammation,  hyperplastic  thickening  of  large  or  small  areas,  usually  with 
adhesions,  occurs.  In  such  cases  the  newly  formed  inflammatory  tissue  may  attain 
a  thickness  of  1  cm.  or  more  and  not  infrequently  contains  calcareous  plaques. 

The  third  form  is  called  "primitive  dry  pleurisy"  in  the  sense  that  it  begins 
without  efl'usion  and  often  without  pain,  and  is  not  associated  with  fever.  The 
patient  may  himself  feel  the  pleural  friction.  Finally,  lunited  adhesions  occur 
between  the  la\-ers  of  the  pleura,  but  they  do  not  cause  marked  interference  with 
the  lung  nor  deformity  of  the  chest. 

The  fourth  type  is  the  so-called  "primitive  dry  pleurisy"  described  by  Sir  Andrew 
Clarke,  in  which  the  layers  of  the  pleura  become  adherent  and  tliickened  as  in 
the  forms  just  described.  From  the  visceral  layers  of  the  pleura  bands  of  connective 
tissue  penetrate  and  traverse  the  lung  almost  as  if  they  were  true  trabecuhie.  The 
effect  of  these  bands  as  they  contract  is  to  produce  bronchiectasis  and  some  distor- 
tion of  the  lung  in  its  lower  lobe,  where  the  process  is  nearly  always  situated.  The 
condition  is  really  a  pleurogenous  interstitial  pneumonia.  These  cases  are  not 
identical  in  character  with  those  due  to  old  empyema. 

Occasionally  in  chronic  pleurisy  large  calcareous  plates  are  de\'eloped  in  the  newly 
formed  inflammatory  tissues. 

HYDROTHORAX. 

This  condition  is  to  be  clearly  separated  from  ordinary'pleural  effusion  due  to 
inflammatory  changes.  Pleural  effusion  due  to  inflammation  is  usually  unilateral, 
but  hydrothorax  is  often  bilateral.  The  fluid  in  the  pleural  cavities  is  present 
as  a  result  of  transudation  in  cases  of  renal  disease,  cardiac  disease,  profound 
anemia,  or  any  cause  which  tends  to  impede  circulation  or  to  increase  the  readi- 
ness with  which  the  serum  can  escape  from  the  blood\-essels.  Thus  it  may  develop 
in  cases  of  thrombosis  of  the  vena  azygos  during  the  course  of  typhoid  fever. 
While  it  is  true  that  hydrothorax  is  often  bilateral,  it  sometimes  happens  that 
it  is  unilateral,  if  perchance  the  obstruction  to  the  flow  of  blood  or  lymph  is 
produced  by  some  lesion  which  aft'ects  only  one  side  of  the  chest.  This  occurs 
much  more  frequently  on  the  right  side  than  on  the  left,  in  those  cases  in  which  the 
cause  is  cardiac  disease.  Fetterolf  and  Landis  have  shown  that  such  effusions 
come  from  the  visceral  layer  of  the  pleura  and  are  due  to  pressure  of  a  dilated 
heart  on  the  pulmonary  veins.  When  the  eft'usion  is  right-sided  the  pressure  is 
due  to  a  dilated  right  auricle.  When  on  the  left  side  it  is  due  to  pressure  by  dilata- 
tion of  the  left  auricular  appendix  and  of  the  left  ventricle. 

When  it  is  present  in  the  course  of  cirrhosis  of  the  liver  it  is  probaljly  due  to 
the  presence  of  associated  pulmonary  tuberculosis.  Osier  asserts  that  such  an 
eft'usion  may  occasionally  occur  in  what  he  designates  as  "perfectly  healthy  men." 

The  fluid  in  hydrothorax  is  usually  of  low  specific  gravity  (see  Pleurisy  with 
Effusion),  and  clear  or  but  slightly  opalescent,  yellowish  or  straw-colored.  It  is 
not  rich  in  cells,  and  those  cells  that  are  present  consist  largely  of  relatively  volu- 
minous flat  endothelial  cells.  Fibrin  is  usually  absent.  If  an  injury  or  obstruction 
of  the  thoracic  duct  is  present,  the  fluid  may  be  chylous  in  character. 

Again,  if  such  a  patient  is  given  iodide  of  potassium  and  the  fluid  is  withdrawn 
by  aspiration  iodine  will  be  found  in  it,  whereas  if  the  fluid  is  due  to  inflammation 
iodine  is  absent.     The  fluid  is  placed  in  a  test-tube,  a  few  drops  of  fuming  nitric 


PNEUMOTHORAX,   IIYDROPXEC MOTIIORAX,  PYOPNEUMOTHORAX     429 

acid  are  added,  and  then  it  is  shaiven  with  some  chloroform,  when  if  iodine  is  present 
a  red  color  will  appear,  which  sinks  to  the  bottom  of  the  tube  with  the  chloroform. 

Hydrothorax  can  often  be  relieved  by  the  free  use  of  a  saline  purgative,  such  as 
half  an  ounce  of  magnesium  sulphate  given  every  morning  before  breakfast  and 
by  cardiac  tonics  if  they  are  needed.  If  it  causes  symptoms  by  pressure  it  must 
be  removed  by  aspiration.     (See  Pleurisy  with  Effusion.) 

Bloody  effusion  into  the  pleura  is  met  with  in  cases  of  cancer  of  the  pleura  and 
of  Bright's  disease.  It  is  more  indicative  of  the  presence  of  the  former  malady. 
I  have  more  than  once  seen  a  simultaneous  pleural  and  abdominal  bloody  effusion 
due  to  a  general  carcinomatosis. 

When  pleural  effusion  is  tapped  a  second  time,  or  when  the  needle  has  been 
introduced  more  than  once  in  the  search  for  fluid,  it  not  infrequently  happens  that 
the  liquid  obtained  is  blood-stained,  owing  to  wounding  of  a  bloodvessel  bj-  the 
instrument.  Of  course,  this  possibility  must  be  remembered  when  a  bloody 
eft'usion  is  found.  Sometimes  a  true  hemothorax  arises  from  this  cause,  or  it  is 
due  to  a  leakage  from  an  eroded  bloodvessel. 

PNEUMOTHORAX,  HYDROPNEUMOTHORAX,  PYOPNEUMOTHORAX. 

Definition. — Pneumothorax — that  is,  the  presence  of  air  in  the  pleural  spaces — 
is  rarely  present  as  the  result  of  disease  unless  it  is  associated  with  fluid  (hydropneu- 
mothorax)  or  pus  (pyopneumothorax).-  As  the  result  of  injm-ies  to  the  chest  and 
to  the  lungs  it  not  rarely  appears  as  true  pneumothorax,  as  after  the  fracture 
of  a  rib,  or  as  the  result  of  a  stab  wound. 

History. — As  long  ago  as  the  time  of  Hippocrates  a  succussion  sound  on  shaking 
a  patient  suft'ering  from  empyema  or  pleural  effusion  was  recognized,  but  it  was 
not  until  the  time  of  Laennec,  about  2200  years  later,  that  the  value  of  this  sign 
was  appreciated  as  indicating  the  presence  of  both  fluid  and  air  in  the  chest. 

Etiology. — The  most  common  cause  of  pneumothorax  is  pulmonary  tuberculosis, 
and  it  arises  as  a  result  of  the  perforation  of  the  pleura  tlirough  the  visceral  layer. 
In  order  that  air  may  enter  the  pleural  space  the  tuberculous  cavity  must  directly  or 
indirectly  communicate  with  a  patulous  bronchus,  thereby  affording  a  communica- 
tion between  the  lung  and  the  thoracic  cavity.  West  believes  that  fully  90  per 
cent,  of  the  cases  are  due  to  this  cause.  In  many  cases  this  accident  is  prevented 
by  an  acute  or  subacute  pleurisy  occurring  at  the  area  diseased,  so  that  the  pleura 
is  thickened  or  the  two  layers  glued  together.  This  is  particularly  prone  to  be  the 
case  when  a  cavity  has  formed;  and  were  it  not  for  this  protective  process  the 
condition  of  pneumothorax  would  be  commonly  met  with.  In  still  other  cases, 
however,  these  very  adhesions  result  in  pnemnothorax,  for  dm-ing  some  severe 
exertion  they  are  torn,  and  so  the  air  finds  an  opening  through  which  to  escape. 

As  a  rule,  the  perforation  occurs  in  the  lower  part  of  the  upper  lobe,  or  in  the 
upper  part  of  the  middle  lobe.  Pneumothorax  develops  on  the  left  side  nearly 
twice  as  often  as  on  the  right.  West,  however,  believes  that  the  two  sides  are 
nearly  equally  affected.  At  times  the  opening  tlirough  which  the  air  escapes  is 
so  small  that  it  cannot  be  found.     Sometimes  there  is  more  than  one  perforation. 

Very  much  more  rare  as  causes  of  pneumothorax  are  bronchiectasis,  pulmonary 
abscess,  and  pulmonary  gangrene.  So  rare  are  they  that  when  cases  of  this  kind 
occur  they  should  be  reported.  This  holds  true  as  well  of  cases  which  develop 
from  rupture  of  a  vesicle  in  cases  of  emphysema  of  the  lungs.  Pneumothorax 
has  arisen  in  the  course  of  whooping-cough,  diphtheria,  and  typhoid  fever. 

Pneumothorax  occurs  three  times  as  often  in  men  as  in  women. 

Symptoms. — The  onset  of  pneiunothorax  is  often  very  sudden  and  severe,  but 
at  times  it  develops  so  insidiously  that  no  signs  of  its  presence  are  noted  by  the 
patient  until  he  attempts  to  make  some  exertion,  when  dyspnea  ensues.    In  cases 


430  DISEASES  OF  THE  PLEURA 

of  sudden  onset  there  is  not  only  urgent  dyspnea,  but  sometimes  syncope  to  the 
point  of  unconsciousness.  These  severe  symptoms  are  mucli  more  prone  to  develop 
in  a  patient  who  has  slight  pulmonary  disease  than  in  one  who  has  well-advanced 
lesions,  because  in  the  latter  case,  the  lung  being  already  partly  useless,  the  other 
lung  is  ready  to  compensate  for  the  inactivity  of  the  diseased  part.  When  the 
accident  occurs  on  the  comparatively  healthy  side  death  may  s])ccdily  ensue. 
In  some  instances  the  pain  may  be  so  severe  that  angina  pectoris  is  thought  to  be 
present. 

Physical  Signs. — The  physical  signs  in  these  cases  of  pneumothorax  consist 
in  bulging  of  the  interspaces  on  the  affected  side,  and  at  times  the  development 
of  subcutaneous  emphysema.  There  is  also  in  many  cases  a  distinct  increase  in 
the  size  of  the  chest  on  that  side.  If  the  air  escapes  on  the  right  side  the  liver 
is  markedly  depressed  and  the  heart  is  displaced  to  the  left.  In  left-sided  cases 
the  heart  may  be  pushed  to  the  right  of  the  median  line. 

Percussion  reveals  hyperresonance  unless  there  has  been  an  old  pleurisy  with 
secondary  pleural  thickening.  If  the  lung  is  adherent  to  the  chest  wall  and  col- 
lapsed by  pressure,  or  consolidated  by  tuberculosis,  a  dull  note  may  be  present. 
In  a  case  of  this  character  under  my  care,  in  a  patient  whose  general  health  seemed 
to  negative  the  possibility  of  tuberculosis,  this  state  was  confirmed  at  autopsy; 
much  relief  was  given  before  death  by  frequently  permitting  the  air  to  escape  from 
the  chest,  over  part  of  the  chest  wall  through  a  hollow  needle. 

Auscultation  reveals  an  absence  of  vesicular  murmur  over  the  area  of  hyper- 
resonance, and,  perhaps  loud  amphoric  breathing  over  the  lung,  particularly  if  it 
contain  a  cavity  which  freely  communicates  with  the  pleural  space. 

Diagnosis. — In  considering  the  possible  presence  of  pneumothorax  in  the  type 
which  is  insidious  the  following  conditions  must  be  included:  A  large  cavity  may 
give  somewhat  similar  physical  signs,  but  the  limited  area  over  which  they  are 
manifested  or  demonstrable  separates  the  two  states.  Emphysema  of  the  lungs 
is  excluded  by  the  universal  presence  of  breath  sounds  and  the  fact  that  the  con- 
dition is  bilateral.  Rupture  of  the  diaphragm  with  diaphragmatic  hernia  should 
be  considered  if  some  injury  has  been  suffered,  and  pyopneumothorax  subjjlirenicus 
must  be  excluded  by  study  of  the  pulmonary  signs  above  the  area  in\ol\cd  and 
of  the  condition  of  the  epihepatic  and  epigastric  areas. 

Prognosis. — The  prognosis  of  pneimiothorax  depends  largely  upon  the  cause  of 
the  condition  and  the  associated  states  of  effusion  and  empyema.  INIuch  depends 
upon  the  suddenness  of  onset.  I  have  seen  death  occur  in  twelve  hours  in  cases 
with  sudden  onset,  and  cases  are  on  record  of  death  in  twenty  minutes.  On  the 
other  hand,  if  the  dyspnea  is  not  severe  the  pulmonary  condition  may  be  actually 
benefited  by  the  temporary  rest  enforced  by  the  collapse  of  the  lung.  \Vcst  has 
placed  the  mortality  at  70  per  cent.,  and  of  these  fatal  cases  75  per  cent,  died  within 
two  weeks  and  90  per  cent,  within  a  month.  In  those  cases  which  do  not  die  soon 
after  the  onset  of  this  condition  death  may  result  either  from  empyema  and  cxliaus- 
tion,  or  from  the  progress  of  the  imderlying  disease.  If  the  heart  is  feeble,  if  the 
other  lung  is  far  advanced  in  disease,  and  if  the  strength  of  the  patient  is  badly 
impaired  the  prognosis  is,  of  course,  bad.  Recovery  takes  place  in  about  10  per 
cent,  of  the  cases  of  simple  pneumothorax  without  fluid. 

Treatment. — The  treatment  of  pneumothorax  consists  in  the  relief  of  pain,  if 
it  be  very  severe,  by  a  small  dose  of  morphine — say,  \  of  a  grain  gi\-en  hypodermi- 
cally.  If  the  dyspnea  is  marked  a  large  hollow  needle,  or  aspirating  cannula,  should 
be  introduced  into  the  chest,  but  not  attached  to  the  aspirator.  The  pressiure  in 
the  chest  will  cause  more  air  to  escape  than  will  flow  in,  and  as  the  lung  is  already 
collapsed  any  damage  caused  by  its  entrance  is  done.  To  prevent  the  air  from 
entering,  the  finger  may  be  temporarily  used  as  a  valve  on  each  inspiring  movement 
until  a  wash-bottle  can  be  so  arranged  that  the  air  will  escape  through  the  water 


DISEASES  OF  THE  MEDIASTINUM  431 

it  contains  and  then  cannot  return.  If  tiie  air  constantly  reaccumulates  the  case 
should  be  treated  by  a  drainage  tube  inserted  as  in  the  treatment  of  empyema. 
(See  Empyema.) 

If  edema  of  the  other  lung  is  threatened,  dry  cups  should  be  applied  over  its 
base  and  atropine  given  freely  hypodermically. 

When  serous  effusion  is  present,  or  when  empyema  is  a  complication,  the  con- 
ditions should  be  treated  as  described  when  discussing  these  conditions. 

A  most  exhaustive  study  of  this  subject  has  been  made  by  West  in  London, 
and  more  recently  by  Emerson  in  Baltimore. 

When  hydropneumothorax  is  present  the  lower  part  of  the  chest  is  flat  on  percus- 
sion as  in  ordinary  pleural  effusion,  above  this  is  an  area  of  hj^iierresonance,  and 
above  this  again  is  the  Skodaic  resonance  due  to  the  compressed  lung.  On  shaking 
the  patient  a  succussion  sound  is  heard,  and  when  the  patient  is  erect  miscuUation 
may  reveal  "metallic  tinkling,"  which  is  supposed  to  be  due  to  the  dropping  of  fluid 
into  the  liquid  at  the  base  of  the  chest.  Succussion  and  metaUic  tinkling  are  the 
most  important  signs  of  hydropneumothorax.  Another  valuable  sign  is  the  so- 
called  "coin  sound"  produced  by  striking  a  large  coin,  held  against  the  chest  wall, 
with  another  coin.  The  physician  listens  to  the  back  of  the  chest  as  the  percussion 
is  done,  by  an  assistant,  on  its  anterior  surface,  and  closes  his  unemployed  ear  with 
his  finger-tip.  If  the  coin  be  struck  so  that  the  sound  has  to  be  transmitted  tlirough 
the  chest  at  the  level  of  the  fluid  the  sound  is  very  indistinct.  At  the  level  of  the 
air  it  is  transmitted  with  startling  clearness,  and  at  the  level  of  the  lung  the  sound 
is  again  impaired. 

DISEASES  OF  THE  MEDIASTINUM. 

Under  this  heading  are  considered  diseases  of  the  mediastinum  other  than  those 
of  the  heart  and  aorta.  In  my  Fothergillian  Prize  Essay  I  collected  520  cases  of 
mediastinal  disease,  and  the  facts  there  presented  form  the  basis  for  the  following 
views.  The  statistics  on  their  face  show  that  there  were  134  cases  recorded  as 
carcinoma,  98  as  sarcoma,  21  as  lymphoma  or  lymphadenoma,  and  115  as  abscess. 
In  other  words,  a  large  proportion  of  cases  of  disease  in  this  area  are  due  to  malig- 
nant growths,  for  the  remaining  lesions  are  non-malignant  or  inflammatory.  The 
statistics  apparently  indicate  that  cancer  is  by  far  the  most  frequent  form  of  in- 
dividual growth.  While  we  have  no  right  to  go  "  behind  the  returns,"  in  the  sense 
that  cases  reported  as  cancer  may  be  regarded  as  sarcoma,  it  is  nevertheless  certain 
that  sarcoma  is  really  the  most  frequent  growth  in  the  mediastinum,  because 
tissues  favorable  to  its  growth  are  found  there  in  great  abundance  and  tissues 
susceptible  to  carcinomatous  growth  are  scanty.  Again,  it  is  well  known  that 
up  to  the  middle  of  the  last  century,  and  later,  little  distinction  was  made  between 
cancer  and  sarcoma,  and  so  many  cases  of  sarcoma  were  probably  reported  as 
cancer.  Finally,  lymphoma  are  so  nearly  allied  to  sarcoma  that  it  is  fair  to  add 
them  to  the  so-called  sarcomatous  cases,  making  the  total  119  reported  as  sarcoma. 

The  non-malignant  tumors  of  the  mediastinum  are  fibroma,  teratoma,  dermoid 
cyst,  and  hydatid  cyst. 

Notwithstanding  the  fact  that  the  middle  and  posterior  mediastinal  spaces 
are  more  richly  provided  with  lymphoid  tissues  than  the  anterior  mediastinum, 
the  statistics  prove  that  malignant  growth  is  more  common  in  the  latter  space 
than  in  the  other  spaces.  Thus,  of  the  cases  reported  as  sarcoma  and  cancer, 
in  which  the  space  affected  was  stated,  81  were  in  the  anterior  space  as  against 
28  in  the  posterior  space,  and  only  5  in  the  middle  space  alone,  although  in  many 
other  instances  the  entire  mediastinum  was  invaded. 

For  this  reason  we  should  expect  to  find  that  sarcoma  in  a  very  large  proportion 
of  cases  occurred  as  a  secondary  growth  in  the  mediastinum;  but  an  examination 
of  the  literature  of  the  subject,  both  as  regards  general  opinion  and  reports  of  cases, 


432  DISEASES  OF  THE  PLECRA 

shows  such  a  conclusion  to  be  erroneous.  Indeed,  the  mediastinum  seems  to  rarely 
suffer  from  any  form  of  this  disease  save  the  primary,  and  even  in  those  cases  in 
\\'hich  the  lesions  were  scattered  all  througli  the  body  from  liead  to  foot,  tliis  space 
seems  to  have  escaped  secondary  contamination.  Should  the  growth  a])pear  in 
the  mediastinum,  secondarily,  it  generally  afi'ects  the  posterior  or  middle  spaces, 
owing  to  the  large  number  of  lymphatic  glands  and  like  tissues  which  are  found 
in  these  cases. 

It  is  a  curious  fact  that  mediastinal  growths  are  twice  as  common  in  men  as  in 
women,  although  women  so  much  more  frequently  have  malignant  growths  in 
nearby  tissues,  and  in  them,  as  already  stated,  malignant  growth  of  the  lung  is 
said  to  be  more  common. 

The  average  age  affected  by  mediastinal  tumors  is  about  thirty-seven  years. 

Symptoms. — The  symptomatology  of  mediastinal  tumor  is  by  no  means  clear 
and  well  defined,  since  so  many  other  conditions  may  produce  signs  of  the  same 
character,  and  it  has  been  stated  very  positively  by  certain  writers  before  the 
days  of  the  ,f-rays  that  such  a  growth  cannot  be  diagnosticated  during  life. 

Although  this  assertion  seems  rather  sweeping,  there  is,  nevertheless,  some 
truth  in  it,  and  in  many  cases,  where  we  have  no  history  to  guide  us  and  no  e^•idence 
of  a  growth  elsewhere,  the  diagnosis  may  be  well-nigh  impossible. 

liarge  tumors  are  found  in  the  anterior  mediastinmn,  which  ha\'e  not  been  diag- 
nosticated or  suspected  until  a  postmortem  has  been  made,  not  from  any  lack  of 
ability  on  the  part  of  the  physician,  but  because  the  sjmptoms  of  mediastinal 
disease  have  either  been  entirely  absent  or  masked  by  others  of  more  importance 
elsewhere.  Thus,  in  a  case  reported  by  Bruen,  an  old  woman,  aged  seventy  years, 
entered  the  Philadelphia  Hospital  with  decided  symptoms  of  renal  disorder,  which 
in  a  few  days  caused  her  death.  Although  an  examination  was  made  of  the  chest, 
as  a  matter  of  routine  duty,  no  special  physical  signs  were  discovered,  and  the 
disease,  which  was  sarcoma  in  the  anterior  mediastinum,  was  not  discovered  until 
the  body  was  placed  on  the  postmortem  table.  The  only  symptoms  of  such  a 
condition  of  affairs  before  death  consisted  in  slight  dyspnea  and  cough,  both  of 
which  were  supposed  to  arise  from  the  renal  lesions;  and  this  is  the  more  remarkable, 
since  the  growth  weighed  fourteen  ounces,  was  si.x  inches  long  by  five  inches  broad 
and  four  inches  in  diameter,  or,  in  other  words,  was  about  the  size  of  a  normal  adidt 
heart.  No  signs  of  sarcoma  existed  elsewhere  in  the  body  from  which  one  might 
suspect  any  malignant  disease. 

The  first  symptoms  complained  of  by  the  patient  vary  quite  as  much  as  do  the 
later  ones,  and  depend,  as  do  their  successors,  upon  the  parts  most  in\'olved.  By 
far  the  largest  number  of  sufi'ercrs  notice  some  interference  with  respiration,  particu- 
larly on  exertion,  which  soon  increases,  so  that  there  may  be  constant  dyspnea, 
and  even  attacks  of  iMrtial  suffocation. 

The  dyspnea  and  other  disturbances  of  respiration  are,  in  many  instances,  due 
to  several  ratiier  than  any  single  cause,  since,  in  addition  to  the  mechanical  pressure 
by  the  growth  on  the  air-passages,  we  may  also  have  such  interference  with  the 
circulation  of  the  blood,  particularly  in  the  thoracic  veins,  that  pleural,  pericardial, 
or  mediastinal  effusions  of  serum  may  occur. 

Eff'usions  into  the  abdomen  may  occiu",  o\\ing  to  involvement  of  the  ascending 
vena  cava,  but  such  a  condition  is  rather  rare,  probably  owing  to  the  fact  that  the 
ascending  cava  more  frequently  escapes  than  does  the  descending.  Dropsy  of  the 
lower  extremities,  without  abdonn'nal  effusion,  sometimes  comes  on. 

In  still  another  class  of  cases  the  pulmonary  vein  may  be  obstructed,  and  edema 
of  the  lung  may  develop.  Hypostatic  congestion  is  by  no  means  rare,  the  patient 
often  beuig  forced,  by  cardiac  weakness,  pleural  eff'usion,  or  pressure  on  the  trachea, 
to  lie  in  one  position.  In  some  cases  loud  venous  miu-murs  can  be  heard  in  the 
jugular  and  other  large  superficial  veins,  and  care  has  to  be  exercised  as  to  the 


DISEASES  OF  THE  MEDIASTINUM  433 

diagnosis  of  the  true  cause  of  the  distress.  The  ribs  and  sternum  may  undergo 
gradual  erosion  and  destruction  from  pressure,  and  the  growth  appear  on  the  surface 
of  the  body. 

In  a  certain  number  of  cases  the  nerves  of  the  thorax  seem  to  be  more  afi'ected 
that  the  rest  of  its  contents,  and  involvement  of  the  vagi  or  the  recurrent  laryngeal 
nerves  may  bring  on  a  long  train  of  obscure  and  dangerous  symptoms,  both  as 
regards  the  circulation,  respiration,  digestion,  speech,  and  swallowing. 

Tumors  of  the  mediastinum  invading  the  lungs  have  frequently  been  mistaken 
for  chronic  and  even  acute  pneumonia,  growing,  as  they  do,  along  the  larger  bron- 
chial tubes  and  bloodvessels. 

Without  doubt,  in  a  certain  number  of  cases,  either  hj-postatic  pneumonia, 
or  pneumonia  due  to  pressure  on  the  bronchial  vessels,  develops  as  the  tumor 
invades  the  lung,  and  in  such  cases  it  is  absolutely  impossible  to  make  a  diagnosis 
unless  there  are  symptoms  of  pressure  in  the  mediastinum.  Walsh  has  stated 
that  if  the  lesion  be  due  to  a  tumor,  the  afl'ected  side  will  increase  in  bulk  rather 
than  diminish,  and  that  dyspnea  out  of  proportion  to  the  degree  of  consolidation 
points  to  a  mediastinal  disorder  rather  than  one  confined  to  the  lungs. 

In  a  very  large  proportion  of  cases  of  mediastinal  disease  the  condition  is  one 
of  abscess.  There  were  115  cases  in  my  collection  of  520  of  mediastinal  disease. 
The  proportion  of  acute  and  cold  abscess  in  79  cases  in  which  the  differentiation 
was  made  was  48  to  31. 

The  most  constant  and  severe  symptom  is,  in  nearly  all  cases,  the  deep-seated 
pain,  which  increases  in  severity  from  first  to  last,  seldom  remitting  until  suppura- 
tion has  taken  place  and  the  pus  has  found  some  outlet.  If  the  case  be  one  of 
cold  abscess,  these  painful  symptoms  may  be  masked  by  other  more  pressing  ones, 
such  as  dyspnea  and  edema  from  pressure;  although  it  should  not  be  forgotten  that 
such  symptoms  may  appear  with  equal  severity  in  both  varieties  of  the  disease. 
In  the  acute  variety  all  the  symptoms  of  ordinary  inflammation  appear,  such  as 
rigors  and  periodical  or  constant  fever. 

As  recovery  took  place  in  about  40  per  cent,  of  the  cases  of  mediastinal  abscess 
according  to  the  statistics  of  preantiseptic  days,  it  ought  to  occur  much  more 
frequently  now. 

Mediastinal  growths  are  usually  of  such  a  nature  as  to  be  beyond  either  medicinal 
or  surgical  treatment,  but  abscess,  dermoid  cysts,  and  teratomata  are  sometimes 
operable. 


28 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


DISEASES  OF  THE  PEEICARDIUM. 

PERICARDITIS. 

Acute  Pericarditis. — Definition. — i\cute  pericarditis,  sometimes  called  acute 
fibrinous  or  acute  serofibrinous  pericarditis,  is,  as  its  name  implies,  an  acute  inflam- 
mation of  the  pericardium,  the  serous  membrane  which  en\elops  the  heart. 

Etiology. — Acute  pericarditis  is  practically  always  due  to  the  presence  of  some 
infecting  micro-organism,  although  certain  conditions  existing  simultaneously 
may  predispose  to  the  infection  by  lowering  vital  resistance.  In  the  great  majority 
of  cases  it  is  due  to  acute  articular  rheumatism,  in  comparatively  few  it  develops 
as  a  complication  of  croupous  pneumonia,  the  pneimiococcus  being  its  cause,  and 
it  also  develops  as  a  complication  of  scarlet  fever,  in  which  disease  the  streptococcus 
associated  with  this  malady  is  probably  the  provoking  factor.  Acute  pericarditis 
is  also  frequently  associated  with  renal  disease,  and  is  often,  under  these  circum- 
stances, a  form  of  terminal  infection.  So,  too,  it  may  develop  in  the  course  of 
various  infectious  diseases,  such  as  smallpox,  erysipelas,  typhoid  fever,  and  even  in 
measles.  Septic  infections,  such  as  general  septicemia  and  idcerative  endocarditis, 
may  cause  it.  In  diabetes  it  occurs  as  a  terminal  infection.  Of  course,  tuberculosis 
and  syphilis,  diseases  which  aft'ect  every  tissue,  may  also  affect  this  one. 

Acute  pericarditis  also  develops  by  direct  extension  from  inflammation  in  neigh- 
boring parts,  in  distinction  from  infection  which  takes  place  through  the  blood. 
Thus,  inflammation  of  the  mediastinal  tissues  may  produce  it,  as  in  diseases  of  the 
bronchial  glands,  of  the  sternum,  or  of  the  vertebrae.  So,  too,  pneumonia  and 
pleurisy  affecting  nearby  portions  of  the  lung  maj'  cause  inflammation  of  the 
pericardium.  In  infections  involving  the  myocardium  the  overlying  serosa — 
that  is,  the  visceral  layer  of  the  pericardium — rarely  escapes.  So,  too,  pericarditis 
may  be  the  first  indication  of  impending  rupture  of  that  part  of  the  aorta  covered 
by  pericardium. 

Pericarditis  may  also  be  due  to  injury  to  the  chest  wall  or  to  the  membrane 
itself. 

It  is  evident,  therefore,  that  acute  pericarditis  is  nearly  always  a  condition 
secondary  to  some  other  affection,  and  that  it  is  very  rarely  primary.  When  it  is 
primary  it  is  usually  due  to  tuberculosis.  (See  articles  on  Croupous  Pneumonia, 
Acute  Rheumatic  Fever,  and  Typhoid  Fever.) 

Frequency. — The  frequency  of  pericarditis  as  a  primary  disease  is  very  limited, 
but  as  a  secondary  aft'ection  it  is  great.  Very  many  cases  present  no  sign  of  it 
during  life,  yet  the  condition  is  found  at  autopsy.  It  occurs  almost  as  frequently 
in  children  as  in  adults,  although  at  one  time  this  class  of  patients  was  supposed 
to  be  not  so  commonly  attacked  as  older  persons.  Sturges  found  it  present  in 
94  out  of  100  cases  of  fatal  heart  disease  in  children.  Of  these  cases  54  were  of 
rheumatic  origin.  Indeed,  it  is  probable  that  the  disease  is  less  prevalent  after 
than  before  puberty.  It  occurs  far  more  frequently  in  males  than  in  females, 
and  this  is  particularly  true  after  puberty,  when  the  greater  exposure  and  activity 

(435) 


436 


DISEASES  OF  THE  PERICARDIUM 


of  males  become  dominant  factors  in  causing  rheumatism  and  other  infections. 
At  this  time  the  proportion  is  from  4  to  1  to  6  to  1. 

Pericarditis,  as  we  would  expect,  develops  more  commonly  in  severe  cases  of 
acute  rheumatism  than  in  mild  cases,  but,  on  the  other  hand,  it  is  to  be  borne  in 
mind  that  even  in  those  cases  with  very  mild  joint  symptoms  severe  pericardial 
involvement  may  occur.  Prior  attacks  of  rheumatism  seem  to  increase  the  fre- 
quency of  pericarditis  in  subsecjuent  attacks.  The  condition  usually  comes  on 
during  the  first  week  of  the  disease.  This  is,  however,  by  no  means  always  the 
case,  and  it  may  appear  as  late  as  the  sixtieth  day  of  the  illness  or  during  a  relapse. 

Pericarditis  due  to  renal  disease,  the  Pericardite  Brlglitiqve  of  the  French,  is 
distinctly  a  state  of  advanced  years,  occurring  most  commonly  after  forty-five 
or  fifty  years  of  age.  It  is  more  commonly  met  with  in  patients  suffering  from 
contracted  kidney  than  in  those  that  present  the  parench\matous  form  of  renal 
disease. 

Fig.  so 


Heart  and  pericardium,  acute  serofibrinous  (pneumococcal)  pericarditis.  Most  of  the  anterior 
parietal  layer  of  the  pericardium  has  been  cut  away,  showing  the  \-illous  (shaRgj-)  irregular  projec- 
tions of  the  fibrin.  To  the  left,  where  the  parietal  pericardium  is  reflected  over  the  right  auricle  aud 
great  vessels,  cohesion  of  the  layers  may  be  seen;  later,  had  the  patient  recovered,  such  fusiou  of  the 
layers  would  have  consituted  the  basis  from  wluch  organized  fibrous  adhesions  would  have  formed. 


Pathology. — As  in  inflammation  of  the  pleura,  so  in  inflammation  of  the  pericar- 
dium, it  is  well  to  recognize  three  forms  of  acute  pericarditis,  viz.,  the  acute  dry 
OT  fibrinous,  the  acute  exudative  (serofibrinous),  and  the  purulent  type.  In  the  first 
stage  of  all  these  forms  of  pericarditis  the  lining  surface  of  the  pericardium  is  lustre- 
less, opaque,  and  somewhat  roughened  by  a  delicate  fibrinous  exudate.  It  is  also 
hyperemic  and  may  be  dotted  with  petecliire.  It  is  the  rubbing  together  of  the 
two  layers  of  the  pericardium  at  this  stage  that  causes  tlie  characteristic  friction 
sound  of  the  disease.  As  the  inflammation  progresses  the  membrane  becomes 
completely  covered  by  the  exudation  of  fibrin,  which  may  assume  a  villous  forma- 
tion.    Adhesions  between  the  layers  of  the  pericardium  also  take  place. 

In  the  serofibrinous  form  a  considerable  quantity  of  serum  is  poured  out  into 


PERICARDITIS 


to  I 


the  sac,  and  particles  of  fibrin  and  leukocj'tes  are  found  in  it.  The  quantity  may 
be  so  large  as  greatly  to  distend  the  sac,  displace  the  heart,  and  interfere  with  its 
function,  particularly  by  pressure  upon  the  auricles  and  cava?.  In  many  cases 
as  much  as  three  pints  haA-e  been  found  in  the  sac.  West  quotes  cases  in  which 
the  pericardial  sac  contained  no  less  than  five  pints  (due  to  scurvy),  yet  recovery 
occurred  after  aspiration. 

In  the  purulent  form  {pyoyericardrnm)  the  serum  and  fibrin  are  mixed  with  pus 
cells  and  erythrocytes.  Pyopericardiimi  may  arise  as  a  primary  purulent  pericar- 
ditis or  be  converted  from  the  serous  form  by  infection  with  the  Streptococcus, 
Pneumococcus,  or  Staphylococcus  pyogenes  aureus.  Sometimes  the  tubercle  bacillus 
acts  as  a  pyogenic  organism  in  this  space. 

There  is  some  difference  of  opinion  as  to  the  frequency  of  pyopericardium.  Two 
opinions  which  represent  the  two  sides  of  this  question  are  as  follows:  Samuel 
West  speaks  of  it  as   "one  of  the 

rarest  of  clinical  rarities,"  but  Battin  Fig.  si 

says  "  it  is  a  disease  seldom  suspected, 
still  more  rarely  diagnosed,  and 
hardly  ever  treated,  and  yet  it  is 
one  that  is  present  in  3  per  cent,  of 
the  deaths  in  the  records  of  the 
Children's  Hospital." 

That  the  latter  view  is  correct  is 
shown  by  the  fact  that  Breitung  in 
324  cases  of  pericarditis  found  that 
108  were  serofibrinous,  30  hemor- 
rhagic, and  20  purulent,  or  6.1  per 
cent.  In  769  autopsies  collected  by 
Still  24  instances  of  pyopericardium 
were  found,  and  11  were  due  to  in- 
fection by  the  pnemnococcus.  Scott 
found  it  in  no  less  than  16  cases  out 
of  40  (40  per  cent.),  and  in  38  cases 
of  croupous  pneumonia  the  same 
reporter  found  pyopericardium  in  17, 
or  44.7  per  cent. 

Symptoms  of  Acute  Fibrinous  Peri- 
carditis.— The  sjTuptoms  of  acute 
fibrinous  pericarditis  are  often  not 
pronounced .  Pain  would  supposedly 
be  a  well-marked  symptom,  but  it  is 
not  present  in  all  cases,  although 
when  it  is  present  it  may  be  severe. 

Fortunately  pain  from  this  cause  is  rare  in  children.  ^Mien  it  occurs  it  is 
usually  felt  from  the  right  edge  of  the  sternum  to  the  left  nipple  and  is  fairly 
constant,  although  it  has  sharp  exacerbations.  In  other  cases  the  pain  is  chiefly 
situated  in  the  epigastrimu,  or  a  sense  of  precordial  distress  develops,  and  the  breath- 
ing may  be  oppressed.  The  action  of  the  heart  is  rapid,  often  reaching  100  or  120 
and  even  160  beats  per  minute  in  severe  cases.  The  temperature  is  usually  in- 
creased, but  seldom  rises  above  102°  or  103°.  In  some  cases  it  is  not  abnormal. 
Nervous  symptoms  are  sometimes  notable  and  great  restlessness  or  even  active 
deliriuvi  may  ensue,  resembling  that  of  delirium  tremens.  Vomiting  is  a  common 
symptom. 

Physical  Signs. — ^The  physical  signs  of  acute  fibrinous  pericarditis  are  as 
follows:  Palpation  over  the  base  of  the  heart  at  the  third  interspace  may  reveal 


Area  in  which  pericardial  friction  sound  is 
best  heard. 


438  DISEASES  OF  THE  PEniCAUDlVM 

friction  fremitus  in  well-marked  cases,  and  amcidiation  will  show  a  distinct  friction 
sound  in  the  same  area  when  the  disease  is  estahiished.  Tliis  sound  is  creaking 
and  dry  and  has  been  called  the  "saddle-leather  sound,"  in  that  it  resembles  the 
creaking  of  an  ordinary  English  leather  saddle  when  it  is  first  used.  It  differs 
from  the  friction  sound  of  pleurisy  in  that  it  is  to  and  fro  and  docs  not  occur  with 
tlie  respirations.  At  times  it  lias  a  gallop  rhythm  with  a  trij)le  sound  as  of  a  horse 
galloping.  If  the  stethoscope  be  pressed  against  the  chest  the  sound  can  usually 
be  intensified.  These  sounds  vary  with  the  severity  of  the  inflammation  of  the 
pericardium  and  the  action  of  the  heart,  being  more  sharply  defined  when  the  action 
is  violent  than  when  it  is  depressed.  Indeed,  \ariation  in  the  action  of  the  heart 
may  cause  a  loud  friction  sound  at  one  \-isit  and  a  lack  of  it  at  the  next.  As  a 
rule  the  pericardial  friction  sound  is  limited  to  the  area  of  the  cardiac  base  about 
the  third  or  fourth  interspaces,  but  it  may  be  heard  at  the  apex  or  along  the  sternum. 

Diagnosis  of  Acute  Fibrinous  Pericarditis. — Acute  dry  pericarditis  can  scarcely 
be  confused  with  any  other  state,  but  several  conditions  resemble  it  somewhat. 
Thus  in  cases  of  early  phthisis  there  is  occasionally  heard,  near  the  apex  of  the  left 
lung,  a  cardiopulmonary  murmur  or  puffing  sound  during  inspiration,  occurring 
with  each  beat  of  the  heart,  and  persisting  if  the  patient  holds  his  breath  on  a  full 
inspiration,  but  disappearing  on  expiration.  Another  similar  condition  is  the  so- 
called  "  pleuropericardial  friction  sound,"  which  is  apparently  due  to  the  beating 
of  the  heart  against  the  margin  of  the  lung.  Both  of  these  sounds  are,  however, 
more  in  the  nature  of  murmurs  than  friction  sounds. 

Symptoms  of  Serofibrinous  Pericarditis. — With  the  development  of  effusion,  in  cases 
which  go  on  to  that  state,  symptoms  of  cardiac  embarrassment  begin  to  show  them- 
selves. The  evidences  of  cardiac  disturbance  are  not  always,  however,  in  direct 
proportion  to  the  amount  of  fluid,  for  in  some  instances  large  accumulations  of 
fluid  cause  so  little  inconvenience  as  to  be  overlooked,  while  in  others  in  which  the 
fluid  is  moderate  in  quantity  they  are  severe.  It  is  important  that  these  variations 
in  the  severity  of  the  symptoms  be  remembered,  because  it  is  humiliating  in  the 
extreme  to  find  after  some  time  that  an  unsuspected  pericardial  eft'usion  is  present. 
Probably  the  most  constant  symptoms  are  dyspnea,  a  dusky  skin,  an  anxious  fades, 
and  a  rapid  p)uhe,  which  varies  in  volume  and  speed  with  the  respirations.  The 
voice  is  somewhat  husky,  and  active  delirium  may  be  present  as  in  the  dry  form. 

Diagnosis  of  Pericardial  Effusion. — When  the  pericarflimn  is  well  filled  with 
fluid  the  sac  presents  a  peculiar  pear-shaped  swelling  which  consists  of  two  spheres 
superimposed,  the  smaller  one  above  the  larger  one.  It  extends  across  the  middle 
zone  of  the  chest  from  a  little  to  the  left  of  the  right  nipple  to  a  little  to  the  left  of 
the  left  nipple,  and  from  the  central  tendon  of  the  diaphragm  nearly  to  the  top 
of  the  sternum.  The  pressure  of  this  fluid  upon  the  heart  and  its  great  vessels 
may  very  markedly  interfere  with  their  proper  movement,  but  it  docs  not  greatly 
change  its  position. 

Physical  Signs. — The  physical  signs  of  pericardial  eft'usion  are  as  follows: 
On  inspection  the  apex  beat  is  absent  and  in  many  cases  it  cannot  be  found  on 
palpation  unless  the  patient  is  turned  on  his  face.  The  chest  over  the  heart  may 
be  slightly  bulging,  and  palpation  may  reveal  the  fact  that  the  first  rib  can  be 
felt  projecting  more  prominently  from  beneath  the  clavicle  than  in  health.  So, 
too,  inspection  may  reveal  some  prominence  of  the  epigastrium,  and  there  may  be 
unusual  tenderness  on  palpation  of  this  area. 

The  heart  sounds,  on  auscultation,  are  distant  and  feeble  and  the  area  of  cardiac 
dulness  is  greatly  enlarged.  Thus  it  extends  to  the  right  of  the  sternum  to  a  level 
below  that  which  forms  the  base  of  the  cardiac  triangle,  and  to  the  left  of  the  nipple. 
There  is  also  enlargement  of  the  area  of  cardiac  dulness  at  the  base  toward  the 
left.  The  presence  of  dulness  in  the  fifth  interspace,  to  the  right  of  the  sternum 
(Rotch's  sign),  of  dulness  as  high  as  the  second  cartilage  or  second  interspace 


PERICARDITIS  439 

(Sansom's  sign),  combined  with  dulnt'ss  over  the  sternum  between  these  points, 
are  pretty  sure  signs  of  pericardial  effusion,  particularly  if  at  the  left  infrascapular 
angle  there  is  dulness  on  percussion  (Kwart's  sign).  The  area  of  dulness  is  that  of 
a  flattened  cone,  or,  as  Ewart  has  well  said  "  it  is  that  of  a  bag  of  fluid  spreading 
out  at  the  base."  This  view  has  been  combated  by  Dr.  I'rederick  Shattuck, 
but  the  distended  sac  does  undoubtedly  take  this  shape,  although  inability  to 
demonstrate  its  outline  does  not  exclude  effusion  by  any  means. 

In  doubtful  cases,  resort  to  the  .r-rays  may  aid  greatly  in  deciding  the  question 
of  the  presence  of  effusion. 

The  most  important  states  to  be  differentiated  from  pericardial  effusion  are 
cardiac  dilatation  and  hypertrophy,  and  aneurysm  of  the  aorta  with  some  leakage 
into  the  pericardial  sac.  The  first  is  the  condition  most  apt  to  mislead  the  physi- 
cian. I  have  seen  this  occur  several  times  and  I  have  seen  the  heart  punctured 
on  two  occasions  in  an  endeavor  to  aspirate  the  pericardial  sac  in  the  belief  that 
effusion  was  present  when  in  reality  the  condition  was  one  of  great  cardiac  dilatation 
with  pericardial  adhesion.  The  presence  of  feeble  and  distant  heart  sounds,  the 
absence  of  a  definite  apex  beat,  and  the  manifest  cardiac  embarrassment  all  aided 
in  producing  an  erroneous  \'iew  in  these  cases.  In  such  a  case  the  history  of  old 
valvular  difficulty  and  the  dift'use  character  of  the  apex  beat  should  help  us  to  a 
clear  view  of  the  condition.  In  cardiac  hypertrophy  the  distinct  apex  beat,  the 
strong  action  of  the  heart,  and  its  clear  sounds  separate  the  two  conditions.  An 
aneurysm  of  the  root  of  the  aorta  with  some  pericardial  effusion  may  be  most 
misleading.  In  a  case  of  this  kind,  seen  by  me,  aspiration  of  the  pericardial  sac 
caused  rupture  of  the  aorta  and  instant  death. 

Very  large  pericardial  eft'usions  have  been  taken  for  left-sided  pleural  eft'usions, 
and  an  encapsulated  pleural  eft'usion  has  been  taken  for  an  effusion  into  the  peri- 
cardium. 

Prognosis  of  Acute  Pericarditis  with  and  without  Efiusion. — This  is  good  in  cases 
in  which  the  heart  is  not  seriously  crippled  by  the  eft'usion  or  by  associated  endo- 
cardial changes.  The  outlook  is  favorable  in  proportion  to  the  smallness  of  the 
effusion  and  the  benignity  of  the  disease  causing  it.  In  pneumonia  and  renal 
disease  the  prognosis  is  worse  than  it  is  in  rheumatism,  in  which  disease  it  is  good. 

In  the  great  majority  of  cases  pericardial  eft'usion  imdergoes  absorption.  This 
happens  in  this  sac  far  more  frequently  than  in  the  pleural  sacs,  perhaps  because 
of  the  constant  action  of  the  heart.  When  the  eft'usion  persists  it  must  be  removed. 
(See  Treatment.)  Life  is  sometimes  prolonged  for  many  weeks  even  after  pyoperi- 
cardium  develops.  Coutts  has  recently  reported  the  case  of  a  child  of  four  years 
that  lived  seventeen  weeks  and  died  only  after  operation.  Nevertheless,  pyoperi- 
cardium  is  a  very  fatal  condition. 

Treatment. — In  the  early  stages  of  acute  pericarditis,  if  the  heart  is  OA-eracting 
and  irritated,  tinctiu-e  of  aconite  may  be  given  with  advantage  to  quiet  its  action 
and  to  diminish  friction.  An  ice-bag  may  be  placed  over  the  precordium  in  cases 
of  pneumonia  with  this  complication,  and  in  rheiunatism  several  fly  blisters  may 
be  used.  Later  if  the  heart  becomes  feeble  the  best  stimulants  are  the  aromatic 
spirit  of  ammonia,  Hoft'mann's  anodyne,  and  alcohol.  Digitalis  except  in  small 
doses  is  rarely  of  any  value,  and  may  be  prevented  from  acting  properly  by  reason 
of  the  fever  or  because  there  is  not  room  in  the  pericardial  sac  for  full  diastole  to 
take  place  under  its  influence. 

If  the  quantity  of  effusion  be  very  great  it  must  be  removed  by  aspiration  or 
incision.  The  latter  operation  is  always  essential  if  pus  is  present,  and  even  if 
serum  is  present  incision  is  safer  because  it  is  by  no  means  easy  to  diagnosticate 
the  presence  of  fluid  beyond  a  doubt  and  more  difficult  still  to  be  siu-e  of  the  part 
of  the  sac  farthest  away  from  the  heart.  Aspiration  may  be  therefore  in  the 
nature  of  a  plunge  in  the  dark.     Incision  carefully  made  is  safer.     The  best  spot 


440  DISEASES  OF  THE  PERICARDIUM 

for  operative  interference  depends  upon  the  individual  conditions  and  the  position 
of  the  apex  beat.  The  usual  areas  of  election  are  in  the  fourth  interspace  at  the 
left  edge  of  the  sternum  and  at  the  fifth  right  interspace  at  the  edge  of  the  sternum. 

When  incision  is  practised  for  pyopericardium  the  mortality  is  high,  but  never- 
theless it  must  be  performed  if  recovery  is  to  occur.  Out  of  51  cases  collected 
by  Porter  20  recovered  and  31  died. 

The  use  of  purgatives,  diuretics,  and  diaphoretics  to  cause  the  removal  of  the 
fluid  is  almost  useless. 

Chronic  Pericarditis  (Adhesive  Form). — Definition  and  Pathology. — By  chronic  ad- 
hesive pericarditis  is  meant  a  condition  in  which  one  or  all  of  the  following  patho- 
logical conditions  arise  as  a  result  of  an  inflammatory  process,  which  involves  the 
pericardium  and  often  the  tissues  that  surround  it: 

(1)  There  may  develop  a  state  in  which  partial  or  localized  adhesions  take  place 
between  the  visceral  and  parietal  layers  of  the  pericardium.  Several  such  adhesions 
may  be  present  in  the  pericardium  at  the  same  time.  These  adhesions  may  be 
immediate  or  consist  in  long  strings  of  fibrous  tissue  stretching  across  the  pericardial 
sac.     They  are  commonly  found  near  the  base,  but  also  occiu-  at  the  apex. 

(2)  In  the  second  class  of  cases  the  two  layers  of  the  pericardium  are  closely 
adherent,  and  the  walls  of  the  sac  in  some  cases  are  much  thickened.  Here  again 
the  adhesion  maj'  not  be  universal,  but  in  patches,  although  at  times  the  entire 
sac  is  obliterated  so  that  the  heart  is  surrounded  by  a  thick  and  tough  capsule 
composed  of  the  two  layers,  which  cannot  be  separated. 

(3)  In  still  a  third  class  the  inner  surfaces  of  the  pericardium  are  not  so  much 
involved  as  the  outer  surface,  and  as  a  consequence  we  find  adhesions  to  the  chest 
wall  or  to  the  pleura.  It  is  perhaps  hardly  fair  to  class  this  type  with  those  already 
named,  because  the  pericarditis  in  these  instances  is  usually  the  result  of  a  spread 
of  inflammation  from  neighboring  parts,  as  from  the  pleura  or  mediastinal  tissues. 

(4)  Another  type,  and  the  most  serious  of  all,  is  that  in  which  the  internal  and 
external  layers  are  glued  together,  and  the  external  layer  is  adherent  to  neighboring 
tissues  so  that  the  heart,  its  membranes,  and  adjacent  parts  are  bound  up  in  an 
inflammatory  mass  or  mat.  If  the  mediastinal  tissues  are  not  aft'ected  the  con- 
dition is  called  "pericarditis  externa  et  interna,"  but  if  the  mediastinal  tissues  are 
included  it  is  given  the  name  of  "indurative  mediastinopericarditis."  In  some 
cases  the  tissues  for  nearly  the  whole  length  of  the  left  edge  of  the  sternum  may  be 
involved. 

(5)  Finally,  a  form  of  chronic  pericarditis  occurs  which  affects  the  visceral 
layer  of  the  pericardium  almost  solely,  and  encloses  the  heart  in  a  thickened  inner 
layer. 

Related  to  the  latter  condition  is  the  so-called  "multiple  serositis"  or  the  "peri- 
carditic  pseudocirrhosis  of  the  liver"  of  Pick,  to  which  the  name  "iced  liver"  has 
been  given  by  Curschmann.  In  such  cases  the  pericardium  suffers  from  a  chronic 
hyperplastic  or  fibroid  inflammatory  process,  which  likewise  aft'ects  the  serous 
membranes  elsewhere,  whence  the  name  "multiple  serositis."  In  other  words,  in 
this  diseased  state  all  serous  membranes  of  the  thoracic  and  upper  abdominal  zones 
are  involved  in  a  hyperplastic  process  which  is  prone  to  affect  the  pericardium  in 
particular.  In  some  instances  the  pericardial  sac  contains  fluid,  but  in  others  it  is 
closed  by  the  adhesions  between  its  walls,  and  which  go  on  even  to  calcification. 
When  the  condition  is  well  developed  the  pericardium  and  pleura?  are  adherent  to 
one  another  and  to  all  adjacent  tissues,  and  the  peritoneimi  is  also  thickened  and 
adherent  to  nearby  organs.  The  liver  is  adherent  to  the  diapliragm  and  even  to 
the  stomach,  colon,  omentum,  and  belly  wall.  It  is  the  profuse  hyperplasia  of 
the  peritoneiun  which  causes  the  organs  it  covers  to  look  as  does  a  cake  which  has 
been  "iced."  The  two  symptoms  of  this  condition  which  are  most  constant  and 
characteristic  are  large  ascites  and  a  gradually  increasing  failure  of  cardiac  power. 


PERICARDITIS 


441 


The  cause  of  the  excessive  ascites  is  the  perihepatitis  and  the  compression  of  the 
abdominal  vessels  by  the  newly  formed  connective  tissue.  Beyond  these  two  sjTiip- 
toms  the  manifestations  of  the  process  are  practically  identical  with  those  of 
adherent  pericardium,  as  will  be  described  below.  The  malady  is  a  very  slow 
and  chronic  process,  lasting,  it  may  be,  for  years. 


Heart,  left  ventricle.     Adherent  pericardium,  with  lipomatosis  of  the  adhesions  and  slight  fatty- 
infiltration  of  the  myocardium. 


Symptoms  of  Adhesive  Pericarditis. — The  symptoms  of  the  milder  forms  just 
described  are  so  moderate  that  no  thought  of  their  existence  is  had  till  autopsy 
reveals  them.  It  is  in  the  well-developed  types  that  the  condition  may  cause 
symptoms  which  are  definite.  Indeed,  in  some  cases  it  may  be  impossible  to 
correctly  diagnosticate  even  the  most  severe  forms.  The  subjective  symptoms 
are  pain  in  the  frecordium  or  a  sense  of  constriction.  This  pain  may  be  dull  and 
constant  or  paroxysmal,  arousing  the  suspicion  of  true  angina  pectoris.  Palpita- 
tion is  another  common  symptom  and  in  some  instances  the  action  of  the  heart 
is  irregular  and  hobbling.  Shortness  of  breath  on  exertion  is  also  present  and  at 
times  the  right  ventricle  becomes  engorged  and  secondary  engorgement  of  the  liver 
and  lungs  ensues.  Finally,  what  is  taken  for  ordinary  cardiac  dropsy  due  to  valvu- 
lar disease  develops.     In  other  cases  pleural  effusion  develops  from  this  cause. 


442  DISEASES  OF  THE  PERJCARDirM 

The  result  of  these  adhesions  is  enlargement  or  hypertrophy  and  dilatation 
of  the  heart.  This  change,  however,  does  not  occur  in  all  cases  and  it  is  chiefly 
present  in  cases  in  which  valvular  lesions  coexist.  The  pressure  jiroduccd  by  the 
thickened  membranes  results  in  some  obstruction  to  the  flow  of  blood  in  the  great 
veins  at  tlie  cardiac  base,  and  tliis  causes  jugular  distention. 

Diagnosis  of  Adhesive  Pericarditis. — The  physical  signs  to  he  scarclicd  for  in 
making  a  diagnosis  are  as  follows: 

Inspection  may  reveal  depression  of  the  precordial  area  and  a  drawing  together 
of  the  ribs  so  that  the  intercostal  spaces  are  narrowed.  In  place  of  this  condition 
in  this  part  of  the  chest,  there  may  be  distinct  bulging.  Again,  the  apex  beat  is 
often  much  displaced  and  as  the  pericardium  is  adherent  to  the  chest  wall  changes 
in  posture  do  not  alter  its  position.  The  usual  displacement  of  the  apex  is  upward 
and  outward.  In  other  instances  the  apex  beat  cannot  be  seen  or  felt  in  its  usual 
place,  but  a  transmitted  impulse  can  be  found  in  the  epigastrium.  Perhaps  the 
most  important  diagnostic  symptom  is  retraction  of  the  chest  wall  at  systole. 
This  retraction  may  be  at  the  apex  or  along  the  left  edge  of  the  sternimi  in  the  third, 
fourth,  and  fifth  interspaces.  Roberts  states  that  if  the  right  ventricle  is  greatly 
enlarged  the  impulse  can  be  seen  to  the  right  of  the  sternum.  Broadbent  has  called 
attention  to  the  fact  that  in  many  of  the  well-marked  cases  of  adherent  pericardium 
marked  sj'stolic  retraction  of  the  lower  ribs  on  the  posterolateral  aspect  of  the  chest 
is  visible,  if  the  patient  is  in  a  good  light  and  the  physician  regards  his  back  and 
side  from  a  distance.  This  retraction  is  in  the  nature  of  a  tug  at  systole.  It  is 
emphasized  by  a  deep  inspiration.  Again,  if  the  physician  will  place  his  head 
directly  against  the  chest  in  this  area  he  may  have  transmitted  to  it  a  shock  at  the 
time  of  systole.  In  some  cases  the  adhesions  between  the  pericardium  and  the 
diaphragm  may  prevent  the  normal  epigastric  respiratory  movements. 

Percussion  may  reveal  in  some  cases  an  increase  in  the  area  of  cardiac  dulness, 
but  it  is  not  constant.  Avsculiation  may  show  reduplication  of  the  piJmonary 
second  sound,  and  a  rough  and  widely  distributed  friction  sound,  and  a  somewhat 
prolonged  presystolic  murmur  at  the  apex  which  is  not  necessarily  due  to  mitral 
stenosis. 

The  pulse  often  presents  irregularities,  particularly  at  the  time  of  the  inspiratory 
movements,  the  so-called  pulsus  paradoxus.  Sudden  collapse  of  the  cer\'ical 
veins  on  diastole  may  also  be  present. 

It  must  be  distinctly  understood  that  these  signs  are  often  absent  or  are  difficult 
to  discover.  There  is  perhaps  no  more  difficult  diagnosis  than  that  of  some  cases 
of  adherent  pericardium.  The  history  of  a  severe  or  repeated  attacks  of  acute 
rheumatic  fever  is  an  important  point  in  judging  of  the  likelihood  of  its  presence, 
particularly-  if  there  is  also  a  history  of  pericarditis.  Progressive  cardiac  weakness 
without  valvular  lesions  in  a  young  person  should  raise  the  suspicion  of  this  state, 
particularly  if  an  insidious  ascites  and  dropsy  of  the  lower  extremities  develop. 

Prognosis  of  Adhesive  Pericarditis. — The  j^rognosis  is  of  course  \'er\-  grave  if  the 
symptoms  are  severe  and  if  the  occupation  is  .strenuous.  With  adequate  rest 
life  may  in  sonu'  cases  be  ])rol(ingcd  for  years  if  the  inflammatory  state  is  stationary. 

Treatment  of  Adhesive  Pericarditis. — The  treatment  cannot  be  curative  for  obvious 
reasons.  It  can  only  be  palliative,  by  rest,  good  food,  and  the  relief  of  dropsy  by 
purges  and  diuretics.  A  sufficient  niunber  of  cases  ha\'e  been  successfully-  treated 
by  operation,  to  break  up  adhesions,  to  justify  cardiolysis. 

HYDROPERICARDIUM. 

This  is  a  state  of  fluid  in  the  pericardium  due  to  transudation  from  vessels  which 
are  pressed  upon  by  growths,  or  it  results  from  hemic  or  vascular  changes  due  to 
renal  disease.     It  is  not  an  inflammatorv  effusion. 


PNEUMOPERICARDIUM  443 

Symptoms. — Symptoms  and  physical  signs  are  absent  except  when  the  fluid 
becomes  copious  enough  to  cause  cardiac  embarrassment,  when  the  condition 
of  the  patient  is  found  to  be  like  that  produced  by  an  ordinary  serous  pericardia! 
effusion  due  to  true  pericarditis. 

Prognosis. — The  prognosis  depends  upon  the  cardiac  state  and  the  underlying 
cause.     It  is  usually  grave,  because  of  the  underlying  malady. 

Treatment. — The  treatment  consists  in  free  purgation,  if  the  patient  is  able 
to  stand  it,  and  the  use  of  diuretics.  Otherwise  it  is  that  of  general  dropsy.  (See 
Chronic  Parenchymatous  Nephritis.) 


HEMOPERICARDIUM. 

Blood  in  the  pericardial  sac  arises  from  stab  and  other  wounds,  and  it  is  also 
present  in  cases  of  purpura  and  of  profound  diseases  of  the  blood.  In  other  cases 
it  arises  from  aneurysm  of  the  aorta  early  in  its  upward  course,  and  finally  it  may 
be  due  to  rupture  of  the  heart  or  aneurysm  of  one  of  the  coronary  arteries.  Even 
in  these  cases  death  may  be  postponed  a  nimiber  of  days.  If  a  large  amount  of 
blood  escapes  into  the  pericardium  the  heart  is  stopped  by  the  pressure  on  its  surface 
and  on  the  great  veins  at  its  base,  so  death  is  not  due  to  actual  loss  of  blood.  This 
result  is  what  one  would  expect,  and  I  proved  its  truth  some  years  ago  in  an  experi- 
mental research. 

When  the  condition  is  due  to  disease  it  usually  is  hopeless.  When  due  to  injury 
the  pericardium  should  be  opened,  the  blood  removed,  and  if  a  wound  in  the  heart 
exists  it  should  be  closed.  There  are  many  cases  of  this  sort  on  record  in  which 
operation  has  been  performed  and  in  which  life  has  been  saved. 


PNEUMOPERICARDIUM. 

Air  or  gas  in  the  pericardium  appears  as  the  result  of  injury,  whereby  air  enters 
the  sac,  or  again  as  the  result  of  a  cavity  in  the  lung  perforating,  through  adhesions, 
into  this  space.  It  also  may  develop  in  cases  of  cancer  or  other  ulcerative  lesions 
of  the  esophagus,  with  adhesions  between  this  tube  and  the  pericardium,  followed 
by  perforation  of  the  growth.  Again,  it  occurs  rarely,  as  the  result  of  perforation, 
in  pneumopyothorax.  Cases  are  on  record  in  which  a  gastric  ulcer  has  caused 
adhesions  to  the  diaphragm  followed  by  perforation,  and  so  pneumopericardium 
has  developed.  In  still  other  instances  the  gas  which  is  present  is  due  to  the 
presence  of  the  Bacillus  aerogenes  capsidatus  or  other  gas-producing  organisms. 

The  mere  presence  of  air,  or  gas,  in  this  cavity  is  such  an  abnormal  state  that 
some  serous  effusion  nearly  always  takes  place  within  a  few  hoiu-s;  so  that  all 
cases  of  pneumopericardium  are  really  to  be  considered  as  hydropneumopericardium 
and  as  they  speedily  become  purulent  by  infection  they  are  usually  instances 
of  pyopneumopericardium. 

Symptoms. — The  symptoms  resemble  those  of  pericarditis  with  efYusion,  except 
that  a  considerable  part  of  the  area  of  cardiac  dulness  may  give  a  high-pitched 
resonant  note  on  percussion.  This  area  of  resonance  varies  greatly  with  the  posture 
of  the  patient,  being  larger  when  he  is  recumbent  than  when  he  is  erect.  Another 
symptom  which  is  quite  characteristic,  if  it  can  be  discovered,  is  a  peculiar  crackling 
sound  due  to  the  action  of  the  heart  in  stirring  up  the  fluid  and  the  air.  Sometimes 
these  sounds  are  gurgling  or  churning  in  character.  Thej'  have  been  compared  to 
the  splashing  of  water  on  a  mill-wheel.  There  is  but  one  condition  which  can 
produce  symptoms  like  these,  and  that  is  a  large  cavity  in  the  lung  near  the  heart 
in  which  the  fluid  contents  are  disturbed  by  the  movements  of  the  heart. 


444  ruSEASES  OF  THE  HEART 

Prognosis. — The  prognosis  is,  of  course,  very  grave,  but  recovery  has  occurred. 

Treatment. — The  treatment  depends  largely  upon  the  cause.  If  the  case  is 
one  of  perforated  esophageal  cancer  it  is  of  course  hopeless;  in  an  instance  of  trau- 
matism with  perforation  surgical  interference  may  give  good  results. 

PYOPERICARDIUM. 

(See  Pekicarditis  with  Effusion.) 


DISEASES  OF  THE  HEART. 

HYPERTROPHY  AND  DILATATION  OF  THE  HEART. 

Definition. —  Hypertrophy  of  the  heart  is  a  condition  in  which  there  is  a  growth 
above  normal  of  its  muscular  fibers  resulting  in  an  increase  in  the  size  and  particu- 
larly in  the  muscular  power  and  weight  of  the  viscus. 

In  dilatation  one  or  more  of  the  cardiac  cavities  is  more  capacious  than  normal; 
the  wall  may  be  normal,  increased  or  decreased  in  tliickness,  with  a  cardiac  power 
less  than  its  muscular  development  would  indicate. 

These  conditions,  which  at  first  glance  seem  diametrically  opposed  to  one  another, 
are  in  reality  nearly  always  present  simultaneously  in  varying  degree.  For  this 
reason  I  consider  them  side  by  side. 

When  the  wall  of  the  ventricle  is  increased  in  thickness  without  any  alteration 
in  the  size  of  its  cavity  the  condition  is  called  simple  hypertrophy.  When  the 
cavity  is  larger  than  normal  it  is  called  eccentric  hypertrophy,  or  hypertrophy  with 
dilatation,  and  when  the  cavity  is  decreased  in  size  it  is  known  as  concentric  hyper- 
trophy. 

When  dilatation  is  combined  with  hypertrophy  it  is  called  actii'c  dilatation. 
When  there  is  no  hj'pertrophy,  but  thinning  of  the  walls  alone,  it  is  called  passive 
dilatation. 

Hypertrophy  of  the  Heart. — The  existence  of  concentric  hypertrophy  has  been 
denied.  It  certainly  is  very  rare.  Simple  hypertrophy  is  also  rare,  but  eccentric 
hypertrophy  is  one  of  the  most  common  of  secondary  pathological  changes. 

A  large  number  of  causes  produce  cardiac  hypertrophy  with  dilatation.  Sonic- 
times  they  act  singly,  but  not  rarely  several  of  them  are  associated.  The  most 
common  cause  is  valvular  disease,  which  by  its  resulting  regurgitation  of  obstruc- 
tion increases  the  labor  of  the  heart.  The  second  cause  of  importance  is  a  state 
of  the  bloodvessels  which  renders  the  propulsion  of  the  blood  more  difficult  than 
in  health.  This  obstruction  to  the  free  flow  of  blood  may  be  general,  as  in  cases 
of  artcriocai^lllary  fibrosis;  or  localized,  as  when  there  is  roughening  or  narrowing 
of  the  aorta,  or  when  a  tumor  presses  upon  the  aorta;  or,  again,  in  cases  of  aneurysm. 
Other  localized  causes  of  hypertrophy  are  emphysema  of  the  lungs  or  chronic 
phthisis  and  adherent  pericardium. 

The  increase  in  the  size  of  the  heart  in  cases  of  hypertrophy  is  sometimes  very 
great.  Thus,  this  organ,  which  in  the  healthy  man  weighs  about  nine  ounces, 
or  270  grams,  and  in  the  healthy  woman  about  eight  ounces  (240  grams),  may  weigh 
as  much  as  53  ounces  (1590  grams).  Usually,  however,  the  increase  does  not  go 
beyond  fifteen  ounces  (450  grams). 

A  heart  which  has  undergone  hypertrophy  is  broadened  or  widened  at  its  a^ex, 
but  the  actual  increase  in  the  size  of  this  organ  at  this  point  depends  largely  upon 
the  part  of  the  heart  which  is  chiefly  affected.     Thus,  in  cases  in  which  the  right 


HYPERTROPHY  AND  DILATATION  OF  THE  HEART  445 

ventricle  is  chiefly  involved,  this  part  of  the  heart  is  often  far  larger  than  that  part 
formed  by  the  left  ventricle,  which  seems  small  by  contrast.  When  a  hypertrophied 
heart  is  incised,  its  walls  are  found  to  be  much  thickened  and  the  columnie  carneae 
and  papillary  muscles  larger  than  normal.  The  enlargement  is  due  to  both  an 
increase  in  the  number  and  size  of  the  muscle  fil^res. 

Symptoms  and  Physical  Signs  of  Cardiac  Hypertrophy. — The  chief  symptom  of 
ordinary  eccentric  hypertrophy,  when  it  is  adequate  to  compensate  for  the  valvular 
lesion,  or  to  overcome  resistance,  may  be  said  to  be  the  maintenance  of  a  comfortable 
life  and  a  normal  circulation.  Many  persons  develop  this  state  without  any 
knowledge  of  there  being  present  any  valvular  disease,  and  remain  in  perfect  health 
for  years. 

If  the  physician  chances  to  examine  such  a  case  he  may  find  a  cardiac  murmur 
and  then  on  closer  study,  discover  the  following  physical  signs,  provided  the  process 
is  well  developed.  On  inspection  the  precordium  is  bulging,  but  the  impulse  trans- 
mitted to  the  chest  wall  is  regular  and  deliberate  in  distinction  from  the  cardiac 
hurry  and  irregularity  present  when  compensation  is  ruptured.  The  apex  beat 
is  more  diffuse  than  is  normal  and  is  often  in  the  sixth  or  seventh  interspace  instead 
of  in  the  fifth,  and  it  is  farther  toward  the  axilla  than  in  health.  On  palpation 
the  apex  beat  is  found  to  be  forcible  and  it  may  be  heaving,  but  if  the  patient  be  a 
full-chested  individual  these  local  signs  may  not  be  present.  If  emphysema  of  the 
lungs  causes  these  enlarged  organs  to  overlap  the  heart  they  may  hide  much  of  the 
hypertrophy.  Percussion  may  reveal  increase  of  the  area  of  cardiac  dulness  to 
the  left,  to  the  right,  and  downward.  Auscultation,  instead  of  reveahng  an  exagger- 
ation of  the  first  sound,  reveals  that  it  is  more  distant,  perhaps  because  the  thick- 
ness of  the  heart  walls  muffles  the  sound,  but  the  aortic  sound  is  accentuated  unless 
the  aortic  valves  are  diseased. 

If  the  patient  takes  violent  exercise  he  may  complain  of  palpitation  and  the 
thumping  of  his  heart. 

When  hypertrophy  begins  to  fail  the  patient  complains  of  shortness  of  breath 
on  exertion,  of  palpitation  and  oppression,  and  if  he  persists  in  keeping  on  his  feet 
the  sjTuptoms  of  cardiac  failure  (see  ^'ah'ular  Disease)  develop.  The  first  physical 
signs  of  the  failure  will  be  some  reduplication  of  ihs  first  sound  and  diminution  in  its 
clearness.  This  reduplication  is  best  heard  just  inside  the  apex  beat  when  it  first 
develops,  but  later  it  can  be  heard  over  a  large  area.  The  period  between  the  first 
and  second  sound  is  prolonged  as  if  the  ventricle  was  able,  only  with  the  greatest 
endeavor,  to  slowly  expel  its  blood.  This  means  diminution  of  the  period  in  which 
the  heart  muscle  can  obtain  nourishment  through  its  coronary  vessels. 

The  causes  for  this  failure  are  various.  In  some  instances  the  degenerative 
changes  in  the  myocardium  and  in  the  bloodvessels  which  are  incident  to  old  age 
are  the  determining  factors.  In  others  some  acute  illness — as  t\-phoid  fe-\-er, 
influenza,  pnemnonia,  or  renal  disease — may  be  the  cause;  or,  again,  severe  exercise 
may  produce  so  much  exhaustion  of  the  heart  muscle  and  acute  dilatation  that  the 
cardiac  power  is  impaired  for  all  time. 

Diagnosis. — Cardiac  hj'pertrophy  must  be  separated  from  several  important 
conditions  which  are  by  no  means  rare.  From  dilatation  hypertrophy  is  differ- 
entiated by  the  facts  that  the  impulse  in  the  former  is  feeble,  in  the  latter  it  is 
strong,  and  by  the  feeble  heart  soimds  in  the  former  as  compared  to  the  stronger 
ones  in  hypertrophy.  So,  too,  palpation  of  the  apex  in  dilatation  reveals  a  diffuse 
and  feeble  impulse  and  in  hypertrophy  a  forcible  beat. 

From  pericardial  effusion  it  is  differentiated  by  the  fact  that,  though  the  area  of 
cardiac  dulness  is  increased  in  both  states,  the  cardiac  impulse  and  cardiac  sounds 
are  muffled  in  effusion  and  exaggerated  in  hj"pertrophy.  From  displacement  of 
the  heart  it  can  be  differentiated  by  the  fact  that  though  the  apex  beat  is  displaced 
the  general  area  of  cardiac  dulness  is  not  increased  in  eases  of  displacement. 


44G  DISEA,SES  OF  THE  HEART 

Again,  in  certain  cases  in  which  the  chest  wall  is  thin  and  the  lung  is  retracted 
so  that  it  fails  to  cover  the  heart  as  in  health,  the  heart  may  be  so  close  to  the  chest 
wall  that  its  area  of  dulness  will  be  abnormally  large  and  its  apex  beat  unduly 
forcible  and  diti'use.  In  such  a  case  the  careful  study  of  the  state  of  the  lung  and 
pleura  will  make  the  condition  clear. 

Of  the  functional  disorders  that  produce  overaction  of  the  heart  and  so  cause 
apparent  but  not  real  hypertrophy,  "tobacco  heart,"  the  irritable  heart  of  exoph- 
thalmic goitre,  and  that  of  neurotic  individuals  must  be  remembered. 

Prognosis. — As  cardiac  hypertrophy  in  its  common  form  is  compensatory  in 
character,  and  as  it  very  rarely  becomes  excessive,  in  the  sense  that  it  is  beyond  the 
needs  of  the  patient,  the  prognosis  in  a  case  in  which  it  is  present  deals  not  with  the 
question  of  how  much  greater  will  hypertrophy  become,  but  rather  how  much 
longer  will  hypertrophy  enable  the  heart  to  supply  the  bloodvessels  with  blood  in 
satisfactory  quantities.  Unlike  most  alterations  from  the  normal  as  the  result 
of  disease,  this  change  is  distinctly  advantageous  to  the  patient. 

The  question  as  to  how  long  the  hypertrophy  will  be  maintained  can  only  be 
answered  after  its  provoking  cause  or  causes  have  been  determined.  If  the  hyper- 
trophy following  valvular  disease  of  the  heart  is  adequate,  if  the  patient  is  a  young 
and  otherwise  healthy  adult,  and  if  the  valvular  lesion  is  not  progressive,  the  prog- 
nosis as  to  the  maintenance  of  the  condition  is  usually  good,  but  will  depend  upon 
the  good  habits  of  the  patient,  particularly  as  to  alcohol,  hard  work  and  exposure, 
and  upon  the  particular  valve  which  is  diseased.  (See  Prognosis  of  Valvular 
Lesions.)  If  the  hypertrophy  is  the  result  of  arteriocapillary  fibrosis  with  its 
associated  renal  changes,  the  duration  of  life  except  under  the  most  favorable 
conditions  is  brief,  because  the  arterial  obstruction  is  constantly  increasing  and 
the  heart  is  constantly  exposed  to  increasing  strain,  increasing  toxemia,  and  is 
poorly  nourished  by  its  own  coronary  arteries. 

Treatment. — There  is  no  treatment  for  compensatory  hypertrophy  except  to 
maintain  it  by  care  as  to  manner  of  life,  and  the  use  of  digitalis  and  rest  if  its  integ- 
rity or  maintenance  is  threatened.  I  have  seen  a  few  cases  of  aortic  regurgitation 
with  great  hypertrophy  in  which  rest  in  bed  and  moderate  doses  of  tincture  of 
aconite  ha^^e  given  better  results  than  rest  and  digitalis,  but  in  these  cases  the  patient 
had  been  accustomed  to  severe  toil,  and  when  he  was  put  at  rest  seemed  to  have 
excessive  cardiac  power,  as  shown  by  throbbing  and  oppression.  On  the  other 
hand,  when  liypertrophy  seems  excessive,  it  is  not  rarely  in  reality  lacking,  and 
the  violence  of  the  heart  movements  may  be  aborti\-e  efforts  at  circulation.  Often 
the  use  of  nitroglycerin  at  such  times  will  be  advantageous  if  the  arterial  pressure 
is  high. 

Dilatation  of  the  Heart. — Passive  dilatation  (without  hypertro])hy)  may  be 
caused  by  valvular  lesions,  as  the  result  of  which  the  cavities  of  the  heart  become 
distended,  but  hypertrophy  does  not  develop.  Of  these  the  chief  cause  is  sudden 
and  prolonged  strain,  and  the  feebleness  often  due  to  myocardial  disease.  Ob.struc- 
tion  to  the  How  of  blood  in  the  pulmonary  vessels  may  cause  dilatation  of  the  right 
side  of  the  heart,  as  in  cases  of  pneumonia,  in  cases  of  pleurisy  with  cH'usion,  and 
in  cases  of  acute  pulmonary  edema  complicating  uremia. 

A  common  cause  in  men  over  fifty  years  is  sudden  effort,  as  in  lifting  a  heavy 
weight  or  climbing  rapidly  a  steep  flight  of  steps.  In  the  yoimg  and  vigorous 
sudden  strain  may  be  followed  by  rapid  return  of  the  dilated  heart  to  its  normal 
size,  but  in  those  further  on  in  years,  or  who  have  valvular  or  myocardial  disease, 
an  acute  strain  often  results  in  permanent  dilatation.  It  is  very  common  for  old 
men  to  try  to  prove  that  they  are  "as  young  as  they  used  to  be,"  and  to  attempt 
athletic  feats  which  are  followed  by  acute  dilatation  and  perhaps  immediate  death, 
or  death  in  a  few  days  or  weeks.  In  other  instances  the  heart  suft'ers  from  a  gradual 
dilatation  from  prolonged  strain,  as  in  soldiers  on  the  march.     Not  rarely  dilatation 


HYPERTROPHY  AND  DILATATION  OF  THE  HEART  447 

develops  during  the  course  of  one  of  the  acute  infectious  diseases  or  during  con- 
valescence. 

When  the  strain  is  very  gradual,  instead  of  meeting  the  increased  demand  by 
increased  efi'ort,  the  heart  slowly  dilates  and  is  perhaps  never  able  to  empty  its 
cavities  of  blood. 

The  intrinsic  causes  of  dilatation  are  myocarditis,  fatty  degeneration,  fatty 
infiltration,  and  serous  infiltration  from  pericarditis.  In  some  cases,  however, 
no  adequate  intrinsic  cause  can  be  found. 

Symptoms  of  Cardiac  Dilatation. — The  symptoms  and  physical  signs  of  passive 
dilatation  are  usually  such  that  a  diagnosis  is  readily  made.  When  it  is  sudden 
in  onset  an  acute  or  partial  syncope  with  labored  respiration  and  thoracic  oppression 
may  be  present. 

When  the  onset  is  more  gradual  the  main  sjTnptoms  are  impaired  circulation, 
a  tendency  to  syncope  on  suddenly  standing  or  sitting  up,  congestion  of  the  kidneys 
causing  albumimma,  and  a  poor  capillary  circulation  which  causes  the  skin  of 
the  hands  to  remain  pallid  long  after  pressure.  Many  persons  so  afflicted  cannot 
lie  down  without  urgent  dyspnea  and  cardiac  distress.  The  pvke  is  small  and 
irregular,  and  the  arterial  tension  loiv.  In  other  cases  the  pulse  wave  may  be  vol- 
uminous, but  feeble. 

An  inspection  of  the  precordium  shows  that  the  apex  beat,  if  visible  at  all,  is 
diffuse  and  displaced  outward  and  downward.  On  placing  the  finger-tip  on  the 
spot  where  the  apex  beat  seems  most  marked,  the  examiner  is  surprised  to  find  no 
impulse  or  one  which  is  very  slight.  There  is  often  visible,  but  rarely  palpable, 
pulsation  near  the  ensiform  cartilage  or  in  the  epigastrium.  Care  must  be  taken 
that  the  overlying  lung  does  not  lead  to  an  erroneous  belief  as  to  the  presence  of 
cardiac  feebleness.  If  the  whole  hand  is  placed  o^•er  the  disturbed  surface  of  the 
precordium  it  is  remarkable  how  little  impulse  is  discernible.  Percussion  shows 
an  increase  in  the  area  of  cardiac  dulness  to  the  left,  to  the  right,  and  downward. 
Often  it  is  also  increased  upward. 

On  auscultation  the  first  sound  of  the  heart  may  be  short  and  small,  valvular 
and  flapping,  though  fairly  loud,  and  if  the  heart  is  strong  enough  there  may  be  a 
systolic  murmur  at  the  apex,  due  to  mitral  regurgitation  arising  from  stretching 
of  the  mitral  orifice.  As  in  ruptured  compensatory  hypertrophy  the  somids  of  the 
heart  may  be  equalized  and  the  space  between  them  may  be  altered  so  that  the 
sounds  are  like  those  of  the  fetal  heart  or  like  the  ticking  of  a  watch.  In  other 
cases  the  first  and  second  sounds  may  occur  close  together  and  the  diastolic  pause 
be  prolonged.  Verj'  often  great  arrhythmia  is  present.  If  in  addition  to  these 
signs  there  is  a  history  of  acute  strain  near  or  remote,  with  symptoms  of  cardiac 
feebleness,  and  particularly  if  there  has  been  an  acute  illness  due  to  infection, 
such  as  influenza  or  pneumonia,  the  diagnosis  of  dilatation  may  be  made.  Some- 
times cardiac  dilatation  causes  pleural  effusion  (see  Hydrothorax). 

Prognosis. — The  prognosis  depends  upon  the  degree  of  the  dilatation,  the  state 
of  the  vessels  and  of  the  heart  muscle  and  of  the  kidneys,  and  last,  but  not  least, 
the  lungs.  When  the  latter  are  filled  with  rales  the  state  is  alarming,  and  if  the 
vessels  and  kidneys  are  diseased  the  outlook  is  hopeless  for  much  betterment. 
If  the  state  of  the  vessels  and  the  general  condition  of  the  patient  indicate  fatty 
myocardial  degeneration  the  prognosis  is  also  bad.  If  these  states  are  absent, 
and  rest  can  be  maintained,  improvement  can  be  hoped  for,  but  a  complete  cure 
with  old-time  vigor  is  rarely  reached. 

Treatment. — The  treatment  is,  first  of  all,  rest  in  bed,  or  in  any  easy  chair  if 
bed  is  impossible  because  of  orthopnea.  The  second  object  to  be  gained  is  the 
removal  of  the  cause  of  the  dilatation,  if  that  be  possible,  as  the  reduction  of  high 
arterial  tension  by  the  use  of  nitroglycerin.  Third,  the  employment  of  digitalis 
and  strychnine  for  effect,  recalling  the  fact  that  once  digitalis  has  produced  its 


448  DISEASES  OF  THE  HEART 

action  smaller  doses  will  maintain  its  influence,  and  also  bearing  in  mind  the  addi- 
tional fact  that  when  it  is  in  full  efTect  sudden  changes  of  posture  are  dangerous. 
Digitalis  may  also  cause  so  much  ventricular  stinnilation  as  to  overdistcnd  the 
auricle,  whicli  is  poorly  protected  by  the  relaxed  mitral  ring. 

When  the  lungs  and  kidneys  are  engorged,  the  ai)piication  of  several  dry  cups 
over  them  is  useful,  and  if  jugular  distention  and  hcjjatic  congestion  is  marked, 
the  patient  may  be  freely  bled  if  he  is  plethoric.  So,  too,  hydragoguc  cathartics, 
such  as  jalap  and  compound  extract  of  colocynth,  may  be  used  to  unload  the  bowels 
and  liver,  but  care  must  be  taken  that  the  patient  is  not  exhausted  by  purging. 
Blue  mass  in  the  dose  of  8  grains  once  a  week  is  useful,  and  the  pill  of  calomel, 
squill,  and  digitalis  mentioned  under  Endocarditis  may  be  used.  If  ascites  is  a 
pressing  symptom  tapping  is  indicated,  while  for  general  anasarca  the  formula 
given  under  Endocarditis,  or  apocyniun  cannabinum  may  be  used,  or  the  digitalis 
given  more  liberally. 

The  diet  should  be  light  and  nutritious,  and  often  it  is  well  to  give  pancreatized 
foods  or  starches  with  taka-diastase.  Great  care  must  be  taken  that  the  stomach 
is  not  distended  by  food  or  drink,  and  if  gas  accumulates  in  the  stomach  it  should 
be  expelled  by  the  use  of  Hoft'mann's  anodyne  in  drachm  doses,  and  b.\'  the  employ- 
ment of  a  turpentine  stupe.  When  dyspnea  is  urgent  morphine  and  strychnine 
are  useful  drugs. 

High  altitudes  should  be  carefully  a\-oidcd  and  only  gentle  exercise  on  level 
ground  be  allowed. 

DISEASE  OF  THE  MYOCARDIUM. 

Disease  of  the  myocardium  may  be  di^■ided  into  two  classes,  \\z.,  degenerative 
and  inflammatory. 

Degenerative  Changes. — Etiology  and  Pathology. — The  degenerati\"e  conditions 
are  as  follows:  In  the  gramdar  form,  sometimes  called  "parenchymatous  degenera- 
tion," there  develops  in  the  protoplasm  of  the  cardiac  muscle  fibres  albuminous 
granules  which  differ  in  size  and  in  number,  and  may  be  present  in  such  an  excess 
as  to  obscure  the  nuclei  and  stria?.  The  aft'ected  muscle  is  cloudy,  softened,  and 
paler  than  in  health,  its  strength  decreased,  and  the  circulation  is  proportionately 
depressed.     In  a  later  stage  some  degree  of  fatty  degeneration  may  also  be  present. 

This  type  of  degeneration  is  observed  in  the  course  of  acute  infectious  diseases, 
as  diphtheria,  typhoid  and  typhus  fever,  the  pyemias,  and  even  as  a  result  of 
severe  burns,  and  in  debilitating  conditions  associated  with  severe  cardiac  work 
or  the  presence  of  toxic  bodies  in  the  blood. 

In  fatty  degeneration  of  the  heart  the  affected  fibres  contain  fat-globules,  which, 
in  marked  cases,  replace  the  structural  elements,  both  the  nuclei  and  protoplasm. 
In  some  instances  this  degenerative  process  is  restricted  to  a  single  focus,  or  it  may 
be  scattered  about  or  dift'use;  in  others  it  is  universal.  When  the  heart  is  examined 
at  autopsy  it  is  seen  to  be  mottled  and  the  papillary  nuiscles  in  particular  will 
reveal  the  fatty  areas,  the  so-called  "Tiger  Herz"  of  the  Germans. 

Ditt'use  fatty  degeneration  is  caused  by  prolonged  nutritional  disorders.  Per- 
nicious anemia  and  leulvcmia  may  also  cause  it,  as  may  poisoning  by  arsenic, 
phosphorus,  and  antimony.  Less  commonly  it  is  a  sequence  of  various  acute 
infectious  diseases  like  diphtheria  and  scarlet  fever  or  t.\'phoid  fever,  and  by 
degenerative  or  atheromatous  changes  in  the  coronary  arteries.  The  local  or  cir- 
cumstantial forms  follow  embolism  or  other  types  of  rapidly  developed  coronary 
occlusions. 

It  is  important  that  fatty  degeneration  be  clearly  separated  horn  fatty  infiltration, 
in  wliich  state  the  muscle  fibres  are  not  altered,  but  have  been  separated  by  the 
projection  of  fatty  masses  between  them.     This  may  cause  some  wasting  or  atrophy 


DISEASE  OF  THE  MYOCARDIUM  449 

of  the  muscle  fibres.  This  state  is  most  commonl.y  met  with  in  very  fat  persons 
and  in  those  who  are  addicted  to  excessive  beer-drinking.  Occasionally  forms  of 
amyloid  and  hyaline  degeneration  of  the  heart  fibres  occur. 

Brown  induration  or  atrophy  of  the  heart  is  often  seen  in  cases  of  chronic  \'alvular 
disease  and  in  old  persons.  The  muscle  is  more  dense  than  normal  and  reddish- 
brown  in  hue,  and  about  its  nuclei  brown  pigment  is  deposited.  Calcareous  degen- 
eration, in  which  the  muscle  fibres  become  infiltrated  with  lime  salts,  is  rare. 

Under  the  name  of  fragmentation  and  segmentation  there  is  seen  a  state  of  the 
heart  muscle  in  which  its  fibres  are  broken  across  in  fragments,  or  its  cells  are 
separated  at  the  point  of  junction  (segmented).  These  changes  may  occur  in 
acute  infectious  diseases  or  in  cases  of  central  nervous  disease.  In  some  cases 
they  are  probably  agonal,  and  it  may  be  that  similar  appearances  are  of  postmortem 
origin,  but  the  frequency  with  which  granular  change  is  seen  at  autopsy  strongly 
indicates  that  it  may  be  present  and  unrecognized  in  life,  not  only  in  fatal  cases, 
but  in  those  who  recover. 

Symptoms  of  Myocardial  Degeneration. — ^The  sjTnptoms  of  degeneration  of  the 
heart  of  the  albuminous  type  cannot  be  considered  as  pathognomonic.  Indeed, 
there  may  be  no  evidence  of  cardiac  failure  until  a  sudden  and  perhaps  fatal  attack 
of  syncope,  after  a  slight  exertion,  reveals  the  alarming  state  of  the  heart  muscle. 
In  other  instances  the:  feeble  cardiac  sounds  on  auscultation  indicate  the  real  condition 
of  the  heart. 

When  fatty  degeneration  is  present  the  same  absence  of  symptoms  may  exist 
until  the  fatal  syncope,  or  the  patient  may  suffer  from  repeated  attacks  of  syncope, 
or  of  vertigo  with  anginoid  seizures.  (See  Stokes-Adams  Disease,  page  450.)  The 
frequency  and  severity  of  these  attacks  are,  however,  by  no  means  in  direct  propor- 
tion to  the  extent  of  the  lesion  in  the  heart  muscle.  In  one  instance  a  fatal  syncope 
occurs,  yet  the  heart  scarcely  seems  altered  in  its  fibres.  In  another  case  the  life 
of  the  patient  persists  and  fairly  good  health  is  maintained  for  years,  yet  at  autopsy 
the  heart  muscle  is  so  fatty  and  soft  that  the  fingers  can  be  pushed  through  it 
as  if  it  were  wet  paper. 

In  some  instances  the  symptoms  complained  of  by  the  patient  seem  to  be  epi- 
gastric and  due  to  disordered  digestion.  How  often  do  we  hear  of  a  man  of  advanced 
years  dying  of  acute  indigestion,  which  is  really  cardiac  failure  with  gastric  symp- 
toms, or  cardiac  failure  caused  by  an  overdistended  stomach. 

The  heart  sounds  when  the  patient  is  in  his  average  state  of  health  are  distant 
and  feeble,  and  his  slow  pulse  is  sinall  and  of  loiv  tension.  Not  rarely  his  radial 
and  temporal  arteries  are  very  calcareous,  but  in  other  cases  they  are  soft  and  devoid 
of  resistance  on  pressure. 

There  still  remain  to  be  considered  several  notable  facts  in  connection  with 
this  disease.  Notwithstanding  the  great  feebleness  of  the  heart  in  some  cases  and 
the  exceedingly  weak  circulation  of  blood,  dropsy  in  any  form  is  a  very  rare  con- 
dition. Indeed,  if  dropsy  occurs  it  is  almost  certainly  due  to  some  complicating  state. 
A  second  fact  is  that  in  some  cases  in  place  of  anginoid  attacks  an  epileptiform  or 
apoplectiform  seizure  occurs.  The  epileptiform  seizure  is  not  that  of  grand  mal, 
but  petit  mal,  with  this  difference,  that  while,  as  in  petit  mal,  there  are  no  convul- 
sions, there  is  a  period  of  profound  unconsciousness  which  is  rather  a  syncope 
than  a  coma  such  as  is  seen  in  true  epilepsy. 

The  apoplectiform  seizures  may  very  closely  resemble  true  cerebral  hemorrhage, 
even  to  the  stertorous  breathing,  the  hemiplegia,  the  unconsciousness,  and  Cheyne- 
Stokes  respirations.  That  the  case  is  not  one  of  apoplexy  is  usually  proved  by 
finding  that  the  high-tension  pulse  of  cerebral  hemorrhage  is  absent  and  replaced 
by  the  low  tension  and  slow  pulse  of  fatty  degeneration. 

Prognosis  of  Myocardial  Degeneration. — The  prognosis  in  all  cases  of  cardiac 
degenerative  change  is,  of  course,  very  grave.  When  it  is  present  in  children 
29 


450  D/SKASliS  OF  THE  IIK.\h'T 

after  acute  infectious  diseases  recovery  may  ensue  under  a  course  of  arsenic,  phos- 
phorus, and  nux  vomica,  with  absolute  rest,  and  fresh  air  and  sunshine,  but  even 
in  this  class  of  cases  sudden  death  often  intervenes.  In  the  fatty  heart  of  advanced 
age,  whether  the  years  be  great  or  the  jiatient  prematurely  old,  the  outlook  is 
bad;  but  as  no  one  can  tell  the  extent  of  the  lesions  in  the  heart,  a  statement  as  to  a 
brief  duration  of  life  is  very  prone  to  Itring  the  physician's  opinion  into  rliscredit 
if  he  attempts  to  name  the  time  of  dissolution.  The  wise  physician  rarely  expresses 
a  positive  opinion  as  to  the  probable  time  of  death  in  any  case,  much  less  in  fatty 
heart. 

Stokes-Adams'  Disease. — Cases  of  extreme  slow  pulse  with  vertigo,  or  syncope, 
or  apoplectiform  or  epileptiform  seizure,  have  been  given  the  name  of  the  "Stokes- 
Adams  syndrome."  The  first  case  was  described  by  Thomas  Spcns  in  1793.  (See 
Bradycardia.)     (Plates  VIII,  IX,  and  X.) 

Associated  with  the  slowness  of  the  pulse  there  is  marked  pulsation  in  the  veins 
of  the  neck,  and  to  use  Stokes'  own  words,  written  in  the  Dublin  Quarterly  Journal 
of  Medical  Science  in  1846,  the  number  of  reflex  pulsations  is  difficult  to  be  estab- 
lished, but  they  are  more  than  double  the  number  of  the  manifest  ventricular 
contractions.  Experimental  and  clinical  studies,  indicate  that  the  symptom- 
complex  in  most  if  not  all  cases  of  this  condition  is  due  to  what  is  now  denominated 
"heart-block."  In  this  state  the  auricles  beat  two,  three,  or  four  times  as  rapidly 
as  do  the  ventricles.  (See  Mitral  Stenosis.)  Most  cases  of  Stokes-Adams  disease 
appear  to  be  primarily  arteriosclerotic  or  syphilitic  in  nature  though  myocardial 
lesions  of  other  origin  may  be  the  cause.  Autopsy  in  some  reported  cases  has  shown 
no  evident  lesion  and  these  have  been  pronounced  neurotic  in  character.  A  point 
to  be  noted  in  autopsies  upon  cases  of  this  disease  is  whether  lesion  of  the  mesial 
leaflet  of  the  tricuspid  valve  has  interfered  with  the  integritv  of  the  muscle  bundle 
of  His. 

Myocarditis. — Defmition. — This  term  is  an  unfortunate  one  in  that  it  is  often 
loosely  applied  to  the  degeneratixe  changes  just  described  as  well  as  to  those 
about  to  be  mentioned.  It  is  also  imfortunate  because  it  seems  to  indicate  that 
there  is  a  primary  inflammatory  state  of  the  cardiac  muscle  fibres,  whereas  the 
changes  in  the  fibres  are  secondary  to  inflammatory  aft'ections  of  the  interstitial 
tissues  of  the  heart  and  of  its  bloodvessels,  which  therel>y  cause  atrophic  and 
degenerative  changes  in  the  muscle. 

There  are  several  forms  of  so-called  myocarditis,  of  which  the  most  common 
is  a  slow,  low-grade  inflammatory  change  called  chronic  interstitial  myocarditis, 
manifested  by  a  wasting  of  the  muscle  fibres  and  the  intercalation  of  fibrous  or 
fibro-elastic  tissues.  There  is  also  an  acute  process,  acute  interstitial  myocarditis, 
of  which  there  are  suppurative  and  non-suppurative  varieties,  the  former  being  a 
manifestation  of  pyogenic  infection  of  the  heart  wall. 

In  the  great  majority  of  cases  the  chronic  form  is  the  result  of  pathological 
changes  in  the  coronary  arteries.  These  \'essels  sutt'er  from  an  obliterative  arteritis 
in  their  finer  branches,  undergo  atheromatous  change,  or  become  plugged  by  an 
embolus  or  thrombus.  The  lesions  which  result  from  these  changes  differ  widely 
in  character,  but  all  greatly  impair  the  usefulness  of  the  heart.  In  all  conditions 
lessening  the  vascular  lumen  and  so  decreasing  the  nutrition  of  the  heart,  there 
develops  an  overgrowth  of  interstitial  tissue  with  atrophy  of  the  muscle  fibres. 
It  is  probable  that  the  process  is  at  no  time  a  true  inflammation,  but  rather  one 
in  which  diminished  blood  supply  causes  atrophy  of  the  musc-le,  followed  by  a 
substitutive  fibrosis. 

When  a  branch  of  a  coronary  artery  is  plugged  the  affected  area  may  manifest 
the  changes  seen  in  an  infarct,  or  when  enough  nourishment  is  available  to  prevent 
actual  necrosis  the  deficient  nutrition  gives  rise  to  fatty  degeneration.  In  either 
case  the  aft'ected  area  mav  lirconic  sdFti'iicd,  and  gi\c  \\a\',  causing  ru])ture,  or 


DISEASE  OF  THE  MYOCARDIUM  4.51 

fibrous  tissue  gradually  takes  the  place  of  the  degenerated  fibres.  Later  the  scar 
tissue  yields  to  pressure  and  a  cardiac  aneurysm  ensues. 

Hypertrophied  hearts  may  show  a  slight  increase  in  the  fibrous  tissue,  and  in 
failing  compensation  and  progressing  dilatation  this  increase  in  interstitial  tissue 
may  be  conspicuous. 

In  some  instances  chronic  myocarditis  is  not  the  result  of  vascular  change,  but 
of  inflammatory  processes  in  the  pericardium  and  endocardium;  and  in  syphilis 
there  is  often  seen  a  marked  increase  in  the  interstitial  tissues  of  the  heart,  wliicli  is 
not  surprising  in  view  of  the  serious  changes  produced  by  this  disease  in  tlie  small 
bloodvessels  everywhere.  Chronic  myocarditis  is  more  common  in  males  than  in 
females. 

Symptoms  of  Myocarditis. — The  immediate  effects  upon  the  patient  produced 
by  the  lesions  just  named  vary  to  an  extraordinary  degree.  Plugging  of  one  of  the 
large  branches  of  a  coronary  artery  usually  results  in  sudden  death. 

In  some  instances,  however,  the  patient  survives  a  severe  attack  of  cardiac 
disturbance,  but  under  these  circumstances  the  plugging  is  usually  in  a  small 
vessel,  and  a  gradual  substitution  circulation  is  established,  not  by  anastomosis, 
for  these  vessels  are  end-arteries,  but  by  the  so-called  vessels  of  Thebesius,  which 
in  some  cases  are  able  to  supply  the  heart  with  an  adequate  cjuantity  of  blood. 

When  the  closure  of  the  vessel  is  gradual  it  not  rarely  happens  that  necrosis 
of  the  area  deprived  of  blood  is  prevented  by  a  blood  supply  through  the  vessels 
of  Thebesius,  so  that  the  death  of  the  patient  is  postponed  until  a  very  extraordinary 
degree  of  atheroma  and  narrowing  in  both  coronary  arteries  is  developed.  The 
coronary  arteries  of  a  well-known  member  of  the  medical  profession  in  Philadelphia, 
who  died  a  few  years  since,  were  so  diseased  that  only  a  tliread-like  passageway 
existed  in  these  vessels,  yet  he  led  an  active  life  to  the  end.  Such  patients  may 
have  no  marked  cardiac  symptoms,  but,  as  a  rule,  repeated  attacks  of  angina  pectoris 
of  increasing  intensity  give  warning  of  the  sudden  death  to  come.  The  other 
symptoms  are  the  same  as  those  described  under  fatty  degeneration  of  the  heart. 

The  physical  signs  of  myocardial  degeneration  are  feebleness  of  the  apex  heat, 
equalization  of  \he  first  and  second  sounds  of  the  heart,  and  evidences  of  feeble  circula- 
tion in  the  lungs  and  in  the  peripheral  systemic  vessels. 

The  prognosis  depends  entirely  upon  the  situation  and  the  degree  of  the  cardio- 
vascular change.  So  far  as  recovery  is  concerned,  that  is  impossible.  The 
probable  duration  of  life  is  also  difficult  to  determine.  Many  cases  with  all  the 
symptoms  of  severe  myocarditis  live  a  long  period,  while  others  die  with  unex- 
pected suddenness. 

Treatment. — We  cannot  expect  very  much  from  treatment  in  patients  suffering 
from  chronic  myocarditis.  It  must  be  evident  from  what  has  been  said,  under 
the  discussion  of  the  pathological  conditions  which  cause  these  states,  that  the 
harm  is  done  before  the  physician  has  an  opportunity  to  place  the  patient  under 
treatment.  The  only  hope  is  that  by  regulating  the  manner  of  life,  by  increasing 
the  action  of  the  kidneys,  if  they  are  sluggish,  by  attending  to  the  digestive  appa- 
ratus, and  by  preventing  undue  cardiac  strahi  through  excessive  muscular  or  mental 
exercise,  we  may  be  able  materially  to  prolong  the  patient's  life.  In  instances 
in  which  the  bloodvessels  are  distinctly  atheromatous  or  fibjoid,  the  use  of  the 
iodide  of  strontium  or  sodium,  in  doses  varying  from  10  to  40  grains  three  times 
a  day,  is  usually  advantageous.  This  treatment  may  be  continued  for  several 
weeks,  and  then  the  patient  may  receive  a  course  of  Donovan's  solution  as  a  general 
tonic,  with  perhaps  a  small  quantity  of  nux  vomica  or  strychnine  added  to  it. 

If  arterial  tension  is  high,  he  should  be  given  nitrite  of  sodium  in  doses  varying 
from  1  to  2  grains  three  or  four  times  a  day,  in  order  that  the  resistance  which  is 
offered  by  tense  vessels  to  the  action  of  the  heart  may  be  lessened.  Under  these 
circumstances,  too,  small  doses  of  digitalis  sometimes  act  advantageously,  particu- 


452  DISI'JASES  OF  THE  HEART 

larly  if  nitroglycerin  is  given  at  the  same  time.  To  give  digitalis  to  a  failing  heart 
and  yet  to  permit  the  arterial  tension  to  remain  liigli  is  of  little  ultimate  advantage 
to  the  patient,  since  it  increases  the  labor  of  the  heart.  It  is  much  more  important 
to  diminish  the  labor  by  the  use  of  rest  and  baths  than  to  stimulate  this  viscus  to 
increased  endeavor  by  large  doses  of  foxglove. 

Strophanthus  may  do  better  than  digitalis  in  some  cases.  It  must  be  remem- 
bered that  if  the  heart  has  undergone  distinct  degenerative  changes  there  is  little 
muscular  fiber  upon  which  the  digitalis  may  exert  its  stimulating  influence,  and 
there  may  be  danger  by  increasing  intracardiac  pressure  of  causing  rupture  of 
some  area  of  white  necrosis,  thereby  causing  cardiac  aneurysm. 

It  is  hardly  necessary  to  add  that  these  patients  should  be  warned  against  exces- 
sive muscular  exercise  or  any  severe  cardiac  strain,  and  they  should  be  advised 
to  lie  down  and  rest  several  times  a  day,  in  order  that  the  heart  may  at  each  period 
of  rest  recover  as  much  strength  as  possible. 

Digestive  disturbances,  which  by  accumulation  of  gas  may  disturb  the  action 
of  the  heart,  must  be  prevented  by  the  institution  of  an  easily  digested  and  simple 
diet,  small  ciuantities  of  food  being  taken  often  so  as  to  avoid  overloading  the 
stomach.  If  there  is  a  tendency  to  an  accumulation  of  gas  in  the  bowel  salol 
may  be  given  as  an  intestinal  antiseptic,  or  in  its  place  a  capsule  of  taka-diastase, 
pancreatin,  nux  vomica,  and  capsicum,  which  is  recommended  in  the  article  on 
Angina  Pectoris,  may  be  administered.  Some  of  these  patients  seem  to  be  greatly 
benefited  by  the  use  of  gentle  massage  every  day  or  every  other  day,  with  the 
object  of  aiding  in  the  circulation  of  the  juices  of  the  body.  Great  care  should  be 
taken  that  the  massage  is  not  so  vigorous  that  the  patient  is  fatigued  by  it.  Strych- 
nine in  the  dose  of  yV  of  a  grain  three  or  four  times  a  day  is  often  exceedingly 
beneficial  to  these  patients,  particularly  if  there  is  any  tendency  to  shortness  of 
breath  on  lying  down. 

In  many  instances  when  the  heart  is  feeble  as  the  result  of  fibroid  changes  in  its 
muscle,  or  when  the  patient  is  convalescing  from  some  disease  like  influenza,  which 
seriously  impairs  the  functional  activity  of  this  organ,  excellent  results  are  some- 
times obtained  by  the  institution  of  what  is  known  as  the  Nauhcim  baths,  which 
were  originally  brought  before  the  profession  by  Schott,  of  Nauheim  in  Germany. 
These  baths  are  composed  of  water  which  is  charged  by  nature  with  large  ciuantities 
of  carbonic  acid  gas.  The  water  is  also  naturally  warm.  The  patient  is  immersed 
in  a  bathtub,  and  immediately  there  is  attached  to  the  surface  of  his  skin  myriads 
of  tiny  bubbles  of  carbonic  acid  gas,  which  as  they  break  produce  a  slight  tingling 
sensation  and  exercise  a  stimulant  influence  upon  the  peripheral  capillaries,  as  the 
result  of  which  these  capillaries  are  dilated  and  dermal  h\-pereniia  is  induced. 
In  this  manner  the  circulation  is  equalized,  internal  congestions  are  overcome,  and 
the  heart  finds  it  easier  to  pump  blood  through  the  dilated  superficial  capillaries 
than  under  ordinary  conditions.  Not  infrequently  when  the  patient  first  enters 
the  bath  a  primary  contraction  of  the  peripheral  capillaries  ensues,  and  this  results 
in  a  momentary  increase  in  the  work  of  the  heart,  so  that  the  patient  for  a  time 
feels  somewhat  oppressed.  Usually  he  remains  in  the  tub  for  ten  or  fifteen  minutes, 
but  this  period  is  go\"erned  by  the  physician  who  superintends  the  use  of  the  baths. 
On  his  remo\'al  from  the  bath  the  patient  is  carefully  dried  by  an  attendant  and 
has  absolute  rest  for  one  or  two  hours.  After  the  baths  have  been  used  for  some 
time  additional  salt  is  added  to  the  bath,  and  water  containing  larger  quantities 
of  gas  is  employed.  In  addition  to  these  baths  the  patients  are  subjected  to  gentle 
resistance  movements  and  massage  so  as  to  improve  the  circulation  of  blood  and 
lymph  in  the  muscles.  Great  care  must  be  taken  that  these  movements  are  not 
sufficient  to  tire  the  heart.  When  valvular  disease  is  very  marked,  these  baths 
are  contra-indicated. 

The  Nauheim  baths  are  also  contra-indicated  in  cases  of  advanced  arteriosclerosis, 


CARDIAC  ANEURYSM 


453 


and  in  chronic  Bright's  disease  if  it  is  well  developed,  although  if  the  renal  difficulty 
is  largely  due  to  congestion  this  plan  of  treatment  is  advantageous.  Aneurysm 
also  contra-indicates  them,  and  Ijronchial  asthma  and  chronic  bronchitis  centra- 
indicate  them,  or  at  least  require  great  caution  in  their  use.  ("ases  of  pulmonary 
tuberculosis  with  cardiac  disease  also  should  not  be  subjected  to  tliis  method,  nor 
should  patients  who  are  sufi'ering  from  far-advanced  degeneration  of  the  heart 
muscle  receive  it.  These  baths  should  never  be  taken  except  under  the  care  of  a 
local  physician. 

It  is  important  to  note  that  the  resistance  exercises,  which  are  carried  out  in 
connection  with  this  plan  of  treatment,  are  probably  equally  beneficial,  if  not 
more  beneficial,  than  the  baths  themselves.  They  consist  in  having  the  patient 
extend  and  flex  his  joints  against  the  resistance  ofi'ered  by  the  attendant. 


CARDIAC  ANEURYSM. 


Aneurysm  of  the  heart  may  occur  in  one  of  three  forms,  viz.,  aneurysm  of  the 
heart  walls,  aneurysm  of  the  valves,  and  aneurysm  of  the  coronary  arteries.  An- 
eurysm of  the  cardiac  walls  consists  in  a  localized 
dilatation  or  pouching  of  the  wall,  and  is  to  be 
separated  from  dilatation  of  the  heart,  to  which 
the  term  aneurysm  is  sometimes  applied  by  French 
writers.  The  aneurysm  usually  aft'ects  the  ventric- 
ular wall.  Hall  has  collected  112  cases,  in  which 
the  site  of  the  aneurysm  was  as  follows:  left  ven- 
tricle, 92  cases;  right  ventricle,  1  case;  left  auricle, 
2  cases;  ventricular  septum — (a)  muscular  part, 
8  cases;  (6)  membranous  part,  7  cases;  auricular 
septum,  2  cases. 

The  left  ventricle  is  therefore  affected  more 
commonly  than  all  of  the  other  chambers  com- 
bined. The  aneurysm  is  usually  near  the  apex 
of  the  ventricle  or  in  the  anterior  wall,  just  above 
the  apex;  67  of  Hall's  cases  were  so  situated. 

The  condition,  as  one  would  naturally  expect,  is 
found  more  frequently  in  males.  In  the  relative 
frequency  in  the  two  sexes,  Thurnam's,  Legg's, 
and  Hall's  and  my  own  statistics  show  a  remark- 
able resemblance.  Of  Thurnam's  40  cases,  30 
were  males,  10  females;  of  Legg's  88  cases,  64 
were  males,  24  females;  and  of  80  cases  collected 
by  me,  59  males,  21  females.  In  a  total  of  208 
cases,  74  per  cent,  were  males,  and  26  per  cent, 
females. 

Aneurysm  of  the  heart  is  a  sequel  of  the  sec- 
ondary myocardial  changes  already  described. 
Thus  the  fibrous  tissue  which  replaces  the  tissues 
which  have  undergone  necrotic  change  may  grad- 
ually yield  before  the  blood  pressure  in  the  ventri- 
cle and  form  a  sac,  which  is  a  true  aneurysmal  dilatation.  This  sac  may  communi- 
cate with  the  ventricle  by  a  small  opening.  In  other  cases  the  ventricular  wall  at  this 
point  yields,  so  that  the  opening  may  be  the  full  width  of  the  sac.  As  in  aneurysm 
of  the  bloodvessels,  the  wall  of  the  sac  is  composed  of  several  layers  made  up  of 
the  visceral  layer  of  the  pericardium,  and  perhaps  of  the  parietal  layer  as  well. 


Front  view  of  heart,  showing  aneu- 
rysm of  left  apex  of  ventricle,  which 
has  perforated  into  the  pericardium. 
The  swelling  of  the  aneurysm  is  visible 
externally,  and  the  heart  wall  at  the 
apex  is  no  thicker  than  brown  paper. 
No  pericardial  adhesion.  The  inter- 
ventricular branch  of  the  left  coro- 
nary artery  is  dissected  out,  and  is 
very  atheromatous,  and  at  the  upper 
end  of  the  groove  is  completely 
blocked  by  a  thrombus,  which  extends 
downward  for  two  and  one-half  inches. 
(From  a  specimen  in  Dr.  I;ittlejohn's 
Museum.) 


454  DT.'^EASES  OF  THE  If E ART 

U  it  lias  l)L'C()mL'  adiicreiit.  Under  this  is  tlie  fibrous  tissue,  anil  hencath  this  again 
t'ormiufj;  the  inner  layer  is  the  endoeardium.     Karely  several  saes  are  present. 

Three  conditions  may  develop  in  such  saes.  They  may  <jive  way  under  pressure, 
causing  sudden  death,  they  may  become  filled  witli  a  clot,  or  their  walls  may  l)e 
calcified.  Sometimes  an  aneurysm  of  this  sort  forms  in  the  septum  and  ruptures 
into  the  right  ventricle. 

In  some  cases  the  aneurysm  may  be  due  to  fatty  degeneration,  witliout  jiriniary 
vascular  disease.  A  softened  spot  in  the  heart  muscle  may  bulge  under  strain, 
and  rupture  may  occur  before  any  real  sac  is  formed.  This  is  commonly  called 
rupture  of  the  heart,  and  usually  involves  the  anterior  wall  of  the  left  ventricle 
near  the  septum;  but  it  may  affect  any  part  of  the  walls  of  the  cardiac  ca\'ities. 

Death  by  rupture  of  the  sac  does  not  occur  as  frequently  as  would  be  imagined, 
and  in  this  respect  cardiac  aneurysm  resembles  aortic  aneurysm.  Out  of  60  cases 
collected  by  Legg,  only  6  died  by  rupture. 

Aneurysms  of  the  cardiac  septa  are  so  rare  as  to  be  curiosities.  Hall  states  that 
only  2  cases  have  been  reported  in  twenty  years. 

An  aneurysm  of  a  valve  is  sometimes  formed  as  a  result  of  endocarditis.  This 
condition  usually  affects  the  aortic  and  mitral  leaflets  with  about  equal  frequency. 
One  leaflet  is  contracted  or  destroyed  and  another  leaflet  then  yields  or  sags,  partly 
because  of  deficient  support,  forming  a  pocket  or  sac  which  projects  into  the  left 
ventricle.  Sometimes  this  sac  ruptures,  and  so  the  valve  becomes  perforated. 
In  other  instances  the  entire  valve  becomes  sacculated. 

Although  atheroma  of  the  coronary  arteries  is  a  very  frequent  lesion,  aneurysm 
of  these  vessels  is  exceedingly  rare.  Hall  could  find  only  25  recorded  cases,  of 
which  17  were  in  males. 

Symptoms. — The  symptoms  of  cardiac  aneurysm  are  not  definite  at  any  time, 
and,  unless  the  sac  is  large,  there  may  be  none.  Hall  tells  us  that  out  of  76  cases 
an  antemortem  diagnosis  was  made  only  once.  When  the  sac  is  large  it  may  cause 
a  marked  increase  in  the  area  of  cardiac  dulness  near  the  apex,  and  produce  distinct 
pressure  symptoms.     A  skiagraph  may  give  valuable  information  of  the  lesion. 

WOUNDS  OF  THE  HEART. 

Wounds  of  the  heart  are  by  no  means  uncommon,  as  the  result  of  shooting  or 
stabbing.  Cases  of  ^eco^•ery  after  both  of  these  forms  of  traimia  are  recorded  in 
considerable  number.  The  stab  wounds  probably  recover  in  greater  number  than 
those  which  suffer  from  bullet  wounds.  Death  is  usually  due  not  to  the  direct 
injiu-y  of  the  lieart,  but  to  the  fact  that  the  pericardial  sac  soon  becomes  filled 
with  blood,  and  the  lieart  is  unable  to  expand.  In  other  words,  even  se\-ere  injury 
to  the  heart  is  not  fatal  imless  the  hemorrhage  be  free,  or  the  organ  is  damaged 
in  some  \'ital  spot,  as  in  His's  atrioventricular  bimdle.  I  proved  these  facts  in  a 
research  carried  out  on  dogs  many  years  ago,  and  a  number  of  surgeons  have  now 
reported  cases  in  which  a  stab  wound  of  the  heart  has  been  exposed  and  sutured,  and 
recovery  has  ensued.  Further  than  this,  I  ha\'e  seen  the  heart  punctured  and  blood 
aspirated  from  its  cavities  without  injury  to  the  patient. 

Gibbon  and  Stewart,  of  the  Jeft'erson  College  Hospital  staff  and  others,  have 
reported  interesting  cases  in  which  cardiac  wounds  were  stitched  with  success. 

ENDOCARDITIS. 

Definition. — Endocarditis  in  an  inflammation  of  the  lining  membrane  of  the 
heart,  the  endocardium.  In  the  great  majority  of  instances  it  chiefly  afl'ects  the 
endocardium  where  it  covers  the  valves  (valvular  endocarditis),  and  rarely  it 
invoh'cs  that  i)art  which  covers  the  walls  of  the  cavities  (mural  endocarditis). 


ENDOCARDITIS  455 

A  distinction  should  also  be  drawn  between  the  acute  and  chronic  form  of  the 
disease  and  between  the  acute  simple,  or  benign,  form,  and  the  so-called  acute 
malignant,  or  ulcerative  type.  It  is  proper  to  state,  howe\'er,  that  many  persons 
deny  the  correctness  of  this  division,  and  regard  the  two  conditions  as  difi'erent 
stages  or  degrees  of  the  same  j)rocess.  Finally,  it  is  to  be  recalled  that  there  are 
two  types  of  chronic  endocarditis,  namely,  that  which  is  the  result  of  the  acute 
variety  due  to  bacterial  infection  and  that  which  arises  in  association  with  chronic 
arteriocapillary  fibrosis  and  atheroma,  whicli  is  a  slow,  retractile  form  of  the  disease. 

Acute  Endocarditis. — Synonyms:  Simple  Endocarditis,  Benign  Endocarditis,  Papil- 
lary Endocarditis. 

Etiology. — Virchow  in  1855  advanced  the  view  that  the  vegetations  on  the  cardiac 
valves  in  septicemia  were  the  result  of  this  state  and  1869  Freiberg  isolated  organ- 
isms in  vegetations.  The  bacterial  origin  of  endocarditis  is  now  generally  admitted, 
but  all  efforts  to  identify  any  particular  organism  as  the  specific  cause  have  pro\'ed 
fruitless.  Many  organisms  have  been  identified  in  the  vegetations.  Of  these 
should  be  mentioned  those  found  in  acute  rheumatism,  pneumococci,  streptococci, 
gonococci,  and  staphylococci,  and,  less  frequently,  the  colon  bacillus,  typhoid 
bacillus,  influenza  bacillus,  tubercle  bacillus,  and  a  number  of  other  bacteria.  The 
greater  number  are  due  to  cocci. 

In  the  article  on  Acute  Articular  Rheumatism  attention  has  already  been  called 
to  the  frequency  with  which  this  condition  complicates  that  malady.  So  constant 
is  this  lesion  during  the  course  of  acute  articular  rheumatism  that  it  may  be  regarded 
as  the  condition  next  in  constancy  to  the  inflammation  about  the  joints.  It  is 
probable  that  in  all  cases  of  acute  rheumatism  a  slight  endocarditis  is  present, 
but  it  may  be  so  slight  that  no  physical  signs  of  its  existence  can  be  elicited. 

In  children  suffering  from  acute  rheumatism  the  involvement  of  the  endocardium 
is  far  more  frequent  than  it  is  in  adults.  Thus,  it  is  generally  considered  that  from 
60  to  SO  per  cent,  of  children  who  have  acute  rheumatism  develop  endocarditis; 
whereas,  the  percentage  usually  accepted  for  adults  is  about  21  per  cent.  Eighty 
per  cent,  is  possibly  too  high,  and  21  per  cent,  is  certainly  too  low  an  estimate. 
It  is  especially  important  to  bear  in  mind  that  mild  articular  sjTnptoms  are  not 
rarely  accompanied  by  severe  cardiac  lesions,  although,  as  a  rule,  the  severity  of 
the  articular  symptoms  and  the  severity  of  the  heart  lesions  go  hand  in  hand.  The 
first  attack  of  rheumatic  fever  is  more  frequently  the  cause  of  cardiac  lesions  than 
subsequent  attacks,  and  the  signs  of  endocardial  inflammation  usually  develop 
during  the  first  ten  days  of  the  illness,  although  in  rare  cases  a  murmur  may  be 
heard  before  any  arthritic  signs  develop. 

When  acute  rheumatism  causes  endocarditis,  it  commonly  affects  the  mitral 
valve.  The  aortic  leaflets  are  comparatively  rarely  affected,  and  the  valves  on 
the  right  side  of  the  heart  only  in  very  rare  instances. 

Next  to  acute  rheumatism  as  a  cause  of  acute  endocarditis  must  be  noted  its 
association  with  chorea,  in  which  disease,  in  its  well-developed  and  typical  forms, 
lesions  of  the  lining  membrane  of  the  heart  are  very  often  present.  The  occurrence 
of  endocardial  disease  in  chorea  is  in  direct  proportion  to  the  severity  of  the  disease, 
but  it  is  difficult  to  decide  how  frequently  true  endocarditis  is  actually  present, 
because  many  choreic  patieiits  present  on  auscultation  functional  murmurs  in  the 
heart  which  disappear  so  rapidly  that  it  is  inconceivable  that  they  could  have 
been  organic  in  origin.  Again,  so -few  cases  of  chorea  come  to  autopsy  during  or 
immediately  after  the  attack  that  it  is  impossible  to  study  the  exact  state  of  the 
endocardium.  If  the  various  statistics  of  frequency  of  heart  murmurs  are  added 
together,  we  find  that  these  sounds  occur  in  about  .31  per  cent,  of  cases  of  chorea. 

In  a  very  considerable  proportion  of  cases  endocardial  infection  takes  place 
during  acute  tonsillitis.  Another  cause  of  endocarditis  is  gonorrhea,  which  causes 
the  ulcerative  type  of  the  disease  more  commonly  than  the  benign  form.     Scarlet 


456 


DISEASES  OF  THE  HEART 


fever  may  also  be  a  causative  factor,  but  wlietlier  this  is  clue  to  direct  infection  of 
the  endocardium  by  the  micro-organism  whicii  causes  scarlet  fever  or  by  its  toxins, 
or  results  from  the  mixed  infection  so  frequent  in  this  disease,  is  not  known.  ]{arely 
endocarditis  is  apparently  due  to  tuberculosis,  for  this  bacillus  has  been  found  in 
the  valve  lesions.  Traumatic  forms  and  endocarditis  due  to  syphilis  have  been 
described.  Occasionally  acute  endocarditis  develops  as  a  result  of  an  exacerbation 
of  the  chronic  form  of  the  disease. 

Endocarditis  has  been  reported  as  present  in  the  fetus  as  a  result  of  the  infection 
of  the  blood  through  the  placenta.  In  this  period  of  existence  the  pulmonary 
valves  are  the  parts  affected. 

Fig.  84 


Heart,  acute  endocarditis.  The  lesion  on  tlio  aortic  leaflets  is  vcrrucosc  and  at  points  ulcerating.  On 
the  lateral  ventricular  aspect  of  the  mitral  valves  are  a  number  of  vegetations,  although  the  contact 
line  and  auricular  surfaces  of  this  valve  were  not  involved.  The  vegetations  on  the  ventricular  surface 
probably  resulted  from  inoculation  by  projecting  vegetations  situated  on  the  aortic  leaflet.  It  is  to  bo 
remembered  that  endocarditis  affects  the  mitral  valves  more  commonly  than  the  aortic  valves. 

Pathology  and  Morbid  Anatomy. — The  degree  of  inflammation  in  the  endocardiinn 
covering  the  cardiac  valves  varies  greatly  in  different  cases.  Its  frequency  on 
the  left  side,  particularly  in  the  mitral  valves,  is  due  principally  to  the  greater 
stress  to  which  these  leaflets  are  subjected  and  also  to  the  higher  oxygen  content 
of  the  arterial  blood.  The  lesions  develop  in  the  auricular  aspect  of  the  mitral 
leaflets  and  the  ventricular  side  of  the  aortic  valves;  this  distribution  depends  upon 
the  friction  and  impact  of  the  blood,  and  the  same  factors  determine  the  distribution 
of  the  vegetations  along  the  lines  of  greatest  pressiu-e,  where  the  leaflets  impinge 
one  upon  another  when  closed. 

The  earliest  lesions  are  rarely  seen,  because  death  seldom  occurs  at  this  time. 
The  aft'ected  area  is  clouded  and  the  valves  slightly  swollen,  due  to  cellular  infiltra- 
tion and  edema.  In  this  softened  condition  the  impact  of  one  valve  upon  another 
roughens  the  surface  along  the  line  of  contact,  and  there  is  deposited  at  this  point 
blood  platelets,  leukocytes,  and  fibrin,  the  quantity  of  each  varying  at  ditt'erent 


ENDOCARDITIS  457 

stages  and  in  different  cases.  This  deposit  on  the  leaflet,  tendon,  or  muscle  is  at 
first  microscopic,  but  by  accretion  may  attain  relatively  massive  proportions,  and 
constitutes  what  is  called  a  vegetation;  essentially  it  is  a  thrombus.  Often  a  row 
of  these  wart-like  bodies  is  festooned  along  the  line  of  contact  or  projects  into  the 
blood  stream.  Their  disturbance  of  the  blood  current  by  obstruction  and  by 
rendering  accurate  coaptation  of  the  opposed  leaflets  impossible,  and  thereby 
permitting  regurgitation,  causes  a  murmur  the  recognition  of  which  is  necessary 
for  accurate  diagnosis  during  life. 

Once  formed,  these  vegetations  are  subject  to  important  changes.  They  may 
be  detached  and  swept  oft'  into  the  circulation,  or  they  may  soften  and  possibly 
be  absorbed.  (See  Complications  of  Ulcerative  Endocarditis.)  Adhesions  between 
leaflets  may  occur,  but  commonly  the  vegetations  organize  and  permanently 
alter  the  contour,  flexibility,  and  elasticity  of  the  valves,  thereby  interfering  with 
their  proper  functions.  Finally,  calcifying  deposits  may  further  add  rigidity  to  the 
already  damaged  leaflets.  In  favorable  cases  the  valve  surface  becomes  smooth, 
but  little  thickening  results,  and  function  is  more  or  less  fully  restored. 

Acute  endocarditis  ends  in  one  of  three  ways:  1.  The  acute  inflammation  may 
subside  and  leave  little  or  no  alteration  behind  it.  2.  The  vegetations  may  persist 
and  form  large  masses  of  an  almost  nodular  character  upon  valves.  3.  The  valves 
become  eroded  or  adherent,  or  cicatricial  contractions  may  lead  to  distortions  and 
consequent  immediate  insufiiciency  or  obstruction. 

Symptoms. — In  distinction  from  physical  signs,  there  are  no  sjTiiptoms  of  ordinary 
acute  endocarditis  of  the  benign  form.  It  is  true  that  the  pulse  may  be  a  little 
quicker  than  before  the  endocardium  was  aft'ected  and  the  fever  a  little  higher,  but 
neither  of  these  sjTnptoms  is  constant  or  characteristic.  Some  palpitation  may 
be  present,  but  so  frequently  are  all  symptoms  absent  that  all  too  frequently  the 
physician  who  is  not  careful  fails  to  discover  endocardial  disease  imtil  the  patient 
begins  to  move  about  and  complains  of  cardiac  weakness  or  dyspnea,  and  then  the 
damage  is  done  and  is  almost  irreparable.  Even  the  presence,  on  physical  examina- 
tion, of  a  murmur  over  the  mitral  or  aortic  area  does  not  prove  the  presence  of 
endocarditis,  because  it  not  infrequently  happens  that  a  murmur  due  to  anemia 
or  to  relaxation  of  the  orifice  is  present.  The  presence  of  the  murmur,  while  not 
pathognomonic  of  acute  endocarditis,  is,  however,  sufficient  ground  for  the  physician 
to  treat  his  patient  as  a  case  with  this  lesion. 

Complications. — These  consist  most  commonly  of  pericarditis  and  embolism 
of  one  of  the  cerebral  or  pulmonary  arteries.  Rarely  acute  cardiac  dilatation 
ensues,  and  sometimes  in  infectious  cases  pneumonia  and  pleuritis  develop. 

Diagnosis. — Care  must  be  taken,  as  just  stated,  that  anemic  murmurs,  murmurs 
due  to  relaxation  of  the  orifices,  and  pericardial  friction  sounds  are  not  mistaken 
for  those  due  to  endocardial  disease.     (See  Vahiilar  Disease.) 

Prognosis. — Death  is  very  rarely  clue  to  acute  simple  endocarditis  in  the  sense 
that  death  comes  diu-ing  the  acute  stage  of  the  disease.  All  too  frequently  it 
follows  as  a  consequence  of  the  changes  produced  in  the  valves  and  heart  muscle 
months  or  years  after  the  acute  stage  has  passed.  A  bad  prognosis  can  always 
be  given  if  the  physician  does  not  strenuously  insist  upon  the  patient  resting  in 
bed  for  several  weeks  after  all  articular  and  valvular  signs  have  ceased.  The 
process  may  affect  not  only  the  valves  but  the  heart  muscle  to  such  an  extent 
as  to  cause  death  during  the  acute  illness.  In  children  the  mortality  is  about 
20  per  cent.  Ill-health  and  death  may  not  come  until  years  afterward,  as  time 
and  chronic  disease  weakens  the  valves  and  heart  muscle.  Fifty  per  cent,  of 
children  who  develop  acute  endocarditis  and  survive  the  acute  attack  succumb 
in  the  next  ten  years,  but  if  they  survive  puberty  the  mortality,  according  to 
Dunn  is  about  7  per  cent.  In  other  words,  such  a  patient  has  far  better  chances 
than  an  adult  who  develops  acute  endocarditis,  because  the  growth  and  reparative 


458  DISEASES  OF  THE  HEART 

power  of  the  surviving  child  compensates  thoroughly  for  the  lesion.  Indeed 
many  of  these  patients  lead  long  and  active  lives. 

Treatment. — To  prevent  endocarditis  in  the  course  of  all  infectious  diseases, 
and  particularly  in  acute  rheumatism,  the  physician  must  insist  on  absolute  rest 
in  bed  all  through  the  illness  and  for  some  time  after  the  attack  has  passed.  The 
diet  should  be  light  and  easily  digested,  and  at  no  time  should  the  digestive  appar- 
atus be  overburdened,  for  active  and  prolonged  digestion  tires  the  heart.  If 
acute  rheumatism  is  present,  the  salicylates  should  be  used  freely  at  once,  not  that 
they  protect  the  valves  directly,  but  they  shorten  the  illness  and  so  diminish  the 
chance  of  involvement  of  the  endocardium.  Over  the  precordium,  as  a  preventive 
of  endocarditis  and  pericarditis,  should  be  placed  six  or  eight  flying  blisters,  and 
alkaline  diuretics,  like  citrate  of  potassium,  should  be  freely  used.  An  ice-bag 
may  be  placed  over  the  heart  if  it  is  very  irritable,  and  tincture  of  aconite  may  be 
given  for  the  same  purpose.  After  the  endocardial  symptoms  have  developed, 
rest  of  the  most  absolute  character  is  the  only  useful  plan  of  treatment.  During 
convalescence  weeks  of  rest  is  again  the  sine  qua  non.  For  the  anemia  often  present 
iron  and  arsenic  are  useful,  as  is  also  cod-liver  oil.  Subsequent  cardiac  feebleness 
is  to  be  treated  by  small  doses  of  digitalis,  as  3  to  5  drops  of  the  tincture  with  10 
drops  of  tincture  of  nux  vomica  three  times  a  day  and  2  drops  of  Fowler's  solution. 

Ulcerative  Endocarditis. — Definition. — Ulcerative  endocarditis  is  a  state  in  which 
the  endocardium  is  ulcerated,  vegetations  are  present,  and  there  is  an  actual  loss 
of  substance  in  the  valvular  tissues,  so  that  a  valve  or  even  a  septum  may  be  per- 
forated. A  French  physician,  Bouillaud,  first  recognized  this  cardiac  state  with  its 
associated  signs  of  pyemia,  but  Kirkes,  of  England,  first  emphasized  the  fact  that 
the  heart  was  the  seat  of  the  difficulty,  and  that  the  symptoms  arose  from  its 
condition.  Since  this  time  a  host  of  pathologists,  including  Yirchow,  Wilks, 
]\Iurchison,  Charcot,  Vulpian,  and  Birch-Hirsclifeld  in  Eiuope,  and  Osier  while 
in  this  country,  ha^■e  studied  this  malady.  It  is  important  to  remember  that 
ulcerati^'e  endocarditis  occurs  in  an  acute  and  chronic  form. 

Etiology. — The  disease  is  always  due  to  microbic  infection  of  the  endocardium. 
It  may  be  due  to  a  secondary  infection,  during  the  coiu-se  of  one  of  the  acute  infec- 
tious diseases  like  typhoid  fever,  scarlet  fever,  pneumonia,  or  tonsillitis,  or  it  more 
rarely  arises  as  a  primary  lesion.  The  organisms  are  usually  the  Staphi/lococciis 
pyogenes  aureus,  the  Streptococcus  pyogenes,  and  the  Pneumococcus,  the  Bacillus 
typhosus,  the  Gonococcvs,  the  Bacillus  coli  communis.  Acute  endocarditis  due 
to  the  meningococcus  of  Weichselbaum  is  very  rare.  A  number  of  cases  ha\-e  been 
reported  in  which  the  meningococcus  has  been  found  in  the  circulating  blood :  one 
by  Gwyn  in  1SS9,  another  by  Salomon  in  1902,  and  a  third  by  ^Ya^field  and  Walker 
in  1903.  The  last  of  these  is  the  only  one  in  which  the  meningococcus  was  demon- 
strated to  be  the  cause  of  the  endocarditis.  Any  damage,  new  or  old,  to  the  surface 
of  a  valve  predisposes  that  part  to  infection.  In  its  subacute  form  this  type  of 
endocarditis  has  been  proved  by  Schottmiiller,  Libman  and  others  to  be  very 
often  due  to  the  Streptococcus  viridans  which  receives  its  name  because  in  culture 
it  produces  a  distinct  green  pigment.     (See  below.) 

Pathology  and  Morbid  Anatomy. — Anatomically,  the  ulcerative  form  may  be 
but  a  later  stage  of  the  acute  simple  type,  and  many  cases  occur  in  which  no  sharp 
line  of  demarcation  can  be  drawn.  Not  infrequently  it  is  engrafted  upon  an  old 
or  chronic  valvular  lesion,  and  patients  ha\^ing  such  lesions  should  be  watched 
closely  during  an  attack  of  any  infectious  disease  associated  with  the  constant  or 
frequent  occurrence  of  bacteremia.  The  infecti\'e  process  in  the  ulcerative  type 
leads  to  necrosis  of  the  already  formed  or  forming  vegetations,  and  even  of  the 
affected  leaflet  or  adjacent  myocardium.  The  fragments  thrown  into  the  circula- 
tion cause  infarction  and  metastatic  lesions  in  many  tissues,  especially  in  the  spleen, 
kidneys,  and  brain.     Marrow  lesions,  joint  complications,  and  other  manifestations 


EXDOCARDITIS  459 

of  septicopyemia  are  often  conspicuous,  ^^'hethe^  the  secondary  processes  l>e 
suppurative  or  not  depends  upon  tiie  character  of  the  infecting  organism.  When 
involving  the  \'al\'C3  of  tiie  right  heart  (as  it  does  more  commonly  than  the  acute 
simple  form),  puhuonary  coniphcations  may  he  conspicuous,  which,  taken  with 
the  fact  tiaat  it  may  be  a  sequence  or  compHcation  of  pneumonia,  further  tends  to 
obscure  the  seat  of  the  primary  lesion.  Occasionally  the  almost  symptomless 
progress  of  the  malady  is  due  to  the  low  virulence  of  the  infecting  organism,  while 
intensely  toxicogenic  bacteria  re\'erse  the  picture  and  cause  evidences  of  severe 
infection  and  toxemia  to  be  manifest. 

Symptoms. — The  objective  symptoms  of  ulcerative  endocarditis  may  be  no 
more  marked  than  those  of  the  simple  form.  Fever  may  not  occur.  If  the  disease 
develops  during  the  course  of  one  of  the  acute  infectious  diseases  or  as  a  result  of 
septicemia,  its  existence  may  not  be  suspected.  If  it  develops  primarily  the 
physician  who  does  not  carefully  study  the  heart  may  believe  that  the  fercr  in 
its  acute  period  of  rise  and  fall  is  the  manifestation  of  one  of  the  ordinary  acute 
infectious  diseases  or  he  may  suspect  sepsis,  t\'phoid  fever,  or  malaria.  Because 
of  these  symptoms,  the  disease  may  be  divided  into  the  septic  form,  the  tj^phoid 
form,  and  the  malarial  form.     A  cerebral  form  also  exists. 

In  the  septic  form  the  patient  presents  the  ordinary  signs  of  septicemia.  Chill 
after  chill  develops,  and  between  the  chills  high  fever  and  sweats  are  present. 
The  patient  looks  profoimdly  septic,  the  tongue  is  dry,  the  eyes  sunken,  and  petechise 
may  be  present  in  the  skin.  The  marked  anemia  is  very  noteworthy,  and  its 
severity  is  diagnostic.  Leukocytosis  is  present  if  the  infection  is  not  exceedingly 
severe.  ^Iidtiple  metastatic  abscesses  may  be  foimd.  The  heart  may  or  may 
not  produce  a  murmiu-,  but  its  action  is  hurried  and  feeble. 

The  typhoid  type  is  closely  allied  to  that  just  described.  The  dry  tongue,  the 
subsidtus,  the  t\"mpanites,  the  diarrhea,  the  mental  stupor,  the  swollen  spleen, 
and  the  remitting  fever  may  all  present  so  t^"pical  a  picture  of  a  case  of  t\"phoid 
fever  that  only  the  constant  recollection  that  such  sjTuptoms  may  be  due  to  ulcera- 
tive endocarditis  will  save  the  physician  from  an  error  in  diagnosis.  Even  epistaxis 
may  develop. 

In  the  malarial  type  the  constant  reciurence  of  moderate  chills,  moderate  fever, 
anemia,  and  some  sweating  may  be  very  misleading. 

In  the  cerebral  form  there  is  severe  headache,  unconsciousness,  and  con^^llsions 
due  to  an  associated  meningitis.  In  some  instances  the  simultaneous  development 
of  septic  arthritis  makes  the  case  resemble  acute  rheumatism.  Burrows  has 
reported  a  case  in  which  \"omiting  and  purging  were  so  se^"ere  that  he  beheved  the 
patient  to  be  suffering  from  homicidal  poisoning. 

Cases  are  recorded  in  which  the  -splenic  enlargement  was  so  great  that  the  patient 
was  thought  to  be  suffering  from  splenomedullary  leukemia.  In  other  cases  the 
diagnosis  of  acute  tubercidosis  has  been  made. 

Albuminuria  and  hematuria  are  common  s\"mptoms,  but  renal  infarction  may 
take  place  ■without  either  albumin  or  blood  being  found  in  the  urine. 

Endocardial  murmiu-s  are  not  always  present.  They  are  shifting  in  time  and 
in  character  and  may  be  foimd  one  day  and  be  lost  the  next.  Further,  it  sometimes 
happens  that  the  murmm-s  change  in  character  from  day  to  day,  owing  to  the 
progressive  character  of  the  lesions.  When  miu-murs  exist  they  are  more  frequently' 
due  to  old  lesions  than  to  the  new  ones  produced  by  the  acute  infection. 

In  that  tj-pe  due  to  streptococcus  riridans  the  s^rmptoms  are  insidious  in  onset 
with  joint  pains  and  aches,  like  those  of  influenza,  with  albuminiu-ia,  and  sometimes 
vomiting  and  diarrhea.  Because  of  its  slow  course  it  is  called  endocarditis  lenta. 
It  is  nearly  always  fatal  in  from  a  few  weeks  to  several  months.  The  kidneys 
suffer  gravely  from  small  septic  emboli.  Although  the  spleen  is  enlarged  and 
petechiiie  may  appear  blood  cultures  are  usually  sterile. 


460  DISEASES  OF  THE  HEART 

Complications. — The  complications  of  ulcerative  endocarditis  are  many  and 
serious.  It  not  infrequently  happens  that  a  septic  embolus  not  only  plujjs  an 
important  vessel,  and  so  causes  an  Infarct  in  such  organs  as  the  kidney,  the  lung, 
and  the  spleen,  but  it  acts  as  a  focus  of  sei)tic  development.  Such  eml)olic  closure 
frequently  occurs  in  the  branches  of  the  left  middle  cereljral  artery,  and  causes 
temporary  or  permanent  aphasia  or  hemijilegia.  Lesions  of  the  cranial  ncr\TS  occur. 
Peripheral  vessels,  such  as  the  popliteal  or  brachial  or  lingual  arteries,  may  also 
be  affected.  Occasionally  violent  abdominal  pain,  followed  by  bloody  stools  and 
signs  of  collapse,  indicates  that  embolism  of  the  mesenteric  vessels  has  taken  place. 
Sometimes  uremia,  due  to  the  septic  nephritis  which  is  present,  ends  the  patient's 
life.     Septic  foci  in  the  skin  and  lymph  nodes  may  develop. 

Diagnosis. — The  points  of  value  in  diagnosis  are  the  suddenness  of  onset  in  some 
cases,  the  up-and-down  temperature  wa\'es,  which  form  steep  curves  on  the  charts, 
the  repeated  rigors,  the  presence  of  distinct  leukocytosis,  the  presence  of  pyogenic 
organisms  In  the  blood,  the  absence  of  the  malarial  organism  and  of  the  Widal 
reaction,  and,  finally,  the  presence  of  great  feebleness  and  irregularity  of  the  heart's 
action.  In  some  cases,  however,  the  diagnosis  from  physical  signs  may  be  practi- 
cally Impossible. 

Prognosis. — It  is  hardly  necessary  to  state  that  the  prognosis  Is  most  grave. 
Recovery  rarely  occurs,  and  death  may  take  place  in  the  first  two  weeks  or  earlier. 
Sometimes  life  is  preserved  for  weeks.  The  duration  depends  largely  upon  the 
character  of  the  infection,  the  condition  of  the  heart  and  of  Its  valves,  and  the 
occurrence  of  complications.  Some  cases  extend  over  a  period  of  several  months, 
and  most  of  them  last  for  several  weeks.  That  healing  may  take  place  and  reco\-ery 
occur  in  cases  of  true  ulcerative  endocarditis  is  proved  by  a  large  number  of  cases 
now  on  record,  in  which  the  condition  has  been  proved  by  subsequent  autopsies 
to  have  existed,  the  patient  dying  of  another  malady. 

Treatment. — The  treatment  of  ulcerative  endocarditis  is  not  very  satisfactory. 
Antistreptococcic  serum  may  be  of  benefit  in  a  few  cases,  pro\'Ided  that  the  strep- 
tococcus is  the  cause  of  the  disease,  and  provided  that  the  variety  of  streptococcus 
used  In  the  preparation  of  the  serum  is  the  same  as  that  present  In  the  heart.  Aside 
from  this  specific  treatment,  the  only  thing  to  do  is  to  support  the  system  by  the 
wise  use  of  tonics,  such  as  tincture  of  the  chloride  of  Iron  and  the  tonic  bitters. 
Full  doses  of  quinine  may  be  used.  The  most  Important  function  of  the  physician 
is  to  maintain  nutrition  by  the  use  of  good  food  and  to  order  no  drugs  which,  by 
disordering  digestion,  will  interfere  with  the  digestive  and  assimilative  functions. 

Chronic  Endocarditis. — As  already  stated,  chronic  endocarditis  is  frequently 
a  sequence  of  one  of  the  acute  forms  just  described,  and,  therefore,  as  a  rule,  it 
afl'ects  the  left  side  of  the  heart  and  the  mitral  leaflets  oftener  than  the  aortic 
valves.  In  some  Instances,  however,  it  depends  upon  alcoholism,  gout,  and  syphilis, 
in  which  case  associated  changes  In  the  heart  muscle  and  bloodx'cssels  are  also 
found.  Libman  has  now  studied  12.5  cases  of  what  he  designates  subacute  bacterial 
endocarditis,  21  of  them  in  the  bacteria-free  stage.  The  five  clinical  features  of 
this  stage  are:  (1)  Marked  progressive  anemia;  (2)  brown  pigmentation  of  the 
face;  (3)  marked  evidence  of  renal  disease;  (4)  marked  enlargement  of  the  spleen; 
(5)  endocarditic  symptoms,  as  periodic  elevation  of  temperature,  petechia",  occa- 
sional joint  symptoms,  and  embolisms.  A  slowly  progressing  valvulitis  or  sclerosis 
of  the  valves,  which  comes  on  insidiously,  Is  frequently  associated  with  arterio- 
sclerosis (arteriosclerotic  endocarditis),  with  cltronlc  renal  disease,  chronic  metallic 
poisoning,  especially  that  due  to  lead,  and  other  conditions  associated  with  high 
arterial  tension,  with  or  without  the  presence  in  the  blood  of  some  specific  irritant 
to  which  the  changes  may  be  ascribed.  As  the  acute  Inflammatory  process  merges 
into  the  chronic  form,  one  or  two  changes  appear  in  the  endocardlmn.  There  is 
an  overproduction  of  connective  tissue  in  the  endocardium,  with  thickening,  stiffen- 


CHRONIC  VALVULAR  DIfiEAHE  AR  A   RESULT  OF  ENDOCARDITIS     4(il 

ing,  and  lessened  elasticity,  which  chiefly  afi^^ects  the  valvular  leaflets.  Following 
this  condition,  as  a  result  of  further  degenerative  changes,  we  find  contractions 
or  localized  yieldings  of  the  valves  which  produce  an  unevenness  of  their  surfaces, 
so  that  their  edges  can  no  longer  be  accurately  approximated;  nor  do  they  permit 
the  free  flow  of  blood  through  the  orifice  which  they  guard,  since  they  are  imable 
to  yield  during  the  period  at  which  a  free  flow  of  blood  should  normally  take  place. 
Even  when  the  valves  are  thickened  and  distorted  they  may  still  be  adequately 
covered  by  endothelium,  but  in  some  instances  the  endothelium  may  be  absent, 
thereby  exposing  calcareous  and  roughened  surfaces  upon  which  fibrin  is  sometimes 
deposited.  The  chief  factors  in  producing  cardiac  failure  in  chronic  endocarditis 
are  irregular  contractions  which  distort  the  valves,  causing  their  edges  to  become 
everted,  inverted,  or  curled  up.  In  addition  the  chordae  tendinese  which  control 
the  valves  guarding  the  auriculoventricular  orifices  become  shortened  and  thickened 
so  that  they  interfere  with  the  free  movement  of  the  valves.  (See  Diseases  of  the 
Myocardium.) 

In  that  form  of  the  disease  in  which  mural  endocarditis  is  present,  patches  of 
sclerosis  or  cicatrices  may  be  seen  over  the  walls  of  the  ventricles.  (See  Chronic 
Valvular  Disease.) 

CHRONIC  VALVULAR  DISEASE  AS  A  RESULT  OF  CHRONIC 
ENDOCARDITIS. 

Chronic  valvular  disease  of  the  heart  is  very  constantly  met  with  in  medical 
practice,  and  its  frequency  is,  as  a  rule,  in  direct  proportion  to  the  age  of  the  patient 
examined.  This  is  due  to  the  sclerotic  changes  which  are  prone  to  take  place  in  ' 
the  valves  as  age  advances,  and  to  the  fact  that  in  those  who  have  passed  the  period 
of  middle  life  the  heart  in  all  its  parts  is  unable  to  withstand  the  strains,  which 
may  come  to  it,  as  well  as  in  earlier  periods.  The  chief  causes  of  valvular  lesions 
may  be  placed  in  three  divisions,  namely:  (1)  those  due  to  infectious  diseases, 
particularly  rheumatism,  which  may  leave  behind  damage  which  only  becomes 
apparent  when  age  or  some  unusual  strain  weakens  the  heart  muscle;  (2)  fibroid 
or  sclerotic  changes  ensuing  as  a  result  of  age,  gout,  syphilis,  and  alcoholism;  (3) 
definite  myocardial  degeneration  and  dilatation  which  does  not  cause  direct  but 
indirect  valvular  failure  in  function,  as  described  elsewhere.  (See  Relative  In- 
sufficiency.) 

Experience  in  the  larger  London  hospitals,  some  twenty-five  years  ago,  led  me 
to  believe  that  cardiac  valvular  disease  was  much  more  common  in  England  than 
in  America.  It  is  interesting  to  note,  however,  that  this  view  was  incorrect,  for  out 
of  59,762  medical  cases  which  are  recorded  in  hospitals  in  London,  there  were 
3059  cases  of  valvular  heart  disease,  or  a  percentage  of  5.1 ;  and  out  of  91,985  medical 
cases  in  hospitals  in  different  cities  in  the  United  States,  there  were  4108  cases  of 
valvular  disease,  or  a  percentage  of  4.4.  The  actual  difference  in  frequency  in 
England  and  America  is,  therefore,  not  very  marked,  not  only  as  regards  endocar- 
ditis, but  acute  rheumatism  as  well.     (See  Acute  Rheumatism.) 

Valves  Affected. — Series  of  statistics  differ  somewhat  as  to  the  relative  fre- 
quency with  which  different  valves  are  affected.  One  difficulty  is  that  there  has 
never  been  a  sufficiently  large  collection  of  statistics  to  give  results  free  from  error. 
Another  difficulty  lies  in  the  differentiation  of  true  and  false  aortic  stenosis;  for 
it  is  evident  that  certain  statistics  which  give  a  large  percentage  of  this  lesion 
include  cases  in  which  there  is  not  true  simple  stenosis  (which  is  quite  rare  without 
regurgitation)  but  cases  in  which  atheroma  and  aortic  roughening  cause  a  systolic 
aortic  murmur. 

All  clinicians  and  pathologists  are  in  accord  in  stating  that  mitral  regurgitation 
is  the  most  common  lesion  by  long  odds.     Jiirgensen  has  analyzed  2470  cases  of 


462  DISEASES  OF  THE  HEART 

valvular  cardiac  disease,  with  the  following  results  as  to  the  relative  frequency 
with  which  valvular  disease  occurs:  mitral  disease,  1G16;  aortic  disease,  457; 
pulmonary  valvular  disease,  56;  tricuspid  disease,  10;  associated  aortic  and  mitral 
disease,  224;  associated  mitral  and  tricuspid  disease,  45;  lesions  at  the  mitral, 
aortic,  and  tricuspid  valves,  24;  and  at  the  aortic  and  tricuspid  ^•alves,  2.  Unfor- 
tunately he  does  not  state  what  the  lesions  are — i.  c,  regurgitant  or  stenotic. 
It  is  an  open  question,  too,  how  many  of  the  cases  of  so-called  mitral  disease  and 
tricuspid  disease  were  secondary  murmurs  due  to  dilatation  of  those  orifices  and 
not  to  true  valvular  defects. 

Some  years  ago,  T.  G.  Ashton,  my  then  chief  of  clinic  at  the  Jefferson  Hospital, 
made  an  analysis  of  1024  cases  of  valvular  disease  met  with  in  life  insurance  exami- 
nations. His  results  showed  that  of  these  557  were  cases  of  mitral  regurgitation, 
136  were  aortic  stenosis,  47  were  aortic  regurgitation,  32  were  mitral  stenosis,  and 
11  tricuspid  regiu-gitation.  I  believe  that  these  statistics,  while  accurate  in  them- 
selves, are  to  some  extent  misleading,  and  that  the  proportion  of  cases  of  aortic 
stenosis  is  too  high  and  mitral  stenosis  too  low.  (See  article  on  Aortic  Stenosis.) 
The  figures  obtained  by  the  analysis  of  90S  cases  of  valvular  heart  disease  treated 
in  Westminster  Hospital,  London,  show  that  the  most  common  single  lesions  are 
mitral  regurgitation,  mitral  stenosis,  aortic  regurgitation,  and  aortic  stenosis,'  in 
order  of  arrangement,  and  that  of  double  lesions  at  one  orifice  the  ^elati^'e  fre- 
cjuency  is  double  aortic,  double  mitral,  double  pulmonary,  and  double  aortic  with 
double  mitral.  Mitral  regurgitation  quite  frequently  occurs  as  the  result  of  aortic 
regurgitation,  through  dilatation  of  the  mitral  orifice. 

Mitral  disease  affects  more  women  than  men;  aortic  disease  more  men  than 
women. 

Aortic  regurgitation  is  the  most  fatal  lesion.  Mitral  stenosis  ranks  second  in 
fatality,  aortic  stenosis  third,  and  mitral  regurgitation  fourth.  The  mortality 
of  double  aortic  lesions  is  greater  than  that  of  double  mitral. 

The  statistics  of  A.  Lockhart  Gillespie,  based  on  a  study  of  1914  cases  treated 
in  the  Edinburgh  Royal  Infirmary,  are  especially  interesting  in  that  they  show 
the  mortality  of  valvular  lesions  in  the  two  sexes  according  to  age.  Gillespie 
found  that  the  maximum  mortality  in  males  with  aortic  incompetence  or  stenosis 
occurs  between  the  age  of  fifty  and  sixty-nine,  but  in  those  with  double  lesions 
the  years  from  twenty-nine  are  those  with  the  highest  mortality.  The  female 
maximum  mortality  in  aortic  incompetence  and  aortic  stenosis  falls  between  the 
years  of  forty-nine  and  fifty.  Mitral  stenosis  proves  most  fatal  at  from  thirty 
to  thirty-nine  years  in  males,  and  from  forty  to  forty-nine  in  females.  The  death 
rate  in  females  between  twenty  and  twenty-nine,  forty  and  forty-nine,  and  sixty  and 
sixty-nine  is  higher  than  in  males  at  similar  periods.  The  death  rate  in  mitral 
incompetence  in  both  sexes  rises  progressively  with  the  age.  In  cases  of  double 
mitral  lesion,  the  male  maximum  mortality  falls  between  thirty  and  forty-nine, 
and  in  the  female  between  fifty  and  sixty-nine. 

Before  proceeding  to  a  consideration  of  the  various  valvular  lesions  it  is  essential 
that  the  mechanism  of  the  valves  in  health  and  disease  be  clearly  understood  (Fig. 
S5).  The  cardiac  valves  are  arranged  in  such  a  way  that  they  prevent  a  reflux 
of  blood  into  that  cavity  which  the  blood  has  just  left  in  the  progress  of  the  normal 
circulation.  As  a  rule,  these  valves  are  cai)al)le  of  fitting  together  so  tightly  that 
they  completely  and  eft'ectively  close  the  orifice  which  they  guard,  but  e\-cn  without 
the  presence  of  any  condition  of  disease  they  may  at  times  give  way,  and  permit 
some  reflux.  The  moderate  reflux  occurring  during  great  muscular  strain  may  be 
regarded  as  a  physiological  attempt  to  relieve  the  blood  pressure  in  the  cardiac 
cavities,  and  if  it  is  not  maintained  for  too  great  a  length  of  time  it  does  no  harm. 

'  This  probably  refers  to  true  stenosis  and  not  to  cases  in  wliifh  only  llic  aortic  systolic  nuirnuir  was 
present.     (See  Aortic  Stenosis.) 


CHRONIC  VALVULAR  DLSEASE  AS  A   RESULT  OF  ENDOCARDITIS     ii\?, 


It  must  also  be  recalled  that  there  are  at  least  two  ways  in  which  the  cardiac 
valves  may  become  incompetent  to  prevent  reflux  of  blood.  In  the  first,  and  by 
far  the  most  common  type,  the  valves  are  diseased,  as  already  described  in  the 
article  on  Endocarditis,  so  that  they  cannot  become  closely  approximated,  or  they 
are  glued  together  in  such  a  way  that  the  same  result  is  achieved,  and  so  they 
also  obstruct  the  flow  of  blood.  In  the  second  type  the  rings,  which  form  the  bases 
of  the  valves  and  the  margins  of  the  orifices,  yield,  and  as  they  relax  the  orifice 
becomes  too  large  to  be  closed  by  the  valves,  which  may  still  be  practically  normal 
in  themselves.  This  condition  exists  for  a  brief  space  of  time  in  acute  cardiac 
strain,  as  just  stated.  It  persists  for  a  long  time  or  becomes  permanent  in  uistances 
where  the  heart  is  feeble  and  the  strain  is 
very  severe  or  prolonged,  and  it  is  frequently 
found  in  cases  of  dilatation  and  feebleness  of 
the  heart  muscle. 

Those  forms  of  valvular  incompetence 
which  occur  in  athletes  or  others  after 
severe  exertion  can  therefore  be  put  aside 
as  beyond  the  scope  of  these  particular 
pages,  although  thej'  will  again  be  discussed 
under  the  head  of  Functional  Disorders  of 
the  heart. 

In  those  cases  in  which  the  valve  becomes 
incompetent  to  close  an  orifice,  and  so  per- 
mits regurgitation  to  take  place,  the  failure 
of  the  valve  is  so  gradual,  as  a  rule,  that 
there  develops  simultaneously  an  increase  in 
the  size  and  strength  of  the  heart  muscle,  so 
that  it  may  by  increased  power  and  activity- 
compensate  for  the  leakage  which  occurs. 
As  a  result  it  very  frequently  happens  that 
this  compensatory  hypertrophy  is  fully  equal 
to  the  increased  demands  made  on  the  heart 
muscle,  and  not  until  the  occurrence  of  a 
severe  illness,  or  until  advancing  years  im- 
pairs the  power  of  its  fibres,  are  any  mani- 
festations of  valvular  lesions  to  be  found  in 
the  patient,  save  the  physical  signs  of 
hypertrophy  and  the  murmur  caused  by 
the  regurgitating  blood.  Sometimes  even 
the  murmur  may  disappear  for  a  time. 

In  cases  in  which  a  valve  is  ruptured  or 
severely  damaged  by  disease  so  that  it  fails  in  its  function  before  the  heart  can 
undergo  compensatory  hypertrophy,  we  often  see  signs  of  great  circulatory  em- 
barrassment from  the  very  first  part  of  the  illness. 

In  all  cases  of  valvular  disease  in  their  early  stages  much  depends  upon  the 
inherent  strength  of  the  heart  muscle  and  its  ability  to  increase  in  power,  and  there- 
fore it  is  evident  that  it  is  of  vital  importance  for  the  patient  to  rest  at  this  period 
in  order  that  the  strength  of  the  heart  may  be  conserved,  and  in  order  that  it  may 
not  be  subjected  to  a  severe  strain  with  associated  dilatation  at  the  most  critical 
period  of  its  existence.  This  is  the  more  important  because  diseases  which  second- 
arily infect  the  valves  usually  impair,  to  some  extent  at  least,  the  myocardium  as 
well. 

In  health,  when  the  valves  are  intact,  the  heart  always  possesses  a  considerable 
degree  of  reserve  energy  and  power,  using  only  a  small  part  of  its  store  of  energy 


Diagram  modified  from  Page  to  show  the 
relation  of  the  various  valves.  A  study  of 
this  diagram  will  render  clear  the  time  of 
the  various  cardiac  murmurs.  Thus  in 
mitral  regurgitation  the  blood  passes  back 
from  the  left  ventricle  to  the  left  auricle  dur- 
ing systole,  and  is  dammed  up  in  the  pulmo- 
nary veins,  the  openings  of  which  are  seen  in 
the  auricular  wall,  producing  pressure  on 
the  pulmonary  valves,  the  sounds  of  which 
are  thereby  accentuated. 


464 


DISEASES  OF  THE  HEART 


in  a  (lay's  work.  As  a  consequence  a  healthy  man  can  run  a  considerable  distance, 
or  leave  his  desk  and  go  hunting,  without  engendering  anything  more  than  fatigue 
of  his  voluntary  muscles  and  some  healthy  cardiac  tire.  This  reserve  energy  is 
kept  for  just  such  purposes.  On  the  other  hand,  if  a  man  who  is  a  sufferer  from 
valvular  or  myocardial  disease,  even  if  he  is  seemingly  in  perfect  health,  attempts 
to  follow  the  first  one,  he  soon  begins  to  suffer  from  cardiac  embarrassment,  and 
if  he  persists  may  become  very  gravely  ill  from  acute  cardiac  failure,  and  rupture 
ills  compensation  by  excessive  exercise  to  such  an  extent  that  he  may  be  bedridden 
for  the  rest  of  his  days.  In  the  latter  instance  nearly  all  his  reserve  energy  is 
being  used  daily  in  the  maintenance  of  a  normal  circulation  and,  having  little 
reserve,  he  cannot  undertake  feats  that  demand  great  calls  upon  his  reserve.  This 
is  illustrated  in  the  following  squares: 


Reserve 

Energy 

Reserve 
Energy 

All  Energ.v 

In  Constant 

Use. 

In  Constant 
Use.. 

In  Constant 
Use. 

health,  large  reserv 

In 

disease,  small  reserv 

•e.                  Far-advanced  disease 
no  reserve. 

In  the  last  square  it  is  seen  that  all  the  reserve  is  in  constant  use,  and,  therefore, 
if  any  extra  exertion  is  made,  the  heart  promptly  fails  and  death  may  occur.  Even 
in  those  cases  in  which  sufficient  hypertrophy  de^'elops  to  adequately  compensate 
for  the  leak  in  the  valve,  the  heart  is  never  as  capable  for  work  as  in  health  because 
the  reserve  is  never  restored  completely  and  the  degree  of  leakage  may  increase 
at  any  moment  of  strain. 

A  consideration  of  these  facts  makes  one  therapeutic  fact  stand  pre-eminent 
above  all  others,  namely,  that  rest  is  the  chief  measure  to  be  instituted  whenever 
compensation  is  failing,  as  by  rest  alone  can  we  expect  to  restore  reserve  energy. 

These  remarks  have  so  far  dealt  with  regurgitant  conditions.  In  stenosis  of 
the  cardiac  orifices  the  same  facts  hold  true,  for  in  such  cases  the  question  is  whether 
the  heart  muscle  possesses  enough  strength  to  drive  the  blood  through  the  obstructed 
area. 

Given  a  case  of  valvular  disease  the  prospects  of  survival  depend  almost  entirely 
upon  the  ability  of  the  heart  to  undergo  compensatory  hyjiertrophy,  and  therefore 
the  prognosis  depends  largely  upon  the  state  of  the  muscle,  the  absence  of  arterio- 
capillary  fibrosis,  which,  if  present,  strains  the  heart  and  wearies  it,  the  ability 
of  the  patient  to  pursue  an  easy  occupation  and  his  willingness  to  avoid  habits 
of  life  which  strain  the  heart. 

AVith  these  preliminary  remarks  we  may  pass  on  to  a  discussion  of  the  individual 
\-.-d\-nIar  lesions,  taking  up  first  of  all  the  most  common  of  them,  namely: 

Mitral  Regurgitation. — Mitral  regurgitation,  often  called  "mitral incompetency" 
or  "mitral  insufficiency,"  depends  in  the-great  majority  of  cases  upon  thickening, 
shortening,  or  distortion  of  the  mitral  leaflets,  those  bicuspid  valves  which  in 
health  guard  the  left  auriculoventricular  orifice,  in  such  a  way  that  the  blood  when 
pressed  upon  by  the  contracting  walls  of  the  ventricle  cannot  regurgitate  into  the 
left  auricle. 

Associated  with  this  valvular  defect  there  are  usually  vegetations  on  the  edges 
of  the  valves  which  prevent  proper  approximation  of  their  edges.  The  chordae 
tendinea^,  which  extend  from  the  ventricular  wall  to  the  leaflets  for  the  purpose  of 
giving  them  support,  are  shortened  so  that  they  will  not  permit  the  full  movement 


CHRONIC  VALVULAR  DISEASE  AS  A   RESULT  OF  ESDOCARDITIS     405 

of  the  valves.  In  some  instances  the  valves,  their  fibrous  bases,  the  chorda;  tend- 
ineffi,  and  even  the  endocardium  are  so  completely  calcareous  that  the  ordinary 
physiological  functions  of  the  part  are  impossible.  It  is  evident  that  it  is  almost 
impossible  for  such  advanced  changes  to  l)e  present  without  at  the  same  time  causing 
some  obstruction  to  the  flow  of  blood  from  the  auricle  to  the  ventricle,  and  therefore 
we  find  that  in  nearly  all  cases  of  well-developed  mitral  regurgitation  some  mitral 
stenosis  also  exists. 


A  large  vegetation  on  the  mitral  leaflet.     (Kast  and  Rumpler.)    It  can  be  readily  seen  that  this 
would  cause  both  a  mitral  obstructive  and  a  mitral  regurgitant  murmur. 

Pathology. — The  morbid  anatomy  has  already  been  discussed  under  the  heading 
of  Endocarditis.  The  morbid  physiology  or  pathology  of  mitral  regurgitation  is 
as  follows: 

During  systole  the  blood  from  the  left  ventricle  in  cases  of  mitral  regurgitation 
flows  in  two  directions.  A  larger  part  escapes  into  the  aorta,  as  in  health,  and  a 
smaller  part  of  it  regurgitates  through  the  imperfectly  guarded  mitral,  or  left 
auriculoventricular  orifice,  into  the  left  auricle.  The  results  of  this  regurgitation 
are  multiple.  In  the  first  place  the  auricle  not  only  receives  blood  during  diastole 
from  the  pulmonary  veins,  but  it  also  receives  the  blood  which  regurgitates  from 
the  left  ventricle.  This  excess  of  blood  requires  the  auricle  to  dilate  beyond  its 
ordinary  capacity,  and  if  the  excess  of  blood  is  great  this  dilatation  of  necessity 
means  distention.  If  the  regurgitation  progresses  gradually  there  is  developed  a 
certain  amount  of  hypertrophy  in  the  auricular  walls  which  enables  the  auricle 
when  it  contracts  to  emptj'  itself  completely  and  to  prevent  continuous  overdisten- 
tion,  but  the  muscular  fibres  in  the  auricle  are  never  well  developed  as  compared  to 
.30 


466  DISEASE.'^  OF  THE  HEART 

tliose  of  the  ventricle,  and  therefore  compensatory  hypertrophy  can  never  be  so 
complete. 

The  second  result  of  this  lesion  is  dilatation  and  hypertrophy  of  the  left  ventricle, 
which  is  due  to  several  causes,  namely,  the  fact  tliat  when  the  left  auricle  empties 
itself  it  delivers  to  the  ventricle  an  excess  of  blood  over  the  normal  quantity,  for 
the  reasons  just  given.  To  hold  this  excess  of  blood  the  ventricle  must  dilate, 
and,  to  expel  it  on  contraction,  the  ventricle  must  undergo  hypertrophy.  The 
general  system  still  reciuires  as  much  blood  as  before,  and  in  order  to  provide  it 
with  that  quantity  the  ventricle  must  increase  its  activity  in  order  that  the  amount 
lost  by  regurgitation  may  be  compensated  for  by  increased  cardiac  action. 

The  third  result  is  found  in  dilatation  and  hj^pertrophy  of  the  right  ventricle, 
the  labors  of  which  are  increased  by  the  fact  that  the  engorgement  of  the  left 
auricle  renders  it  difEcult  for  the  pulmonary  veins  to  emptj^  themselves  into  it. 
As  a  conseciuence  they,  and  their  tributary  branches,  become  engorged,  raising 
the  resistance  in  the  pulmonary  vessels,  and  so  the  right  ventricle  finds  it  less  easy 
to  pump  blood  through  the  lungs.  If  the  pulmonary  engorgement  is  very  marked, 
and  dilatation  develops  in  the  right  ventricle  more  rapidly  than  does  compensatory 
hypertrophy,  there  is  produced  an  insufficiency  of  the  tricuspid  valves  guarding 
the  right  auriculoventricular  orifice. 

Fourth,  the  right  auricle  now  feels  the  same  stress  as  was  felt  primarily  by  the 
left  auricle,  and  it  undergoes  dilatation  and  hypertrophy,  but  this  hypertrophy 
is  rarely,  if  ever,  adequate  to  the  task  set  before  it,  and  as  it  fails  to  properly  empty 
itself,  evidence  of  engorgement  of  the  jugular  veins  becomes  manifest  in  that 
they  become  swollen,  the  liver  and  kidneys  are  congested,  and  edema  develops 
in  the  lower  extremities. 

Fifth,  certain  definite  changes  take  place  in  the  lungs.  As  a  result  of  their 
being  constantly  engorged  with  blood,  they  suft'er  from  brown  induration  and 
atheromatous  changes  appear  in  the  pulmonary  arteries  and  veins  as  years  go  by. 
Finally,  we  find  in  addition  serious  congestion  at  the  bases  of  the  lungs  as  a  result 
of  impotence  of  the  right  ventricle  and  obstruction  to  the  flow  of  blood  from  the 
pulmonary  veins. 

Lastly,  we  find,  at  autopsy,  in  these  cases  red  atrophy  of  the  liver  and  congested, 
cyanotic  kidneys. 

In  those  cases  in  which  there  is  no  primary  disease  of  the  mitral  leaflets,  but 
in  which  they  fail  because  of  acute  dilatation  of  the  ventricle  so  that  the  auriculo- 
ventricular orifice  is  widened  and  the  \'alves  cannot  close  it,  there  is  developed  the 
same  train  of  symptoms  save  that  they  are  more  rapid  in  onset  and  more  severe. 
This  condition  develops  after  great  cardiac  strain,  in  which  the  aortic  \alves  are 
ruptured  or  the  left  ventricle  and  its  aiu-iculoventricular  orifice  greatly  dilated. 
The  resulting  engorgement  of  the  lungs  may  be  so  severe  that  their  bloodvessels 
may  rupture  and  profuse  hemoptysis  ensue.  These  patients  nearly  always  succumb 
shortly,  or  remain  chronic  invalids,  because  the  stress  develops  so  suddenly  that 
compensatory  hypertrophy  cannot  take  place.  We  have,  therefore,  an  apparent 
paradox,  namely,  that  actual  disease  of  the  mitral  valves  is  rarely  so  serious  in  its 
consequences  as  is  sudden  incompetency  of  these  valves  due  to  other  causes. 

In  those  cases  in  which  the  relaxation  of  the  mitral  orifice  takes  place  because 
of  cardiac  feebleness  after  an  acute  illness,  or  after  severe  exercise  in  healthy  youth, 
there  are  frequently  no  subjective  symptoms,  and  perfect  recovery  usually 
occurs. 

Still  another  cause  of  mitral  incompetence,  aside  from  actual  primary  valvular 
disease,  is  Bright's  disease,  which  increases  arterial  tension  and  thereby  throws  an 
increased  strain  on  the  left  ventricle  and  the  mitral  valves  when  the  blood  is  to  be 
thrown  out  into  the  aorta.  Usually  in  these  cases  the  renal  condition  indirectly 
impairs  the  power  of  the  ventricle,  rendering  its  nutrition  faulty  through  impoverish- 


CHRONIC  VALVULAR  DISEASE  AS  A   RESULT  OF  ENDOCARDITIS    4tu 


ment  of  the  blood  and  toxemia,  and  valvular  failure  then  arises  as  a  result  of  gradual 
widening  of  the  auriculoventricular  orifice. 

Symptoms. — It  must  be  evident  from  what  has  just  been  said  that  many  cases 
of  mitral  regurgitation  may  present  no  symptoms  for  years  after  tlie  lesion  is 
established,  for  as  it  develops  so  does  a  compensatory  hjqiertrophy  develop.  It 
is  only  upon  extra  exertion,  which  the  heart  is  not  prepared  to  meet,  that  symptoms 
of  cardiac  embarrassment  ensue,  and  if  the  exertion  is  not  very  severe  and  not 
repeated,  the  dysjmea  and  palpitation  from  which  the  patient  suffers  may  be  con- 
sidered by  him  as  due  to  indigestion.  If  no  illness  impairs  the  heart  muscle  and 
no  laborious  pursuit  causes  it  too  great  stress,  the  patient  advances  in  comfort 
to  old  age,  when  symptoms  develop  as  a  result  of  the  fact  that  his  arterial  tension 
gradually  increases,  thereby  giving 

his  heart  more  work  to  do  at  each  Fig.  87 

beat,  and  at  the  same  time  his  heart 
muscle  undergoes  the  changes  inci- 
dent to  advancing  years.  When 
compensation  "ruptures,"  to  use  the 
ordinary  term  applied  to  this  unfor- 
tunate state,  subjective  and  object- 
ive signs  appear. 

The  subjective  symptoms  (that 
is,  those  felt  by  the  patient)  vary 
considerabljf  in  the  early  and  mild 
degrees  of  failing  compensation.  In 
some  instances  sJiortness  of  breath  on 
exertion  brings  the  patient  to  the 
physician,  in  other  instances  digestive 
disturbances  due  to  hepatic  congestion 
and  secondary  gastric  catarrh  are 
complained  of,  and  in  others  the 
patient  may  complain  of  a  cough, 
which  is  due  to  a  mild  pulmonary 
congestion  and  bronchitis  having 
its  origin  in  the  cardiac  failure.  In 
still  another  class  they  may  suffer  ex- 
cessively from  cold  in  moderately  cold 
weather,  and  perhaps  become  easily 
fatigued  while  walking  in  cold  air 
because  the  cold  contracts  the  per- 
ipheral capillaries  and  so  increases 
the  labor  of  the  heart.  When  the 
failure  of  the  heart  is  well  marked, 
dyspnea,  inability  to  lie  down  because 

of  oppression,  and  pain  in  the  epigastrium  are  perhaps  the  symptoms  of  which 
the  patient  will  most  complain. 

The  objective  symptoms  (that  is,  those  seen  by  the  physician)  are  even  more 
characteristic.  The  capillary  circulation  is  sufficiently- impaired  to  produce  some 
stasis  and  consequent  cyanosis  of  the  lips  and  finger-tips  or  even  of  the  face.  The 
fingers,  particularly  in  young  persons  in  whom  the  disease  has  lasted  for  some  time, 
are  club-shaped — that  is,  they  do  not  taper,  but  have  thickened  tips;  there  is  more 
or  less  edema  of  the  feet  and  ankles,  and  perhaps  blood-spitting  as  a  result  of  intense 
pulmonary  engorgement  or  infarction. 

Physical  Signs. — The  physical  signs  in  such  a  case  are  usually  well  developed. 
Inspection  of  the  precordium  reveals  a  diffuse  and  perhaps  forcible  apex  beat. 


Showing  at  -t  the  apex  beat,  ^\hure  the  murmurs 
of  mitral  regurgitation  and  obstruction  can  be  best 
heard.  The  arrow  pointing  to  the  axilla  indicates 
the  direction  in  which  the  regurgitant  murmur  is 
transmitted,  and  the  arrow  pointing  to  the  ster- 
num the  direction  of  transmission  of  the  obstructive 
murmur. 


468  DISEASES  OF  THE  HEART 

Palpation  shows  a  distinct  thrill  in  children,  and  in  this  class  of  patients  this  thrill 
can  frequently  be  seen  as  well.  The  apex  heat  may  be  distinctly  felt  well  outside 
and  below  the  nipple  line.  If  the  compensating  hypertrophy  is  well  developed 
the  apex  beat  may  be  forcible,  but  if  compensatory  hypertrophy  is  lacking  it  is 
feeble  and  diffuse.  On  percussing  the  precordium  the  normal  area  of  cardiac 
duhiess  will  be  found  to  be  enlarged.  This  enlargement  is  usually  transverse  or 
lateral,  so  that  it  may  extend  to  the  right  edge  of  the  sternum  owing  to  enlargement 
of  the  right  ventricle,  and  as  far  as  the  left  of  the  nipple  from  dilatation  and  hyper- 
trophy of  the  left  ventricle. 

Auscultation  provides  us  with  the  signs  that  determine  the  exact  nature  of  the 
lesions,  for  the  signs  so  far  described  are  not  distinctive  of  mitral  regurgitation. 
When  the  ear  of  the  physician  is  applied  over  the  apex  of  the  heart  there  is  heard  a 
soft,  and  often  cjuite  loud,  murmur,  which  occurs  synchronously  with  the  apex  beat, 
or  with  systole,  or  contraction  of  the  ventricle.  This  murmur  is  transmitted  to  the 
left  axilla,  and  it  may  be  to  the  angle  of  the  left  scapula.  Sawtelle  and  Grey 
have  done  much  to  prove  that  the  transmission  of  the  murmur  toward  the  apex 
takes  place  by  way  of  the  chordae  tendineiB  and  papillary  muscles  and  they  believe 
that  the  occurrence  of  the  murmur  in  the  left  axilla  is  due  to  the  proximity  of  the 
anterior  papillary  muscle  to  that  area.  If  it  is  very  loud  it  may  be  heard  in  any 
part  of  the  chest.  If  the  regurgitation  is  great  enough  to  cause  engorgement  of 
the  lung  the  pulmonary  second  sound,  due  to  a  quick  shutting  of  the  pulmonary 
valves  guarding  the  orifice  of  the  pulmonary  artery,  may  be  louder  than  normal. 
This  is  best  heard  at  the  third  left  costal  cartilage.  When  the  regurgitation  is 
severe  enough  to  have  resulted  in  tricuspid  regurgitation  from  engorgement  of 
the  right  side  of  the  heart,  there  may  be  heard  at  the  fifth  costal  cartilage  on 
the  right  side  a  comparatively  soft  systolic  murmur  due  to  this  secondary  le;dv, 
but  in  some  instances  the  mitral  murmur  completely  obscures  the  tricuspid 
murmur.  In  others  the  tricuspid  murmur  can  be  heard  only  at  the  ensiform 
cartilage. 

It  is  of  vital  importance  for  the  physician  to  recall  the  fact  that  a  murmur  so 
slight  as  to  be  almost  inaudible  is  not  an  indication  of  the  presence  of  a  small 
and  unimportant  lesion  of  the  mitral  valve.  On  the  contrary,  the  presence  of  a 
faint  murmur  often,  but  not  always,  indicates  that  the  heart  is  too  feeble  to  drive 
the  blood  with  sufficient  force  to  make  the  murmur  clearly  audible. 

The  pulse  of  mitral  regurgitation  varies,  of  course,  with  the  extent  of  the  lesion 
and  the  degree  of  compensation.  It  is  usually  nearly  normal,  though  lacking 
somewhat  in  volume  even  when  compensation  is  complete.  It  is  irregular  and 
small  when  compensation  is  insufficient.  When  compensation  is  ruptured,  it  is 
very  small  and  hobbling. 

Diagnosis. — It  is  desirable  to  separate  mitral  regurgitation  due  to  dilatation 
of  the  mitral  orifice  from  mitral  regurgitation  due  to  true  valvular  disease.  This 
is  in  many  cases  impossible  if  the  action  of  the  heart  is  already  seriously  impaired, 
the  more  so  because  in  many  instances  the  secondary  dilatation  produces  some 
widening  of  the  orifice.  While  the  physical  signs  may  not  be  distinctive  the  absence 
of  any  history  of  rheumatism  or  other  infection  which  aft'ects  the  valves,  and  the 
presence,  or  history  of  the  presence,  of  any  exhausting  illness  which  weakens  the 
heart  muscle,  or  of  any  strain  which  has  dilated  the  orifice,  would  indicate  that 
dilatation  rather  than  true  valvular  disease  is  present.  This  is  particularly  true 
if  the  strain,  though  moderate,  has  occurred  during  convalescence,  while  the  heart 
is  weak.  This  differentiation  is  important  because  in  some  cases  with  returning 
health  and  strength  the  leak  may  cease  and  perfect  recovery  ensue,  whereas  if  the 
valve  is  actually  diseased  good  health  can  come  only  from  compensatory  hyper- 
trophy and  the  murmur  will  probably  always  persist. 

The  possibility  of  a  murmur  being  due  to  anemia  is  also  to  be  recalled,  but 


CHRONIC  VALVULAR  DISEASE  AS  A   RESULT  OF  ENDOCARDITIS     4f.O 

hemic  murmurs  are  usually  very  soft  and  are  best  heard  near  the  base  rather  than 
at  the  apex. 

The  diagnosis  of  mitral  regurgitation  is  therefore  chiefly  based  upon  the  presence 
of  a  murmur  heard  most  clearly  with  systole  at  the  apex  and  transmitted  to  the 
axilla. 

Prognosis. — The  prognosis  in  a  case  of  mitral  regurgitation  depends  upon  the 
age  of  the  patient,  his  occupation,  the  general  condition  of  his  vitality,  and  the 
severity  of  the  lesion.  When  a  child  develops  mitral  disease  it  often  does  not 
survive  puberty,  chiefly  because  dilatation  in  such  a  case  is  usually  excessive  and 
because  the  constantly  increasing  demands  of  its  gro^^th  require  of  its  heart  more 
than  it  can  provide.  In  young  adults  who  will  rest  after  damage  to  the  valves 
during  an  attack  of  rheumatism  until  compensation  is  really  established,  the 
prognosis  is  good,  provided  that  the  subsequent  occupation  is  not  too  strenuous, 
although  with  the  onset  of  old  age  vascular  changes  will  probably  cause  breakdown. 
In  feeble  persons,  however,  the  prognosis  may  be  unfavorable  from  the  onset, 
particularly  if  hypertrophy  is  lacking  and  dilatation  is  marked.  In  old  persons 
the  prognosis  is  bad  for  obvious  reasons,  since  the  heart  cannot,  at  this  time  of 
life,  readily  gather  new  strength  to  meet  new  demands. 

If  syphilis  or  alcoholism  are  factors  in  the  case  the  prognosis  is  grave,  and  if  the 
kidneys  are  diseased  the  prognosis  is,  of  course,  very  bad.  So,  too,  the  presence 
of  arteriocapillary  fibrosis  with  high  arterial  tension  is  a  serious  or  grave  factor, 
in  that  it  gives  the  heart  so  much  work  to  do.  (For  the  relationship  of  this  lesion 
to  age  and  mortality,  see  page  462,  in  article  on  Chronic  Valvular  Disease.) 

Treatment. — (This  is  discussed  at  the  end  of  the  articles  on  Valvular  Disease.) 

Mitral  Stenosis. — Definition. — By  mitral  stenosis  we  mean  a  condition  of  the 
tissues  composing  the  mitral  valves  or  siu^rounding  the  left  auriculoventricular 
orifice  whereby  the  blood  is  prevented  from  passing  with  normal  ease  from  the  left 
auricle  to  the  left  ventricle.     It  is  sometimes  called  "mitral  obstruction." 

Etiology  and  Pathology. — Mitral  stenosis  is  more  common  in  females  than  in 
males,  although  the  reason  for  this  is  not  clear.  Cabot  denies  this  but  Sir  Dyce 
Duckworth  found  that  out  of  264  cases  of  this  disease  177  were  females,  and  other 
statistics  are  practically  in  accord  with  Duckworth's.  It  is  due  to  gluing  together  of 
the  mitral  valves  as  the  result  of  acute  endocarditis  arising  from  acute  rheumatism. 

With  this  adhesion  of  the  valves  there  is  often  associated  a  growth  of  vegetations 
on  their  edges  and  not  uncommonly  thickening  and  sclerosis  of  the  chordte  tendinese, 
the  papillary  muscles  and  the  leaflets  themselves,  so  that  the  parts  lose  their  elas- 
ticity and  are  so  stiffened  that  they  are  unable  to  move  out  of  the  way  of  the  blood 
stream  when  it  seeks  to  pass  into  the  ventricle.  This  sclerotic  process  is  so  marked 
in  some  cases  that  the  tissues  may  seem  almost  cartilaginous  in  character,  and  in 
advanced  life  lime  salts  may  be  deposited  to  such  an  extent  that  the  fibrous  tissue 
is  calcareous  and  even  the  walls  of  the  ventricle  are  infiltrated  by  calcareous  masses. 
In  some  instances  the  adhesions  are  so  complete  that  the  valves  form  a  funnel- 
shaped  tube  through  which  the  blood  must  find  its  way.  In  other  instances  the 
edges  of  the  valves  are  adherent  and  their  margins  thickened,  leaving  only  a  small 
orifice  between  them,  forming  the  so-called  "button-hole"  mitral  orifice,  and  in 
still  other  cases  the  conjoined  edges  of  the  valves  are  so  drawn  or  puckered  that  the 
orifice  when  the  auricle  is  opened  looks  like  the  normal  anus. 

The  funnel-shaped  opening  is  most  commonly  seen  in  children,  but  it  is  not 
always  as  some  have  thought,  a  congenital  lesion;  the  button-hole  orifice  is  much 
more  common  in  adults.  Sansom  states  that  the  proportion  is  one  button-hole 
to  eight  funnels  in  children,  and  that  as  adult  life  is  reached  the  proportion  changes 
to  twenty-five  botton-holes  to  one  funnel. 

There  can  also  be  no  doubt  that  chronic  contracted  kidney  with  associated 
arteriocapillary  fibrosis  not  only  causes  mitral  stenosis,  but  that  even  the  funnel- 


470  DISEASES  OF  THE  HEART 

shaped  opening  just  described  may  be  developed  in  this  type  of  cases.  The  studies 
of  Duroziez  and  Iluehard  in  France,  and  of  (ioodhart,  Sanson),  and  Pitt  in  England 
prove  this  fact.  In  542  autopsies  in  cases  of  interstitial  nephritis,  Pitt  found  mitral 
stenosis  33  times. 

The  results  of  mitral  obstruction  are  overdistention  of  the  left  auricle  and  scanty 
blood  supply  to  the  left  ventricle.  The  engorgement  of  the  left  aviricle  results 
from  its  inability  to  empty  itself,  and  leads  to  dilatation  and  to  some  degree  of 
hypertrophy.  In  some  instances  the  growth  of  muscle  fibres  is  so  scanty  that  no 
true  hypertrophy  ensues,  in  others  they  seem  to  become  actually  atrophied,  but 
in  other  instances  very  complete  compensatory  hypertrophy  develops,  so  that 
the  auricular  wall  is  distinctly  thicker  than  normal.  Indeed,  it  may  appear  as  a 
firm  muscular  mass  which  does  not  collapse  at  autopsy  as  the  ordinary  auricle 
is  wont  to  do.  ^^'hether  hypertrophy  exists  or  not,  dilatation  is  always  present. 
When  such  an  auricle  is  opened  the  endocardium  is  often  found  to  be  thickened  and 
a  laminated  clot  may  line  its  cavity.  In  other  instances  polypoid  or  globular 
coagula  are  attached  to  the  auricular  walls,  and  these  globular  thrombi  may  almost 
fill  the  auricle.  At  times  the  thrombus  is  free,  acting  as  a  ball  valve  in  the  auriculo- 
ventricular  orifice. 

The  accumulation  of  blood  in  the  auricle  leads  to  the  engorgement  of  the  lung, 
and  the  same  changes  occur  in  its  vessels  and  tissues  that  have  been  described 
under  "Pulmonary  Congestion"  and  "Mitral  Regurgitation."  So,  too,  the  right 
\'entricle  undergoes  hypertrophy  and  dilatation  from  similar  causes,  and  the  tri- 
cuspid valves,  even  more  frequently  than  in  mitral  regurgitation,  give  waj',  so 
that  pulsation  of  the  jugular  veins,  pulsation  of  the  liver,  and  edema  of  the  lower 
extremities  finally  develops.  Embolism  often  occurs  in  mitral  stenosis,  and,  as  in 
all  cases  of  embolism  arising  in  the  heart,  the  embolus  usually  lodges  in  the  left 
hemisphere  of  the  brain. 

If  the  narrowing  of  the  auriculoventricular  orifice  is  not  progressive,  and  if  the 
auricle  and  right  ventricle  undergo  compensatory  hypertrophy,  the  signs  of  ad- 
vanced disease  may  not  ensue.  It  is  only  when  auricular  hypertrophy  fails  that 
the  malady  becomes  manifest  and  induces  the  symptoms  of  cardiac  failure  which 
in  all  respects  resemble  those  described  under  Mitral  Regurgitation,  save  that  the 
venous  and  hepatic  pulsation  just  described  are  more  frequently  present. 

Symptoms. — These  consist,  when  compensation  fails,  in  dyspnea,  orthopnea, 
scanty  urine,  pulmonary  congestion,  and  occasionally  hemoptysis  from  infection 
or  engorgement  of  the  lungs. 

Physical  Signs. — The  physical  signs  of  mitral  obstruction  are  as  follows: 
Inspection  of  the  chest  reveals  pulsation  at  the  apex  of  the  heart  near  the  nipple, 
and  also  the  base  of  the  heart  close  to  the  sternum,  in  the  second  or  third  left 
intercostal  spaces.  Not  rarely  there  may  be,  in  addition,  epigastric  pulsation. 
If  a  straw,  or  piece  of  cardboard,  be  placed  over  the  pulsating  spots  at  the  apex  and 
base,  it  will  be  found  that  they  do  not  move  synchronously,  but  the  lower  one 
moves  with  the  ventricle  and  the  upper  one  with  the  auricle.  It  has  been  claimed 
that  the  auricle  does  not  produce  this  upper  pulsation,  and  that  it  is  due  to  the 
movement  of  the  conus  arteriosus  of  the  right  ventricle,  but  this  is  seemingly 
disproved  by  the  fact  that  the  two  mo\ements  are  not  synchronous  with  systole. 
If  the  patient  be  a  child  these  pulsations  are  much  more  noticeable  than  if  he  be  an 
adult,  at  which  time  of  life  pulsation  may  be  absent.  Retraction  of  the  interspaces 
from  the  third  to  the  fifth  rib  with  each  systole  occurs  in  persons  with  a  thin  chest- 
wall  and  is  due  to  the  movement  of  the  right  auricle.  In  children  bulging  of  the 
chest-wall  close  to  the  sternum  and  in  the  epigastrium  may  be  quite  marked,  and 
if  pulsation  be  well  defined  in  this  area  and  absent  from  the  region  of  the  nipple, 
indicating  hypertrophy  of  the  right  ventricle,  the  diagnosis  of  mitral  stenosis  is 
strengthened,  provided  that  adherent  pericardium  can  be  excluded. 


Chronic  valvular  dlsease  as  a  result  of  endocarditis   471 


Palpation  does  not  always  give  us  niucli  information,  but  sometimes  it  practically 
decides  the  diagnosis,  for  there  are  three  signs  on  palpation  which  are  noteworthy 
in  this  lesion.  There  is  a  thrill  which  is  presystolic  in  point  of  time  and  is  felt  in 
the  fourth  or  fifth  interspace  inside  the  nipple  line.  It  is  characterized  by  sudden 
arrest  at  the  moment  of  systole.  It  is  thought  by  some  to  be  due  to  the  impact 
of  the  blood  squirted  by  the  auricle  in  a  narrow  stream  against  the  ventricular 
wall.  This  sign  may  be  considered  diagnostic  of  mitral  stenosis  provided  we  have 
excluded  the  possibility  of  aortic  regurgitation,  which  sometimes  causes  a  similar 
sign.  This  thrill  may  be  present  at  one  time  and  entirely  absent  at  another,  and 
it  may  be  absent  when  the  patient  is  in  the  dorsal  decubitus  and  present  when  he 
is  erect,  or,  again,  it  is  present  after  exercise  and  absent  after  rest.  The  second 
sign  of  some  importance  in  the  diagnosis  of  this  disease  by  palpation  is  the  heaving 
impulse,  felt  just  below  the  margin  of 

the  last  costal  cartilage  on  the  left  F"^-  *^ 

side  without  such  impulse  near  the 
nipple.  This  has  already  been  spoken 
of  under  inspection  as  indicative  of 
hypertrophy  of  the  right  ventricle. 
Care  must  be  taken,  however,  that 
signs  of  hypertrophy  of  the  left  ven- 
tricle are  really  absent,  for  it  some- 
times happens  that  an  overlapping 
of  the  lung  covers  the  left  side  of  the 
heart  so  that  it  does  not  transmit  its 
impulse  to  the  chest-wall.  The  third 
sign  on  palpation  is  the  discovery  of 
the  edge  of  the  enlarged  liver,  which 
pulsates,  if  there  is  back  pressure  due 
to  tricuspid  regurgitation,  below  the 
level  of  the  floating  ribs  on  the  right 
side.  Here,  again,  care  is  necessary, 
for  it  often  happens  that  the  liver 
is  moved  by  a  transmitted  impulse 
from  the  heart  muscle  through  the 
diaphragm. 

Percussion  of  the  precordium  may 
reveal,  in  cases  of  mitral  stenosis,  a 
distinct  increase  in  the  area  of  cardiac 
dulness  to  the  right,  with  compara- 
tively little  extension  of  dulness  to 
the  left.  This  is  due  to  the  enlarge- 
ment of  the  right  ventricle.  When, 
however,  the  disease  is  far  advanced  and  the  heart  is  greatly  dilated  or  hyper- 
trophied  the  left  margin  of  dulness  is  distinctly  extended,  and  in  such  cases  the 
area  of  cardiac  dulness  to  the  left  of  the  nipple  line  may  be  very  great. 

Auscultation  is,  of  course,  the  most  important  aid  in  the  diagnosis  of  mitral 
stenosis,  since  it  presents  no  less  than  six  points  of  interest.  The  first  of  these  is 
the  presence  of  a  murmur  which  occiu^s  during  diastole,  gradually  increasing  as 
the  auricle  contracts  until  it  is  loudest  in  presystole,  or  in  a  brief  murmur  which  is 
immediately  presystolic,  and  is  best  heard  between  the  nipple  and  the  sternum, 
on  the  nipple  level  (Figs.  87  and  88).  In  most  cases  the  murmur  can  be  heard  only 
in  this  area,  but  in  some  instances  it  is  so  loud  as  to  extend  all  over  the  chest. 
The  murmur  is  usually  harsher  than  that  of  mitral  regurgitation,  and  is  vibratory 
in  character.     It  is  due  to  the  passage  of  the  blood  through  the  obstructed  auriculo- 


MO  shows  area  of  greatest  intensity  of  a  mitral 
obstructive  murmur;  TR  shows  area  of  greatest 
intensity  of  a  tricuspid  regurgitant  murmur.  The 
fine  lines  indicate  the  area  in  which  is  felt  the  char- 
acteristic thrill  of  mitral  stenosis. 


472  DISEASEfi  OF  THE  HEART 

ventricular  orifice,  and  it  ceases  with  the  close  of  auricular  systole.  At  times  it 
is  so  metallic  as  to  be  musical  rather  than  purring. 

Another  sign  of  importance  is  the  accentuation  of  the  indmonary  second  sound, 
which  is  best  heard  at  the  third  left  interspace,  and  is  due  to  the  high  pressure  in 
the  pulmonary  artery,  produced  by  back  pressure  on  the  column  of  blood  in  the 
lungs.  This  accentuation  is,  however,  not  .so  constant  in  stenosis  as  in  regurgita- 
tion because  of  the  greater  irregularity  of  the  heart  in  stenosis. 

A  third  sign  is  the  reduplication  of  the  second  sound  of  the  heart  so  that  it  appears 
as  a  "tap-tap,"  or  resembles  the  "postman's  knock."  It  is  very  characteristic 
of  mitral  stenosis  and  is  heard  at  two  places:  at  the  apex  and  at  the  base  of  the 
heart.  It  is,  however,  supposed  to  be  due  to  different  causes  at  each  spot.  At  the 
apex  Sansom  believes  it  is  due  to  the  sudden  rush  of  the  blood  into  the  ventricle 
through  the  narrow  orifice  under  the  pressure  of  the  hypertrophied  auricle. 
When  this  reduplicated  second  sound  is  heard  at  the  base,  and  this  is  where 
it  is  usually  heard,  it  is  most  diagnostic,  and  is  supposed  to  be  due  to  an 
asynchronous  closure  of  the  aortic  and  pulmonary  valves,  but  in  all  probability 
the  cause  is  similar  to  the  sound  at  the  apex.  This  is  sometimes  called  the  "gallop 
rhythm." 

The  fourth  sign  of  importance  is  the  loud  and  stidden  snapping  sound  which  is 
heard  at  the  close  of  systole  of  the  ventricle.  It  is  supposed  to  be  due  to  forcible 
snapping  to  of  the  bicuspid  or  mitral  valves. 

The  fifth  sign  is  not  only  somewhat  indicative  of  stenosis,  but  much  more  of 
cardiac  breakdown,  namely,  absence  of  the  first  sound  of  the  heart  at  the  apex. 

Still  a  sixth  sign  of  mitral  stenosis  is  sometimes  of  value,  namely,  great  irregularity 
as  to  rhythm  and  force.  In  no  form  of  valvular  lesion  with  rupture  of  compensation 
is  the  heart  so  tumultuous  as  in  this  disease.  In  mitral  .stenosis  more  than  in 
any  other  disease  partial  or  complete  heart  block  may  develop,  due  to  the  fact 
that  the  inflammatory  process  in  the  valve  goes  deeply  enough  to  partly  or  com- 
pletely cut  off  the  fibres  of  His'  bundle,  so  that  the  impulse  which  arises  at  the 
sino-auricular  node  passes  with  difficulty  or  fails  to  pass  from  the  auricle  to  the 
ventricle.  (See  Plate  VIII  and  Fig.  91.)  This  results  in  lack  of  co-ordination, 
the  auricle  and  ventricle  lieating  asynchronously  each  for  itself.  Usually  in  such 
cases  there  is  a  very  rapid  jugular  pulse  with  an  abnormally  slow  radial  or  carotid 
pulse.  The  ventricle  takes  up  a  beat  of  its  own  which  is  usually  slow  and  the  auricle 
beats  very  fast  so  that  the  ratio  may  be  140  to  40  beats  per  minute  if  the  block 
is  complete.     The  auricular  beat  is  best  seen  in  the  jugulars.     (See  Arrhythmia.) 

As  already  stated,  the  absence  of  a  murmur  may  be  more  indicative  of  grave 
valvular  disease  than  its  presence. 

When  cardiac  breakdown  ensues  it  not  infrequently  happens  that  the  presystolic 
murmur  itself  disappears  because  the  auricle  is  too  feeble  to  drive  the  blood  through 
the  auriculoventricular  orifice  with  enough  force  to  make  a  murmur.  Often  this 
loss  of  power  is  due  to  auricular  fibrillation,  a  condition  in  which  the  auricular 
wall  does  not  contract  but  suffers  from  fibrillary  thrills  and  is  only  a  sac  through 
which  the  blood  passes  to  the  ventricle.  Sudden  death  may  ensue  or  life  may 
persist  for  several  years  in  cases  of  fibrillation.     (Plate  VH.) 

Diagnosis. — ^Mitral  stenosis  is  at  times  the  most  difficult  of  all  the  cardiac  lesions 
to  diagnosticate,  chiefly  because  when  compensation  is  ruptured  no  murnuir  may 
be  present,  and  the  action  of  the  heart  being  exceedingly  irregular  its  sounds  are 
confused.  Again,  stenosis  is  so  frecjuently  associated  with  mitral  regiu-gitation 
that  the  double  murmur  may  cause  confusion,  the  more  so  as  oidy  one  murnmr 
may  be  present  at  one  time  and  both  at  another  time,  and  also  because  the  rcgurgi- 
tiint  murmur  is  often  so  loud  that  it  covers  the  stenotic  muruuir,  with  the  result 
that  unless  the  physician  is  on  the  qui  vlve  to  discover  the  less  noticeable  sound  it  is 
overlooked.     In  cases  which  are  manifestly  ones  of  mitral  stenosis  the  physician 


^  Si 


a)     53  i=P  j3 
O    "5s 


«  3  ft 
-i^  ft  CD 


r; 

So&- 

o 

CJ 

>1 

*-> 

5" 

a 

o 

S^  ^^ 

S 

"  S  o  g 

tt^^ 

ric' 
re 
cle, 
ing 

.s 

^^^1 

ft 

^        ri  c 

^  „r-3  « 

U) 

CHRONIC  VALVULAR  DIfiEAfiE  Afi  A    RESULT  OF  ENDOCARDITLS     473 

need  not  hesitate  to  express  an  opinion,  but  in  tiie  obsc-urc  forms  of  the  disease  he 
should  always  reserve  his  statement  until  he  has  had  an  opportunity  of  examining 
the  heart  several  times  under  conditions  of  rest  and  exercise,  and,  perhaps,  after 
the  use  of  digitalis  or  some  other  drug  to  strengthen  the  muscle. 

As  the  physical  signs  have  already  been  thoroughly  described,  it  is  only  necessary, 
at  this  point,  to  differentiate  mitral  stenosis  from  those  conditions  which  resemble  it. 

The  most  important  of  these  is  the  so-called  "Flint's  murmur"  first  described 
in  1862  by  Dr.  Austin  Flint,  of  New  York.  It  occurs  in  some  cases  of  aortic  regurgi- 
tation, and  is  supposed  to  be  due  to  the  regurgitating  blood  striking  upon  the 
mitral  valves  and  chordte  tendinese  in  such  a  way  that  they  vibrate  and  so  cause  a 
sound.  This  sound  is  diastolic  in  point  of  time  because  it  occurs  after  the  blood  ■ 
has  been  sent  out  into  the  aorta  and  while  the  ventricle  is  receiving  more  blood 
from  the  auricle.  Its  time  of  occurrence  is,  therefore,  practically  identical  with 
the  murmur  of  mitral  stenosis. 

The  following  points  make  the  differentiation  between  mitral  stenosis  and 
"Flint's  murmur"  in  most  cases,  although  in  some  cases  the  separation  may  be 
impossible.  In  cases  with  aortic  regurgitation  auscultation  at  the  second  right 
costal  cartilage  and  along  the  sternum  will  reveal  a  diastolic  murmur,  which  will 
not  be  well  defined  in  these  areas  in  mitral  stenosis  unless  the  mitral  murmur  is  so 
loud  as  to  be  heard  pretty  much  everywhere  in  the  chest.  The  pulse  in  aortic 
regurgitation  is  characterized  by  a  full  wave  followed  by  a  sudden  fall — the  "  Cor- 
rigan  pulse" — whereas  the  pulse  of  mitral  obstruction  is  a  fine  thread,  irregular 
and  feeble.  Again,  in  cases  of  aortic  regurgitation  with  "Flint's  murmur"  there 
are  rarely,  if  ever,  those  well-developed  signs  of  pulmonary,  hepatic,  and  splenic 
engorgement  which  have  been  described  as  occurring  in  mitral  stenosis,  nor  does 
the  patient  so  frequently  suffer  from  hemoptysis  due  to  pulmonary  congestion  or 
infarction.  Further  than  this,  the  sharp,  snapping  first  sound  of  the  heart  char- 
acteristic of  mitral  obstruction  is  not  present  with  "Flint's  murmur." 

A  second  condition  resembling  mitral  stenosis  is  tricuspid  stenosis.  On  general 
principles,  this  latter  lesion  can  be  excluded  on  the  rule  of  probabilities,  for  tri- 
cuspid stenosis  is  an  exceedingly  rare  lesion.  If  it  exists  it  is  usually  heard  best 
in  the  tricuspid  area  (the  area  of  the  fourth  right  intercostal  space),  but  it  may  be 
clearly  heard  in  the  mitral  area,  and  as  tricuspid  stenosis  and  mitral  stenosis  exist 
together  in  some  cases  and  occur  simultaneously,  they  may  not  be  separable  and 
nothing  be  known  of  the  lesion  on  the  right  side  of  the  heart  until  autopsy. 

At  times  children  suffering  from  adhesive  pericarditis  present  a  presystolic 
sound  like  that  of  stenosis.  It  is  to  be  discovered  by  the  signs  of  adhesive  pericardi- 
tis (which  see).  In  every  case  of  valvulitis  due  to  rheumatism  we  should  bear  in 
mind  the  possible  if  not  the  probable,  presence  of  adherent  pericardium.  The 
presence  of  this  condition  is  rendered  likely  if  the  liver  is  not  only  enlarged,  but 
very  firm,  and  if  ascites  develops  in  excess  of  that  seen  in  cardiac  dropsy.  This 
point  is  of  importance,  because  if  the  pericardium  is  adherent  we  cannot  expect 
very  good  results  from  digitalis  nor  from  any  other  method  of  treatment. 

When  a  patient  presents  himself  with  a  disordered  circulation  and  confused 
or  irregular  heart  sounds,  and  no  murmur,  it  must  be  recalled  that  while  such  a 
state  may  be  due  to  tobacco  heart,  it  may  also  be  caused  by  mitral  stenosis  with 
no  murmur  or  be  due  to  excessive  doses  of  digitalis. 

Prognosis. — The  prognosis  of  mitral  stenosis  is  not  as  favorable  as  is  that  of 
mitral  regurgitation  or  aortic  stenosis,  and  children  nearly  always  succumb  to  it 
before  they  reach  adult  years.  Adults  who  have  a  severe  lesion  also  rarely  survive 
for  many  years  after  it  begins,  but  there  are  very  marked  exceptions  to  this  rule. 
Thus,  I  have  under  observation  at  present  a  case  of  mitral  stenosis  which  I  examined 
twenty-two  years  ago,  and  who  was  told  thirty  years  ago  that  the  lesion  existed. 
During  all  these  years  (he  is  now  sixty-nine  years  of  age)  he  has  led  a  very  active 


474  DISEASES  OF  THE  HEART 

life,  both  physical  and  mental,  with  no  cardiac  embarrassment,  although  he  had 
an  attack  of  hematuria  when  I  first  saw  him,  which  was  due  to  an  infarction  of  the 
kidney.  During  this  time  he  has  taken  no  treatment,  except  at  rare  intervals, 
his  compensation  being  complete. 

In  young  women  with  mitral  stenosis,  marriage  and  consequent  child-bearing 
often  cause  rupture  of  compensation  and  death. 

The  aA'cragc  age  at  death  in  cases  of  this  disease  is  stated  by  Sansom  to  be  about 
thirty-two  and  seven-tenth  years.  (See  General  Discussion  of  \'alvular  Lesions 
and  Their  Effect  on  Mortality,  page  462.)  (For  treatment  see  close  of  these 
articles.) 

Aortic  Stenosis. — Definition. — Aortic  stenosis,  often  called  "aortic  obstruction," 
is  a  condition  in  which  the  left  ventricle  finds  it  more  difficult  than  normal  to 
expel  the  blood  through  the  aortic  orifice,  because  this  orifice  is  narrowed  by  disease. 
The  murmur  which  is  produced  by  the  blood  under  these  circim: stances  is  systolic 
in  point  of  time,  for  it  occurs  as  the  left  ventricle  expels  its  contents.  It  is  best 
heard  at  the  second  right  costal  cartilage  or  under  the  sternum,  at  its  upper  portion. 
It  is  of  \ital  importance,  however,  to  recall  the  fact  that  the  presence  of  a  systolic 
murmur  at  this  point  is  not  necessarily  indicative  of  actual  obstruction  of  the  aortic 
orifice.  An  aortic  systolic  murmur  does  not  necessarily  mean  an  aortic  valvular 
lesion.  The  murmur  is  usually  due  to  roughening  of  the  lining  of  the  aorta  by 
atheromatous  plaques.  Aneurysm  may  also  be  provocative  of  such  a  sound. 
So  rare  is  true  simple  aortic  obstruction  that  it  may  be  said  that  the  presence  of  a 
systolic  aortic  murmur  is  in  most  cases  probably  not  due  to  this  lesion,  unless  it  is 
associated  with  aortic  regurgitation.  Some  clinicians  of  repute  assert  that  they 
have  never  seen  pure  aortic  stenosis  without  regurgitation.  Cabot  states  that 
in  252  autopsies  made  at  the  Massachusetts  General  Hospital  on  persons  with 
valvular  disease,  there  was  not  a  single  instance  of  uncomplicated  aortic  stenosis. 

Etiology. — The  causes  of  aortic  obstruction  are  multiple.  In  the  first  place, 
it  may  be  the  result  of  rheumatic  endocarditis  of  so  severe  a  t;\'pe  that  not  onh' 
the  mitral  but  the  aortic  valves  are  involved,  for  it  is  only  in  rare  cases  that  rheu- 
matism attacks  the  aortic  valves  and  lea^•es  the  mitral  vah-es  imtouched.  In  such 
a  case  the  endocardium  covering  the  ^'alves  is  roughened  in  patches,  and  upon 
these  patches  is  deposited  fibrin  from  the  blood  stream,  which,  with  proliferated 
cells,  form  granulations  and  vegetiitions,  fibrous  thickening,  and,  finally,  the 
deposition  of  lime  salts.  If  the  inflammation  is  severe  the  edge  of  the  valves  may 
become  glued  together,  and  so  a  funnel-shaped  opening  is  formed,  which  is  much 
narrower  than  the  normal  aortic  orifice.  In  rare  instances,  instead  of  the  valves 
being  adherent  and  thickened,  they  are  adherent  and  thinned,  so  that  they  appear 
atrophied.  Such  a  condition  is  found  at  times  in  children  and  is  thought  to  be 
congenital,  but  even  in  young  children  the  cause  may  be  rheimiatism,  and  Sansom 
asserts  that  the  condition  may  be  due  to  rheumatic  endocarditis  in  intra-uterine 
life.  Rheumatism  may  be  considered  the  usual  cause  of  aortic  obstruction  in 
children  or  in  those  who  have  not  as  yet  reached  advanced  years. 

The  cause  of  aortic  obstruction  is  often  not  acute  in  character,  as  in  the  types 
just  described,  but  chronic,  being  due  to  a  gradual  atheromatous  change,  which, 
having  involved  the  aorta  itself,  spreads  to  the  aortic  valves,  and  causes  a  slowly 
progressive  thickening  and  calcification  of  their  tissues.  This  is  the  form  of  stenosis 
which  is  often  of  a  very  advanced  type,  so  that  the  orifice  may  be  but  a  small 
slit  or  chink  through  which  the  blood  escapes. 

From  what  has  just  been  said,  it  is  easy  to  understand  how  it  is  that  obstruction 
to  the  flow  of  blood  in  the  area  of  the  aortic  valve  is  exceedingly  rare  as  a  single 
lesion.  The  very  nature  of  the  morbid  changes  which  take  place  in  the  tissues 
at  this  i)()int  renders  the  simultaneous  existence  of  aortic  obstruction  and  regurgita- 
tion proiiable,  for  the  valves  at  the  aortic  orifice  are  either  glued  together  as  a 


CHRONIC  VALVULAR  DISEASE  AS  A   RESULT  OF  ENDOCARDITIS     475 


result  of  rheumatic  endocarditis,  or,  more  commonly,  are  thickened  by  chronic 
endocarditis  and  calcareous  deposits.  In  either  instance  they  are  not  only  in  the 
way  of  the  blood  as  it  passes  out  of  the  ventricle,  but  they  are  incapable  of  prevent- 
ing its  regurgitation,  since  they  are  too  thick  and  too  stiff  to  approximate  their 
edges.  In  other  instances  the  presence  of  vegetations  on  the  valves,  in  addition 
to  these  changes,  adds  to  the  impairment  of  their  functional  activity. 

The  secondary  changes  produced  by  aortic  obstruction  are  chiefly  connected 
with  the  left  ventricle.  Under  favorable  conditions  this  portion  of  the  heart 
usually  develops  a  satisfactory  compensatory  hypertrophy,  the  muscle  fibres 
gaining  in  strength  and  size  as  the  process  of  narrowing  in  the  aortic  area  gradually 
progresses.  As  a  consequence,  it  not  rarely  occurs  that  even  an  extreme  degree 
of  aortic  obstruction  is  accompanied  by  such  a  complete  compensatory  hj-pertrophy 
that   the   presence  of  the   lesion    is 

only  discovered   at   autopsy.     It   is  '"■■  ^'' 

interesting  to  note  that  the  hyper- 
trophy of  aortic  obstruction  differs 
somewhat  from  that  of  aortic  regur- 
gitation in  the  fact  that  the  \en- 
tricular  walls  increase  in  thickness 
without  undergoing  any  great  dilata- 
tion, whereas,  in  aortic  regurgitation 
they  both  dilate  and  hypertrophy, 
causing  eccentric  hypertrophy. 

So  long  as  the  compensatory  hy- 
pertrophy of  the  left  ventricle  in 
aortic  obstruction  is  adequate,  prac- 
tically no  changes  occur  in  the  other 
parts  of  the  heart.  It  is  only  when 
compensation  ruptures  that  symp- 
toms of  impaired  circulation  ensue, 
as  the  mitral  valves  give  way  under 
the  strain,  and  congestion  of  the  left 
auricle  and  of  the  lungs  develops. 
This  may  in  time  increase  the  labor  of 
the  right  ventricle  and  lead  to  its  hy- 
pertrophy. 

Symptoms  and  Physical  Signs. — Pa- 
tients suffering  from  aortic  obstruc- 
tion rarely  present  or  complain  of 
any  symptoms  which  are  in  any  way 
characteristic    of    the     lesion.       At 

times  a  sense  of  constriction  or  oppression  is  felt  over  the  aortic  area,  as  it  is  in 
cases  of  aortitis  or  atheroma  of  the  aorta,  and  as  it  is  felt  in  some  cases  of  true 
angina  pectoris.  When  there  is  an  associated  aortic  regurgitation,  the  symp- 
toms are  of  that  lesion.     (See  Aortic  Regurgitation.) 

The  -physical  signs  vary  considerably  with  the  type  of  patient  examined  and 
with  the  stage  of  the  disease.  In  old  men  whose  chest  walls  are  thickened  and 
rigid  and  whose  lungs  are  often  emphysematous,  so  that  the  edge  of  the  left  lung 
projects  between  the  heart  and  the  chest  wall,  it  may  not  be  possible  to  either 
see  or  feel  an  apex  beat,  even  though  the  heart  be  considerably  hj^Dertrophied. 
On  the  other  hand,  if  the  patient  be  young,  or  the  chest  wall  pliable,  the  apex  beat 
may  be  seen  and  felt  distinctly  and  forcibly,  and  it  is  usually  a  little  below  and  a 
little  outside  the  nipple  because  of  the  hypertrophy.  If  the  action  of  the  heart  is 
forcible  and  the  fingers  are  placed  over  the  second  right  intercostal  space,  a  distinct 


Showing  area  of  greatest  intensity  and  the  direc- 
tion of  transmission  into  subclavian  and  carotid 
arteries  of  the  aortic  obstructive  murmur. 


476  DISEASES  OF  THE  HEART 

thrill  can  be  felt.  This  thrill  is  in  the  nature  of  a  viljration  and  is  often  transmitted 
down  the  sternum  and  even  up  into  the  carotids.  This  thrill  felt  in  the  area 
described  is  very  characteristic  of  aortic  obstruction,  but  it  is  also  felt  in  aortic 
aneurysm. 

The  area  of  cardiac  dulness  on  percussion  is  not  materially  enlarged,  unless 
associated  regurgitation  has  caused  its  well-known  secondary  cardiac  changes. 

Auscultation  reveals  a  murmur  which  is  loudest  at  the  second  right  costal  carti- 
lage near  the  sternum. 

This  sound  is  transmitted  in  most  cases  into  the  vessels  of  the  neck,  and  not 
infrequently  it  is  heard  over  the  sternum  as  low  as  the  ensiform  cartilage.  It 
occurs  with  systole  of  the  heart,  and  it  is  usually  loud  if  compensation  is  preserved. 
Not  only  is  it  loud,  but  it  is  apt  to  be  harsh  and  even  musical,  and  it  is  long  and 
blowing  in  character.     The  aortic  second  sound  is  usually  absent. 

When  rupture  of  an  aortic  valve  takes  place  the  murmur  is  usually  widely  diti'used, 
very  loud  and  musical.  I  showed  a  patient  to  the  College  of  Physicians  of  Phila- 
delphia in  1902  that  possessed  a  murmur  capable  of  being  leard  when  the  ear  was 
eighteen  inches  from  the  chest.  It  could  be  heard  on  top  of  his  head,  in  his  radial 
arteries,  and  if  the  stethoscope  was  placed  so  that  his  lips  encircled  it  the  murmur 
could  be  heard  in  his  mouth.  There  was  also  a  loud  aortic  regurgitant  murmur 
in  his  case.  The  patient  was  a  brakeman  who  suffered  from  sudden  and  se\'ere 
dyspnea  and  syncope  on  lifting  a  heavy  weight,  and  who  had  a  history  of  syphilis. 

The  pulse  in  aortic  obstruction  is  small  {pulsus  jjurvus)  because  the  heart  cannot 
expel  a  large  wave  of  blood  through  the  narrow  aortic  opening.  The  wave  rises 
gradually  and  then  falls  gradually,  unlike  the  sharp  upward  jerk  felt  in  aortic 
regurgitation. 

Diagnosis. — Sufficient  emphasis  has  already  been  placed  on  the  fact  that  a 
systolic  murmur  at  the  second  right  costal  cartilage  does  not  mean,  necessarily, 
aortic  obstruction,  but  if  the  time  of  the  murmur,  the  thrill,  the  peculiar  pulse  and 
atheromatous  vessels  are  present  in  an  old  person  the  diagnosis  is  fairly  certain. 
When  the  murmur  is  due  to  atheroma  of  the  aorta  alone  the  aortic  second  sound 
is  usually  sharp  and  clear  instead  of  being  impaired  as  it  is  in  true  obstruction. 
Aneurysm  is  excluded  by  the  absence  of  the  characteristic  signs  of  that  state. 
(See  Aortic  Aneurysm.) 

Sewall  asserts  that  an  aortic  stenotic  murmur  heard  at  the  apex  disappears 
on  pressure  of  the  stethoscope,  and  so  separates  itself  from  the  systolic  murmur  of 
mitral  regurgitation. 

Prognosis. — The  prognosis  in  a  case  of  aortic  stenosis  is  generally  considered 
as  more  favorable  than  in  any  other  valvular  lesion,  but  in  each  individual  case 
the  physician  must  base  his  prophecy  as  to  life  upon  the  age  of  the  patient,  the 
state  of  his  arteries,  and  the  condition  of  the  kidneys.  The  mere  presence  of 
far-advanced  atheroma  in  aged  persons  who  have  an  aortic  stenotic  lesion  is  not 
necessarily  of  evil  import.  As  Sir  Clifford  Allbutt  well  says,  "  Wc  see  well-to-do  old 
ladies  leading  tranquil  lives  up  to  four-score  years  or  more  with  systolic  aortic 
murmurs  of  a  quarter  of  a  century's  standing."  On  the  other  hand,  in  somewhat 
younger  persons,  who  have  more  fibrous  and  less  calcareous  arterial  changes,  the 
prognosis  is  not  so  good,  either  because  they  are  at  a  period  of  life  when  they  are 
prone  to  resort  to  exercise  and  so  strain  the  heart,  or  because  there  is  a  tendency 
to  fibroid  heart  as  well.  Allbutt's  view  that  "a  person  who  in  young  or  middle 
life  begins  to  suffer  overtly  from  the  symptoms  of  aortic  stenosis  has  but  a  few 
years  to  live"  is  certainly  correct.  (For  treatment  see  end  of  article  on  ^'alvuIar 
Disease.) 

Aortic  Regurgitation. — Definition. — Aortic  regurgitation  is  often  called  "aortic 
insufficiency"  or  "aortic  incompetency,"  and  consists,  as  its  names  indicate,  in  a 
condition  of  the  aortic  leaflets,  or  of  the  aortic  orifice,  whereby  the  blood  after 


CHRONIC  VALVULAR  DLSEASE  AS  A   RESULT  OF  ENDOCARDITIS     All 

being  expelled  by  the  contraction  of  the  left  ventricle  into  the  aorta  is  permitted 
to  return. 

Etiology  and  Pathology. — By  far  the  most  common  cause  of  this  lesion  is  acute 
rheumatism,  which  causes  the  same  changes  in  the  valves  at  the  aortic  orifice  as 
have  already  been  described  as  taking  place  in  the  mitral  leaflets,  namely,  distortion, 
retraction,  stiffening,  and  the  development  of  vegetations.  As  a  rule,  when  rheu- 
matism is  the  cause  the  mitral  valves  also  suffer  seriously,  so  that  the  aortic  and 
mitral  lesions  coexist.  A  second  common  cause  is  aortitis,  or  atheroma  of  the 
aorta,  which  extends  to  the  valves  and  causes  sclerotic  and  degenerative  changes 
which  alter  the  position  and  functional  ability  of  the  aortic  cusps.  This  atheroma 
may  be  due  to  mere  senility,  or  to  syphilis,  gout,  or  even  malarial  infection.  It  is 
remarkable  how  many  of  these  cases  have  a  history  of  excessive  toil,  excessive 
venery,  and  excessive  drinking,  with  the  result  that  the  blood-\-essels  and  heart 
have  had  to  stand  strain,  toxemia,  and  infection.  The  cases  of  aortic  regurgitation 
which  are  due  to  these  causes  suffer  the  greatest  destruction  of  the  valves,  for  their 
surfaces  may  ulcerate  or  the  deposition  of  an  excess  of  lime  salts  causes  necrosis 
to  such  an  extent  that  only  stumps  of  the  valves  exist. 

A  third  cause,  which  is  much  more  rare,  does  not  primarily  involve  the  ^■alves, 
but  the  aortic  orifice.  The  aortic  ring  undergoes  dilatation  and  as  a  result  the 
valves  cannot  become  approximated.  In  other  words,  the  opening  is  too  large 
for  them  to  close  it.  This  condition  is  met  with  in  cases  of  aneurysm  of  the  aorta. 
It  is  not  by  any  means  as  frequent  as  dilatation  of  the  mitral  orifice,  because  the 
ring  around  the  opening  of  the  aorta  is  largely  made  up  of  fibrous  and  fibro-elastic 
tissues,  that  which  supports  the  mitral  orifice  is  largely  muscular. 

The  question  as  to  whether  a  diastolic  aortic  murmur  can  be  present  without 
disease  of  the  aortic  valves  has  been  much  discussed,  particularly  of  late,  by  Cabot 
and  Locke,  of  Boston,  and  Gibson,  of  Edinburgh.  As  is  well  known,  the  aortic 
ring  is  so  firm  that  it  seems  impossible  that  it  can  yield  as  do  the  rings  of  the  pul- 
monary and  mitral  orifices.  Cabot  and  Locke  believe  that  diastolic  aortic  miu-murs 
are  not  uncommon  in  connection  with  diffuse  or  localized  dilatation  of  the  aorta, 
but  in  view  of  the  evidence  presented  by  Gibson,  we  must,  I  think,  agree  with  him 
that  diastolic  murmurs,  without  valvular  lesions,  are  rare  at  the  aortic  orifices, 
and  that  when  they  occur  they  are  due  to  defective  approximation  of  the  different 
aortic  cusps  rather  than  to  yielding  of  the  aortic  ring. 

A  fourth  cause  is  rupture  of  an  aortic  leaflet  as  the  result  of  violent  strain.  This 
accident  rarelj^  if  ever,  occurs  unless  the  valve  has  already  been  weakened  by  disease. 

A  fifth  cause  is  the  presence  of  vegetations  on  the  aortic  valves,  developing  in 
the  course  of  the  acute  infections  or  chorea.  Some  of  these  lesions  differ  from  those 
due  to  ordinary  endocarditis  in  that  they  are  not  always  permanent,  but  may 
entirely  disappear. 

A  sixth  cause  is  ulcerative  endocarditis,  in  which  great  destruction  of  the  valves 
may  take  place  or  abundant  vegetations  develop.  This  is  usually  due  to  the 
pneumococcus.     (See  Croupous  Pneumonia.) 

A  seventh  cause  is  congenital  malformation,  which  is  exceedingly  rare.  Indeed, 
aortic  regurgitation  due  to  this  cause  is  more  rare  than  are  congenital  defects 
themselves,  for  congenital  defects  in  the  valves  may  not  be  severe  enough  to  permit 
leakage. 

Finally  (eighth)  a  functional  relaxation  of  the  aortic  orifice  occasionally  is  met 
with  in  which  temporary  regurgitation  takes  place  for  the  same  reasons  as  have 
been  described  elsewhere.  I  saw  a  case  of  this  character  w'hile  on  duty  at  St. 
Clement's  Hospital  some  twenty-five  years  ago,  in  a  young  girl  who  had  a  loud, 
aortic  regurgitant  murmur  and  apparently  a  fusiform  aneurysm  of  the  innominate 
artery.  At  the  autopsy  the  vessels  seemed  perfectly  normal  in  size,  but  on  testing 
them  they  were  found  to  be  unusually  yielding  and  elastic. 


47S  DISEASES  OF  THE  HEART 

The  secondary  effects  of  aortic  regurgitation  upon  the  left  ventricle  are  most 
important  and  interesting.  The  left  ventricle  no  sooner  expels  its  contents  into 
the  aorta  and  begins  to  dilate  in  order  to  receive  the  blood  from  the  auricle,  than 
it  also  receives  part  of  the  blood  it  has  just  sent  into  the  aorta  by  reason  of  the 
fact  that  the  aortic  valves  permit  regurgitation.  The  ventricle,  therefore,  contains 
not  only  the  normal  amount  of  blood  from  the  auricle,  but  an  additional  quantity 
from  the  aorta,  and  so  it  becomes  dilated  to  contain  this  excess  and  also  undergoes 
hypertrophy  in  order  to  expel  this  excess  into  the  aorta  and  empty  itself.  Any 
strain  upon  the  heart  increases  the  dilatation,  and  as  a  result  we  often  see,  particu- 
larly in  those  who  live  by  manual  labor,  an  extraordinary  increase  in  the  size  of 
the  heart,  which  is  both  greatly  dilated  and  greatly  hypertrophied,  the  so-called  ec- 
centric hypertrophy  of  aortic  regurgitation  residting  in  the  "  ox  heart"  or  corhovinum. 

The  rapidity  and  degree  of  the  hA^pertrophy  is  extraordinary  in  some  cases. 
Sansom  speaks  of  a  case  in  which  the  heart  was  thought  to  have  gained  an  ounce 
each  week  for  four  or  five  weeks,  and  Dulles  has  recorded  a  case  in  which  the  heart 
weighed  forty-eight  ounces.  When  the  ventricle  is  much  dilated  the  ring  guarding 
the  mitral  orifice  may  yield  and  insufficiency  of  the  mitral  valves  ensue  and  thus 
cause  dilatation  of  the  left  auricle,  congestion  of  the  lungs,  and  hypertrophy  of 
the  right  side  of  the  heart.  In  some  cases  of  aortic  insufficiency,  when  the  cause 
is  atheroma,  the  pathological  process  of  fibrosis  and  calcification  gradually  extends 
to  the  tissues  around  the  opening  of  the  coronary  arteries,  which  are  then  unable 
to  properly  supply  the  heart  with  blood,  or  the  coronary  arteries  themselves  become 
atheromatous.  Under  such  conditions  compensatory  hypertrophy  may  never 
be  established,  or  if  established  rapidly  fails  and  death  ensues. 

Sjrmptoms  and  Physical  Signs. — The  symptoms  of  aortic  regurgitation  are  more 
characteristic  than  are  those  of  any  other  form  of  valvular  disease,  and  are  more 
constantly  met  with  in  such  cases,  although  compensation  may  be  adequate  in 
many  cases  for  a  time  at  least.  Dizziness  and  partial  syncope  often  appear  or 
suddenly  sitting  up  or  on  standing  up,  and  at  times  are  present  even  when  the 
patient  lies  down.  Palpitation  and  dyspnea  on  exertion  are  pressing  symptoms 
if  the  heart  is  feeble,  and  even  when  compensation  is  adequate  pain  in  the  region 
of  the  heart  is  often  a  severe  symptom,  being  radiated  into  the  arms  or  into  the 
neck.  At  this  time  the  attacks  may  be  identical  with  those  of  true  angina  pectoris. 
Siidden  death  occurs  more  frequently  in  this  form  of  valvular  disease  than  in  any 
other. 

When  compensatory  hypertrophy  is  lost  the  patient  is  forced  to  sleep  sitting 
erect  or  nearly  erect  in  an  easy  chair;  he  is  usually  ^'ery  pallid,  but  at  times  cyanotic. 
Cough  and  pulmonary  complications  do  not  ensue  until  the  mitral  valves  give  way. 

When  the  cardiac  failure  is  well  marked,  and  it  is  evident  that  death  cannot  be 
many  days  away,  distressing  mental  symptoms  often  appear.  Hallucinations  are 
pressing  and  even  an  active  delirium  may  develop.  At  times  the  patient  becomes 
suicidal.  In  some  cases  these  mental  disturbances  are  due  to  disordered  and 
inadequate  cerebral  blood  supply,  and  at  times  they  are  due  to  a  complicating 
nephritis  arising  as  a  late  lesion  of  the  general  breakdown. 

Physical  Signs. — The  physical  signs  are  characteristic  when  well  de\eloped. 
On  inspection  the  carotid  arteries  are  seen  to  pulsate  markedly,  and  even  the  head 
may  be  moved  by  the  impulse  transmitted  to  it  by  the  heart.  The  thorax,  in 
the  precordium  and  neighboring  parts,  heaves  with  each  pulsation  of  the  heart 
and  is  often  bulging,  owing  to  the  cardiac  hypertrophy  and  dilatation.  An  ocular 
examination  of  all  the  superficial  arteries  will  show  a  characteristic  throbbing  or 
jerking,  and  if  a  glass  slide  be  lightly  pressed  against  the  lower  lip  capillary  pulsation 
is  readily  seen,  in  that  the  color  of  the  mucous  membrane  rises  and  falls  with  the 
movements  of  the  heart.  Such  capillary  pulsation,  often  called  "  Quincke's  i)ulse," 
can  be  seen  under  the  thumb-nail  when  it  is  gently  pressed  upon,  and  in  the  red 


CHRONIC   VALVULAR  DISEASE  AS  A  RESULT  OF  ENDOCARDITIS    479 


line  produced  on  the  skin  of  the  forehead  by  drawing  the  end  of  a  pencil  over  this 
part.  As  the  arteries  are  often  elongated,  and  therefore  more  tortuous  than  in 
health,  the  impulse  of  the  wave  of  blood  which  tends  to  straighten  the  curves  makes 
the  vessels  move  laterally  as  they  beat,  and  this  increases  the  pumping  effect  which 
is  produced  by  the  so-called  "Corrigan  pulse." 

The  apex  beat  is  always  far  below  and  far  outside  the  nipple  because  of  the 
dilatation  and  hypertrophy  of  the  left  ventricle,  and  also  because  of  the  elongation 
of  the  aortic  arch.  On  Tpalpaiing  the  heart  the  impulse  on  systole  is  powerful  and 
diffuse  except  when  compensation  is  ruptured,  when  it  is  feeble. 

The  'pulse  when  felt  by  the  finger-tips  feels  as  it  looks  on  inspecting  the  arteries. 
With  each  systole  of  the  heart  the  almost  empty  artery  suddenly  gives  to  the 
finger  a  short,  sharp  impulse,  which  equally  suddenly  disappears,  the  vessel  being 
in  an  instant  apparently  as  empty  as 

before.     The  hypertrophied  and  dila-  ^"'-  ^^ 

ted  heart  expels  a  large  wave  of  blood 
into  the  aorta,  of  which  a  part  at 
once  falls  back  into  the  ventricle,  so 
that  what  might  be  called  the  tail  of 
the  pulse  is  lost.  This  is  the  so-called 
"Corrigan  pulse,"  sometimes  called 
the  "water-hammer  pulse,"  or  "trip- 
hammer pulse."  It  can  be  empha- 
sized in  the  radial  arteries  by  raising 
the  hand  above  the  head.  Tliis  pulse 
is  usually  regular  as  to  rhythm  and 
force,  and  the  blood  pressure  is  high. 
If  it  becomes  constantly  irregular,  it 
is  a  sign  of  grave  cardiac  failure. 
Aside  from  high  blood  pressure,  which 
is  usually  aboA^e  160  in  the  arm,  there 
is  an  additional  sign  of  diagnostic 
value.  If  the  patient  is  recumbent 
so  as  to  be  relatively  free  from  hy- 
drostatic variations  in  his  arterial 
tree  it  will  be  found  that  the  systolic 
pressure  in  the  leg  is  always  40  to  100 
points  higher  than  in  the  arm.  This 
difference  is  not  found  in  any  other 
valvular  lesion,  but  it  is  often  absent 
in  children.  If  the  auscultatory 
method  of  estimating  blood  pressure  is  used  the  tapping  soimd  persists  until 
the  mercury  is  practically  at  zero. 

On  percussion  the  area  of  cardiac  dulness  is  found  to  be  greatly  enlarged,  so 
that  it  extends  far  over  to  the  anterior  axillary  line  in  some  instances,  and  tliree 
inches  below  the  nipple.  Dulness  due  to  the  enlarged  heart  is  also  found  even  as 
far  as  the  right  edge  of  the  sternum. 

Auscultation. — Auscultation  reveals  a  diastolic  murmur,  due  to  the  return  of  the 
blood  from  the  aorta  after  the  systole  has  expelled  it  into  the  vessel,  and  while 
the  ventricle  is  once  more  opening  for  a  new  supply  from  the  auricle.  This  murmur 
is  heard  in  its  greatest  intensitj'^  at  the  fourth  left  intercostal  space,  or  at  the  second 
right  costal  cartilage  in  the  so-called  aortic  area.  It  is  heard  at  the  fourth  left 
intercostal  space  because  the  reflux  of  blood  carries  the  murmur  back  into  the  ven- 
tricle, and  because  the  aortic  opening  as  a  matter  of  fact  is  nearer  this  area  than 
the  second  right  intercostal  space  (Fig.  90).     In  still  other  cases  the  diastolic 


Showing  the  area  in  which  the  murmur  of  aortic 
regurgitation  can  be  most  clearly  heard. 


480  DISEASES  OF  THE  HEART 

murmur  may  be  very  clearly  heard  at  the  cardiac  apex  as  well  as  at  the  second 
right  intercostal  area,  although  between  the  two  no  murnuir  at  all,  or  only  a  very 
faint  sound,  can  be  discovered.  The  explanation  of  this  is  that  the  right  \entricle 
occupies  the  anterior  surface  of  the  heart,  except  at  the  extreme  left  edge,  where  the 
left  ventricle  j^rotrudes  and  where  the  apex  comes  closely  in  contact  with  the  chest 
wall. 

The  murmur  of  aortic  regurgitation  is  not  widely  transmitted,  but  is  limited, 
as  a  rule,  to  the  area  described,  although  when  it  is  very  loufl  it  may  be  heard 
everywhere  in  the  chest.  The  quality  of  this  murmur  is  blowing  or  purring.  There 
is  no  accentuation  of  the  pulmonary  second  sound  at  the  third  left  costal  cartilage, 
unless  there  is  an  associated  mitral  regurgitation  or  stenosis.  The  first  sound  of 
the  heart  is  loud  or  prolonged  owing  to  the  large  amount  of  blood  which  has  to  be 
expelled  at  systole.  In  some  cases  a  diastolic  sound  near  the  apex  may  mislead 
the  physician  into  a  diagnosis  of  mitral  obstruction,  but  it  is  in  reality  the  so-called 
"Flint's  murmur."     (See  Mitral  Stenosis.) 

If  the  stethoscope  is  placed  over  any  one  of  the  large  superficial  arteries  there  is 
sometimes  heard,  in  cases  of  aortic  regurgitation,  a  sharp  systolic,  "pistol-shot" 
sound,  which  is  said  to  be  due  to  sudden  filling  of  the  vessel.  This  sound  is  not 
transmitted  from  the  heart,  but  is  local  in  origin.  It  is  a  modification  of  the  arterial 
sound  \\^hich  can  be  elicited  in  most  persons  with  a  strong  pulse,  if  the  artery  is 
occluded  by  pressure  with  a  stethoscope.  Very  rarely  a  diastolic  arterial  sound 
can  be  heard,  the  so-called  "Duroziez  sign,"  which  is  thought  to  be  due  to  a  trans- 
mitted cardiac  sound. 

Diagnosis. — The  symptoms  and  physical  signs  of  aortic  regurgitation  having 
been  described,  it  remains  to  separate  them  from  those  conditions  ^^•hich  possess  a 
resemblance.  Occasionally  in  some  persons  a  diastolic  cardiopulmonary  murmur 
is  heard,  but  it  disappears  with  change  in  posture  and  is  dissipated  or  is  accentuated 
by  forced  expiration  and  inspiration.  At  the  level  of  the  second  and  third  left  rib 
there  is  heard  at  times  a  hemic  murmur  or  hum  due  to  anemia,  but  this  is  systt)hc 
in  time.  Cabot  has,  however,  reported  cases  in  which  diastolic  murmurs  were 
hemic  and  due  to  anemia. 

Finally,  it  is  to  be  recalled  that  the  aortic  regurgitation  murmur  is  often  incon- 
stant, and  if  not  heard  at  one  examination  may  be  at  another,  or  when  the  patient 
exercises  or  changes  his  posture. 

Prognosis. — Facts  in  regard  to  the  relative  fatality  of  aortic  regurgitation  have 
already  been  given.  Allbutt  says  ten  years  constitute  a  long  time  of  life  in  any 
case  of  aortic  regurgitation.  It  is  not  only  a  serious  lesion,  but  it  is  the  vah'ular 
lesion  above  all  others  which  produces  sudden  death;  but  death  in  aortic  regurgita- 
tion is  not  always  sudden.  A  majority  of  cases  gradually  "  play  out"  with  dyspnea, 
dropsy,  and  cardiac  distress.  ]\Iuch  depends  on  the  age  of  the  patient,  his  previous 
habits,  and  the  cause  of  the  disease.  In  a  young  adult  with  a  good  history,  and 
in  whom  the  lesion  has  followed  rheumatism  without  great  injury  to  other  parts, 
compensatory  hyjiertrophy  may  carry  him  along  for  many  years  unless  he  ruptures 
it  by  sc\-ere  strain,  or  it  is  dissipated  by  illness.  When  the  lesion  comes  on  as  the 
result  of  atheroma  it  is  more  serious  because  it  is  evidence  of  general  cardiovascular 
degeneration,  and  the  coronary  arteries,  through  which  the  heart  is  chiefly  nour- 
ished, no  sooner  share  in  the  degenerative  change  than  feebleness  of  the  heart 
ensues.  If  perchance  the  kidneys  share  in  the  cardiocapillary  fibrosis,  the  outlook 
is  all  the  more  grave.  When  fast  living  and  debauchery  are  factors  in  the  case,  and 
an  old  syphilitic  infection  is  impairing  the  myocardium,  the  outlook  is  worse  still. 
(For  treatment  sec  end  of  article  on  "N'alvular  Disease.) 

Tricuspid  Regurgitation. — Definition. — Tricuspid  regurgitation,  or  insuflSciency, 
is  a  condition  in  which  the  blood  flows  backward  into  the  right  auricle  from  the 
right  ventricle,  upon  the  contraction  of  the  latter. 


CHRONIC  VALVULAR  DISEASE  AH  A    RESULT  OF  ENDOCARDITIS     481 

Etiology  and  Pathology. — This  is  a  rare  lesion  and  is  due  to  two  chief  causes. 
It  occurs  most  commonly  as  a  result  of  disease  on  the  left  side  of  the  heart,  whereby 
the  blood  is  dammed  back  into  the  lung  and  so,  by  preventing  free  pulmonary 
circulation,  an  undue  strain  is  thrown  on  the  tricuspid  leaflets.  In  other  instances 
the  primary  obstruction  exists  in  the  lungs,  as  in  pulmonary  emphysema,  fibroid 
phthisis,  and  bronchiectasis. 

As  indicating  the  relative  frequency  of  these  causes,  Newton  Pitt  reports  from 
Guy's  Hospital  that  out  of  405  cases  of  tricuspid  regurgitation  examined  at  autopsy, 
in  a  period  of  twenty-five  years,  200  cases  were  due  to  left-sided  failure  with  valvular 
disease.  Of  this  number  64  were  cases  of  mitral  regurgitation  with  mitral  endo- 
carditis or  adherent  pericardium,  66  were  due  to  mitral  stenosis,  61  to  mitral  with 
associated  aortic  disease,  and  9  had  valvular  lesions  not  named.  In  71  cases  the 
tricuspid  condition  was  due  to  left-sided  failure  without  valvular  disease,  in  56 
cases  the  cause  lay  in  muscular  failure  of  the  whole  heart,  and  in  55  the  lesion  was 
not  left-sided,  but  was  right-sided  alone.  Seven  cases  were  due  to  disease  of  the 
pulmonary  valves,  of  which  5  were  stenosis  and  2  pulmonary  regurgitation.  In 
4  cases  no  cause  could  be  found,  and  in  12  the  reports  as  to  the  exact  state  of  the 
heart  were  too  imperfect  for  analysis. 

The  valves  in  these  cases  are  usually  healthy  and  fail  to  close  the  right  auriculo- 
ventricular  opening  because  the  orifice  is  enlarged  as  a  result  of  dilatation  of  the 
ventricle. 

The  second  cause  of  this  lesion  lies  in  the  heart  itself,  that  is,  an  endocarditis 
involving  the  right  side  of  the  heart.  This  is  generally  stated  to  be  very  rare, 
although  in  fetal  life  endocarditis  is  more  commonly  on  the  right  side  of  the  heart 
than  the  left.  Bramwell,  however,  combats  the  statement  that  acute  endocarditis 
rarely  affects  the  tricuspid  valves,  and  believes  that  endocarditis  of  the  right 
heart  often  exists  and  is  overlooked.  Out  of  28  cases  of  recent  simple  endocarditis 
he  found  disease  of  the  tricuspid  valves  in  14,  or  50  per  cent.  Nevertheless,  the 
lesions  are  not  so  pronounced  as  those  due  to  this  cause  on  the  left  side  of  the  heart. 
In  ulcerative  endocarditis  Osier  found  the  tricuspid  valves  affected  in  19  cases  out 
of  238  instances  of  that  disease. 

A  case  in  which  tricuspid  disease  was  discovered  during  intra-uterine  life  is 
reported  by  Peter,  of  Paris!  ! 

Symptoms  and  Physical  Signs. — When  the  cause  exists  in  the  left  side  of  the 
heart  the  symptoms  are  those  naturally  arising  in  cases  of  pulmonary  congestion 
and  engorgement.  A  low-grade  hronchitis,  with  some  dulness  at  the  bases  of  the 
lungs  posteriorly  from  hypostatic  congestion,  with  cough  and  occasionally  blood- 
stained sputum,  is  discoverable.  The  jugidar  veins  become  distended  and  pulsate, 
the  liver  becovies  enlarged  and  may  pulsate,  and  there  is  marked  cyanosis.  It  is  a 
noteworthy  fact  that  the  presence  of  jugular  pulsation,  while  a  sign  of  well-developed 
regurgitation,  is  not  by  any  means  as  grave  a  sign  as  is  its  absence  in  the  presence 
of  other  evidences  of  cardiac  embarrassment,  because  if  the  right  ventricle  is 
strong  it  may  drive  the  regurgitating  blood  with  sufficient  force  to  cause  jugular 
pulsation,  whereas  if  it  be  weak  no  jugular  pulsation  can  ensue.  On  the  other 
hand,  the  presence  of  jugular  pulsation  shows  that  the  regurgitation  is  a  grave  one, 
because  it  does  not  occur  until  a  considerable  quantity  of  blood  fiows  into  the 
auricle  and  distends  the  veins  sufficiently  to  interfere  with  the  valves,  so  that  they 
cannot  prevent  auricular  regurgitation  as  they  do  in  health. 

A  distinct  impulse  in  the  upper  epigastrium  is  often  present. 

The  pulsation  of  the  liver  is  best  discovered,  if  not  seen,  by  placing  the  finger-tips 
or  hand  against  the  floating  ribs  at  the  side,  and  the  other  hand  near  the  ensiform 
cartilage,  and  then  exerting  gentle  pressure  upon  the  liver  from  both  directions. 
Care  must  be  taken  that  a  directly  transmitted  impulse  from  a  hypertrophied 
heart  is  not  taken  for  true  expansile  pulsation  of  the  liver. 
31 


4S2  DISEASES  OF  THE  IIEART 

On  percussion,  increase  in  the  area  of  cardiac  duiness  to  the  rirjl't  of  the  sternum 
is  demonstrable. 

On  atisndlaiion  at  the  apex  a  soft  systoHc  murmur,  or  purr,  can  l)e  licard,  which 
is  found  to  be  loudest  at  about  the  fifth  intersjjace,  to  the  right  of  tlie  sternum 
or  at  the  base  of  the  ensiform  cartilage,  and  which  may  be  in  a  few  cases  transmitted 
to  the  right  axillary  area.  The  murmur  of  tricuspid  regurgitation  has  been  said 
to  resemble  the  sounds  made  by  a  small  jet  of  escaping  steam,  and  it  may  be  singing 
or  musical.     Diu-oziez  says  that  venous  blood  "sings"  more  than  arterial  lilood. 

Diagnosis. — ^True  tricuspid  regurgitation  must  be  differentiated  from  regurgita- 
tion at  this  orifice,  which  is  temporary  and  not  constant.  These  valves  not  rarely 
give  way  from  severe  strain,  as  in  athletes  during  exertion.  They  act  in  this  way 
as  a  "safety-valve"  to  relieve  undue  pressure,  and  as  soon  as  the  strain  ceases  the 
heart  gradually  returns  to  its  normal  size  and  the  murmiu'  disappears.  So,  too, 
a  similar  murmur  may  develop  in  cases  of  profound  asthenia  resulting  from  pro- 
longed fevers,  particularly  if  the  heart  is  strained  by  the  patient  attempting  to  do 
too  much.     Such  a  murmur  may  or  may  not  pass  away  with  rest. 

Prognosis. — The  prognosis  depends  entirely  upon  the  exciting  cause,  the  age 
of  the  patient,  and  his  general  state  and  manner  of  life.  In  those  who  have  to  do 
manual  labor  the  prognosis  is  usually  bad. 

Tricuspid  Stenosis. — This  condition  sometimes  arises  as  the  result  of  an  attack 
of  endocarditis  involving  both  sides  of  the  heart,  and  is  usually  associated  with 
mitral  stenosis.  In  other  instances  it  is  congenital.  In  the  large  majority  of 
cases  it  is  found  as  an  associated  lesion,  and  it  is  exceedingly  rare. 

In  1899  Newton  Pitt  collected  87  cases  of  tricuspid  stenosis  from  the  postmortem 
records  of  Guy's  Hospital  extending  over  a  period  of  twenty-six  years,  and  compris- 
ing a  total  of  12,000  autopsies.  Leudet,  in  his  Paris  thesis  on  tricuspid  stenosis, 
gives  the  following  figures,  based  on  114  postmortem  examinations  which  were 
collected  from  various  sources,  and  which  include  the  cases  collected  by  Fenwick: 

Stenosis  of  the  tricuspid  valve  alone 11 

Stenosis  of  the  tricuspid  and  of  the  orifice  of  the  puhnonary  arterj-  ....  3 

Stenosis  of  the  tricuspid,  mitral,  and  pulmonary 1 

Stenosis  of  the  tricuspid,  mitral,  and  aortic 21 

Stenosis  of  the  tricuspid  and  mitral 78 

F.  W.  Griffith,  of  Leeds,  has  examined  Leudet's  tabulation  of  cases  and  has 
shown  that  proljably  only  two  of  them  were  unassociated  with  lesions  of  the  other 
valves.     These  figures  show  the  rarity  of  uncomplicated  tricuspid  stenosis. 

Diagnosis. — The  diagnosis  of  the  lesion  during  life  is  usually  very  difficult,  but 
it  can  be  made.  The  murmur,  if  present,  is  presystolic  in  time  and  has  its  greatest 
intensity  at  the  fifth  right  interspace  near  the  stermmi.  As  already  stated,  this 
murmur  is  usually  associated  with  that  of  mitral  stenosis,  and  its  existence  may  be 
completely  masked  by  the  presystolic  murmur  at  the  mitral  orifice.  Additional 
physical  signs  of  tricuspid  stenosis  are  distention  of  the  jugular  \'eins  without 
pulsation,  or  with  very  slight  pulsation  due  to  the  feeble  am-icular  regurgitant 
impulse. 

As  dropsy  is  a  late  symptom  of  severe  mitral  stenosis,  the  early  develoi)ment  of 
dropsy  in  a  case  with  a  presystolic  murnuir  which  is  not  aortic  strongly  indicates 
tricuspid  obstruction. 

Disease  of  the  Pulmonary  Valves. — Lesions  of  the  pulmonary  valves  are  so 
rarely  met  with  that  nian>-  ])ractitiuncrs  of  large  experience  Iiave  never  seen  a 
case  presenting  them.  Wlien  actual  lesions  occur  they  are  nearly  always  congenital, 
and  the  usual  lesion  is  that  of  pidmonary  stenosis  or  obstruction,  for  pulmonary 
regurgitation  is  the  rarest  of  cardiac  lesions.  On  the  other  hand,  there  is  no  area 
at  which  we  listen  for  the  purpose  of  determining  the  state  of  the  heart  valves, 


CHRONIC  VALVULAR  DISEASE  AS  A   RESULT  OF  ENDOCARDITIS     483 

in  which  murmurs  are  so  constantly  found  as  the  so-called  pulmonary  area,  at 
the  second  and  third  left  intercostal  space.  These  murmurs  are  not  due  to  actual 
disease  of  the  pulmonary  valves  or  of  the  pulmonary  artery,  but  they  arise  from 
causes  of  a  non-organic  character  and  are  usually  systolic  in  point  of  time.  These 
functional  murmurs  may  be  due  to  one  of  several  causes,  as,  for  example,  anemia 
and  chlorosis,  producing  the  so-called  hemic  murmur.  They  also  occur  in  pregnant 
women  and  in  women  after  childbirth.  In  other  instances  they  are  present  as  a 
sign  of  Graves'  disease  or  of  nervous  tachycardia,  and  in  still  others  they  arise 
from  some  abnormal  position  of  the  heart,  caused  by  conditions  which  alter  the 
relationship  of  the  heart  muscle  to  its  great  vessels.  These  conditions  all  produce 
a  pulmonary  murmur  which  may  be  considered  as  within  the  area  of  the  pulmonary 
artery  or  near  its  valves.  In  addition  we  sometimes  hear  at  this  point  a  so-called, 
cardiopulmonary  murmur,  which  is  supposed  to  be  due  to  the  effect  of  the  blood- 
vessel upon  the  lung,  or  vice  versa,  in  that  the  murmur  occurs  durmg  forced 
inspiration,  or  expiration.  This  murmur  is  not  rarely  seen  at  this  point  in  early 
tuberculosis  of  the  apex  of  the  left  lung. 

Pulmonary  Stenosis. — The  systolic  murmur  wliich  is  due  to  actual  organic 
disease  at  the  pulmonarj'  valve  is  due  to  stenosis,  as  already  stated,  and  is  commonly 
due  to  gluing  together  of  the  cusps  of  the  pulmonary  valves  in  antenatal  life.  This 
murmiu-  is  more  harsh  than  the  soft  purring  murmiu's  of  the  fimctional  t^'pe  just 
described.  The  patient  usually  has  a  history  of  having  been  cyanotic  all  his  life, 
with  dyspnea  on  the  slightest  exertion.  Percussion  and  palpation  will  usually 
reveal  a  distinct  increase  of  cardiac  dulness  to  the  right  from  h\-pertrophy  of  the 
right  ventricle.  Palpation  also  will  reveal  a  distinct  systolic  tlirill  over  the  area 
of  the  pulmonary  valves. 

The  points  by  which  the  true  systolic  murmur  is  to  be  separated  from  the  func- 
tional murmurs  already  described  are  the  absence  of  systolic  thrill  in  the  case  of  the 
functional  murmurs,  the  harshness  of  the  true  murmur,  and  the  h^-pertrophy  of 
the  right  ventricle  in  cases  of  actual  pulmonary  disease.  From  aneurysm  of  the 
descending  portion  of  the  aortic  arch  the  true  pidmonary  murmur  is  separated  by 
the  fact  that  in  such  a  case  the  hypertrophy  chiefly  involves  the  left  side  of  the 
heart,  by  the  additional  fact  that  there  is  a  bruit,  not  a  miu-mur,  and  by  the  presence 
of  a  bruit  posteriorly  on  the  left  side  between  the  vertebrae  and  scapula.  There 
are  also  pressure  symptoms  in  aneurysm  in  many  cases.  Finally,  if  it  be  aneurysm, 
percussion  of  the  third  left  costal  cartilage  will  reveal  dulness,  which  is  absent  in 
pulmonary  stenosis.  The  murmur  of  aortic  stenosis  is  heard  louder  at  the  second 
right  costal  cartilage  than  at  the  second  or  third  left  cartilage,  and  is  transmitted 
into  the  carotids,  but  the  pulmonary  miu-mur  is  not. 

Pulmonary  regurgitation,  the  rarest  of  all  valvular  lesions,  is  usually  fetal 
in  origin,  but  cases  have  been  recorded  in  which  it  has  arisen  as  a  result  of  ulcerative 
endocarditis.  The  miu-mur  due  to  this  cause  is,  of  course,  diastolic,  and  is  produced 
by  the  blood  falling  back  from  the  pulmonary  artery  into  the  right  ventricle. 
It  is  to  be  separated  from  aortic  regurgitation  by  the  fact  that  it  is  heard  best  to 
the  left  of  the  sternum  instead  of  to  the  right,  and  by  the  absence  of  the  Corrigan 
pulse  of  aortic  disease.  There  are  signs  of  dilatation  and  hj'pertrophy  of  the  right 
ventricle,  and  the  pulmonary  second  sound  may  be  accentuated.  It  is  by  no 
means  uncommon  for  the  existence  of  pulmonary  regurgitation  to  be  unsuspected 
until  autopsy. 

Treatment  of  Chronic  Valvular  Disease. — It  is  of  vital  importance  that  the  physician 
remember  the  fact  that  the  mere  presence  of  a  valvular  lesion  in  the  heart  does  not 
indicate  drug  treatment.  On  the  contrary,  much  harm  is  frequently  done  by  the 
administration  of  cardiac  stimulants  to  patients  who  are  found  to  possess  a  valvular 
lesion,  with  the  result  that  natural  compensation  is  disturbed  and  cardiac  sjTuptoms 


484  DISEASES  OF  THE  HEART 

may  be  noted  by  the  patient  for  the  first  time  in  his  history.  It  is  only  when  the 
patient  presents  symptoms  which  indicate  faihire  of  cardiac  function  that  the 
physician  should  think  of  administering  remedies  ^\•hich  have  a  direc't  influence  upon 
the  heart.  In  other  words,  when  compensation  is  complete,  no  cardiac  treatment 
is  indicated,  but  when  it  is  ruptured  therapeutic  measures  shoulcl  be  instituted. 
I  have  again  and  again  seen  patients  who  have  presented  some  ailment  involving 
other  organs  in  the  body  than  the  heart,  in  whom  the  physician,  on  examination, 
found  a  mitral  regvirgitant  murmur,  and  immediately  proceeded  to  administer 
digitalis,  forgetting  that  the  presence  of  a  murmur  in  the  absence  of  evidences  of 
circulatory  failure  is  not  an  indication  for  the  use  of  the  drug. 

Another  important  point  to  be  borne  in  mind  when  the  physician  is  called  upon 
to  treat  a  case  in  which  compensation  is  failing  is  that,  far  and  above  all  drugs  in 
value,  is  rest  for  the  patient;  not  only  rest  of  the  body,  but  rest  of  the  mind.  The 
heart  is  an  organ  which,  of  course,  cannot  have  complete  rest  at  any  time;  but  its 
work  can  be  diminished  one-half  if  the  patient  can  be  made  to  take  no  exercise, 
and  if  he  will  carefully  abstain  from  business  worries  and  cares.  It  is  a  remarkable 
fact  that  disease  of  the  coronary  arteries  and  of  the  heart  muscle  is  more  common 
in  brain-workers  than  in  those  who  gain  their  living  by  manual  toil,  and  this  is 
an  indication  of  the  fact  that  mental  labor  throws  a  severe  strain  upon  the  heart. 
Careful  observation  will  promptly  prove  that  patients  who  are  not  benefited  by 
digitalis  and  other  cardiac  stimulants,  when  suffering  from  ruptured  compensation, 
will  at  once  improve  if  rest  is  insisted  upon;  for,  manifestly,  the  rupture  of  com- 
pensation is  largely  the  result  of  cardiac  fatigue,  and  this  fatigue  cannot  be  put 
aside  by  the  mere  administration  of  stimulants.  In  order  that  the  juices  of  the 
body  may  be  kept  moving,  it  is  useful  in  these  cases,  when  they  are  made  to  rest 
in  bed,  to  use  more  or  less  vigorous  massage  daily,  its  vigor  depending  upon  the 
strength  of  the  individual.  If  the  massage  is  too  vigorous,  it  may  produce  very 
considerable  fatigue,  and  it  should  not  be  employed  to  this  extent. 

In  all  cases  of  ruptured  compensation  the  patient  should  be  warned  of  the  danger 
of  sudden,  severe  effort,  since,  even  if  death  does  not  ensue  under  these  circum- 
stances, the  heart  may  be  so  dilated  or  fatigued  that  irreparable  damage  is  done 
to  it. 

Digitalis  is  without  doubt  facile  princeps  the  best  of  cardiac  stimulants.  I 
have  proved  that  it  actually  increases  the  muscular  development  of  the  heart,  and 
the  manner  in  which  it  acts  results  in  an  increased  ner-\-e  and  blood  supply  to  this 
viscus  which  is  not  equalled  by  the  results  obtained  from  the  administration  of 
any  other  remedy.  Digitalis  is,  in  a  large  number  of  cases,  given  in  too  large 
doses.  Not  infrequently  as  much  as  10,  or  even  20  minims  of  the  tincture  are 
given  three  times  a  day,  with  the  result  that  in  the  course  of  a  few  days  the  heart 
is  overstimulated  by  the  drug;  its  cumulative  effect  is  produced,  and  instead  of 
doing  good  it  may  do  serious  harm.  I  have  known  of  cases  in  wliich  the  use  of 
full  doses  of  digitalis,  persisted  in  for  a  considerable  period  of  time,  have  resulted 
in  the  sudden  death  of  the  individual. 

When  digitalis  is  given  in  overdoses  it  produces  a  curious  irregularity  of  force 
and  rhythm  in  the  heart,  with  imperfect  systole,  followed  by  wide  diastole,  and 
this  causes  a  hobbling  pulse.  The  urine  may  also  be  reduced  in  amount  instead 
of  increased,  as  it  should  be,  under  the  influence  of  the  remedy. 

It  has  been  my  experience  that  if  the  patient  is  made  to  rest,  small  doses  of 
digitalis  produce  satisfactory  results,  not  more  than  5  drops  of  the  tincture  being 
given  three  times  a  day.  The  only  conditions  in  which  I  think  that  the  use  of 
large  doses  is  justified  are  when  the  condition  of  the  heart  is  found  to  be  exceedingly 
feeble,  and  the  patient's  condition  so  critical  that  immediate  stimulation  is  neces- 
sary; and  again,  when  because  of  idiosyncrasy  or  other  cause  the  heart  is  found  not 
to  respond  to  smaller  doses.     In  the  first  class  of  cases  it  has  been  my  ex-perience 


CHRONIC  VALVULAR  DISEASE  AS  A   RESULT  OF  ENDOCARDITLS     4S5 

that  it  is  better  to  overcome  pressing  cardiac  weakness  by  more  rapidly  acting  and 
diffusible  stimulants  such  as  Hoffmann's  anodyne,  strychnine,  and  caffeine  for 
the  first  twenty-four  or  forty-eight  hours  until  the  digitalis  has  a  chance  to  act; 
for  it  must  always  be  remembered  that  digitalis  is  a  drug  which  produces  its  effects 
very  slowly,  and  maintains  these  effects  for  some  time  after  its  use  has  been  stopped. 
When  large  doses  are  given,  it  has  been  my  experience  that  they  may  be  decreased 
to  about  one-half  or  one-quarter  the  original  quantity  at  the  end  of  a  few  days,  and 
their  effects  maintained  by  the  use  of  smaller  quantities.  I  do  not  think  that  I 
am  exaggerating  the  case  when  I  state  that  digitalis  through  its  abuse,  does  almost 
as  much  harm  as  it  does  good.  (See  my  Text-book  of  Therapeutics,  15th  ed.,  article 
"Digitalis.") 

The  fluid  extract  of  digitalis  may  be  given  in  the  dose  of  from  |  to  5  minims, 
according  to  the  needs  of  the  case.  One-half  to  1  minim  every  eight  hours  is 
usually  sufficient.     A  physiologically  tested  preparation  should  always  be  employed. 

When  dropsy  is  present  it  has  been  held  that  the  infusion  of  digitalis  is  the  best 
preparation,  on  the  ground  that  it  is  more  diuretic.  But  any  slight  increase  in 
diuretic  power  is,  I  think,  counterbalanced  by  the  fact  that  it  is  much  more  apt 
to  disorder  the  stomach,  which  is  in  a  disturbed  condition  in  any  case  of  grave 
disease,  and  particularly  so  in  heart  disease. 

When  digitalis  has  been  given  in  full  doses  to  a  patient  suffering  from  ruptured 
compensation,  he  should  be  warned  against  getting  up  suddenly,  and  particularly 
against  evacuating  the  bladder  when  in  a  standing  position,  as  dangerous  syncope 
may  occur  under  these  circumstances. 

Before  deciding  upon  the  administration  of  any  cardiac  stimulant  in  a  case  with 
ruptured  compensation,  the  physician  shoidd  make  a  careful  study  of  the  state 
of  the  bloodvessels,  and  if  the  arterial  tension  is  higher  than  normal  he  should 
remember  that  the  use  of  nitroglycerin  to  reduce  this  tension,  and  thereby  diminish 
the  work  of  the  heart,  is  a  more  important  therapeutic  procedure  than  the  adminis- 
tration of  a  stimulant  which  simply  urges  the  heart  to  do  more  work  in  the  face  of 
vascular  obstruction.  In  such  a  case  the  fact  that  digitalis  stimulates  the  vasomotor 
system  and  raises  arterial  tension  should  also  be  remembered.  Nitroglycerin 
can  often  be  given  to  advantage  to  prevent  this  arterial  effect  of  the  drug.  Stro- 
phanthus,  which  is  a  much  less  powerful  stimulant  than  digitalis,  possesses  the 
advantage  that  it  does  not  raise  arterial  pressure  by  stimulating  the  vasomotor 
system,  and  can  often  be  given  in  the  dose  of  5  to  10  minims  of  the  tincture  every 
eight  hours  with  advantage.  Large  doses  of  strophanthus  are  prone  to  produce 
an  irritative  diarrhea. 

There  is  a  host  of  drugs  which  have  been  recommended  for  ruptured  compensa- 
tion, but  none  of  them  approach  these  three  in  value,  and  often  when  these  fail 
the  failure  is  due  to  a  mistake  in  the  dose  rather  than  to  a  fault  of  the  drug.  Should 
there  be  any  tendency  to  hypostatic  congestion  of  the  lungs  or  pulmonary  edema, 
digitalis  may  be  freely  given,  and  strychnine  and  atropine  administered  as  vaso- 
motor stimulants.  Two  or  three  dry  cups  over  the  base  of  each  lung  are  also  useful 
under  these  circumstances,  and  sometimes  a  sharp  purgative  may  do  good  if  dropsy 
is  present;  but  the  possibility  of  the  purge  weakening  the  patient  must  always  be 
borne  in  mind. 

Attacks  of  acute  cardiac  failure  are  to  be  combated  by  Hoffmann's  anodyne 
in  the  dose  of  1  to  2  drachms  every  hour  or  two,  or  aromatic  spirit  of  ammonia 
in  the  dose  of  |  to  1  drachm.  If,  associated  with  the  cardiac  failure,  there  is  high 
arterial  tension,  the  nitroglycerin  should  be  used  hypodermically  in  the  dose  of 
^  to  Yiju  of  a  grain,  and  repeated  every  half-hour  until  the  tension  is  lowered,  but 
sometimes  high  tension  is  needful. 

When  marked  dropsy  is  present,  the  use  of  magnesium  sulphate  in  concentrated 
solution,  a  heaping  teaspoonful  to  one-half  glass  of  water  taken  before  breakfast, 


486  DISEASES  OF  THE  HEART 

will  often  do  good  by  removing  large  quantities  of  fluid  from  the  patient's  body. 
A  very  useful  remedy  in  cardiac  dropsy,  both  by  reason  of  its  action  on  the  heart 
and  because  of  its  diuretic  effect,  is  apocynum  cannabinum  given  in  the  dose  of 
from  5  to  30  minims  of  the  tincture  twice  or  tlirice  a  day  until  it  produces  slight 
purgation.  Care  should  be  taken  that  a  tincture  of  real  apocyimm  cannabinum 
is  obtained.  Much  of  that  on  the  market  is  apocynum  androsimcfolium,  which 
has  no  such  therapeutic  properties,  but  which  so  closely  resembles  apocynum 
cannabinum  that  its  lea^-es  are  often  unintentionally  substituted  for  the  true  drug. 
Another  very  useful  prescription  in  cardiac  dropsy  is  a  tablet  composed  of 

Extract  of  sourwood  leaves 2  grains. 

Extract  of  elder  flowers 2  giain.s. 

Extract  of  squill J  grain. 

Take  one  or  two  tablets  three  times  a  day. 

For  generations  physicians  have  been  in  the  habit  of  employing  a  pill  composed 
of— 

Powdered  squiU 1  grain. 

Powdered  digitalis  leaves 1  grain. 

Calomel 1  gi-ain. 

three  times  a  day  in  the  treatment  of  cardiac  dropsy,  for  its  stimulant  and  diuretic 
effect.  If  free  diuresis  is  not  produced  by  this  pill  at  the  end  of  the  third  day 
it  should  be  stopped,  and  a  saline  purgative  administered  to  sweep  out  the  calomel 
from  the  alimentary  canal. 

In  many  cases  of  cardiac  disease,  particularly  if  the  presence  of  anemia  is  marked, 
iron  and  arsenic  are  indicated,  both  on  general  principles  and  because  we  cannot 
expect  to  improve  the  nutrition  of  the  heart  when  it  is  supplied  by  impoverished 
blood. 

It  is  important  to  remember  that  in  nearly  every  case  of  failing  compensation 
there  is  a  certain  amount  of  hepatic  congestion.  This  is  best  relieved  by  the  use 
of  5  or  10  grains  of  blue  mass  given  every  week  or  ten  days.  Frequently  digitalis 
and  other  stimulants  will  act  much  better  after  the  liver  has  been  unloaded  by  the 
mercury  than  they  will  when  this  gland  is  congested. 

When  the  rupture  of  compensation  has  resulted  in  dyspnea  and  anxiety,  morphine 
proves  itself  a  most  valubale  remedy.  It  should  not  be  given  except  in  cases  in 
which  there  is  dire  need  of  rest,  since  if  used  too  frequently  it  loses  its  good  effects, 
and  frequently  causes  constipation  and  disorder  of  digestion.  On  the  other  hand, 
the  quiet  and  rest  produced  by  J  to  :}  of  a  grain  of  morphine  \xi\\  often  cause  mar- 
vellous improvement.  It  has  seemed  to  me  that  it  is  most  satisfactory  in  mitral 
lesions.  If  dropsy  is  present,  it  cannot  be  given  hypodermically  in  the  lower  parts 
of  the  body  because  it  will  not  be  absorbed. 

When  there  is  great  engorgement  of  the  jugular  veins,  and  manifest  distention 
of  the  right  side  of  the  heart  with  pulmonary  congestion,  venesection  to  the  extent 
of  about  8  ounces  to  a  pint,  according  to  the  size  of  the  individual,  is  often  very 
valuable  as  a  means  of  relief.  It  also  is  a  remedy  which  is  to  be  reserved  for  some- 
what desperate  conditions,  as  manifestly  it  is  not  proper  to  bleed  frequently. 

It  is  generally  considered  that  digitalis  does  less  good  in  cases  of  aortic  regurgita- 
tion than  in  other  valvular  lesions,  and  I  believe  this  opinion  is  correct.  Some 
have  taught  that  it  is  contra-indicated  in  aortic  regurgitation.  While  this  may 
be  the  general  rule,  every  now  and  then  we  meet  with  cases  in  which  cautious 
use  of  the  drug  in  this  state  produces  excellent  results,  provided  compensation  is 
ruptured. 

In  some  instances  when  the  heart's  action  is  very  irregular  and  excitable  an 
ice-bag  applied  over  the  precordium  is  advantageous. 

When  the  patient  has  had  syphilis,  chronic  rheumatism,  or  gout,  or  manifests 


DISORDERS  OF  CARDIAC  ACTION  NOT  DUE  TO  VALVULAR  LESIONS     487 

evidences  of  arterial  capillary  fibrosis,  iodide  of  sodium  or  iodide  of  potassium  in 
the  dose  of  10  or  15  grains  three  or  four  times  a  day  is  advantageous. 

The  diet  in  cases  of  valvular  disease  should  be  simple,  l)ut  nutritious.  The 
patient  had  better  eat  four  or  five  small  meals  a  day  than  two  or  three  hearty 
ones,  and  the  greatest  possible  care  should  be  taken  that  foods  which  are  prone  to 
produce  gaseous  distention  of  the  stomach  and  bowels  are  avoided.  Fatty  sub- 
stances are  very  apt  to  produce  such  symptoms,  as  are  also  the  starches,  when  they 
remain  in  the  stomach  undigested  for  a  considerable  period  of  time.  This,  however, 
can  be  put  aside  in  the  case  of  the  starches  by  the  use  of  taka-diastase  or  pancreatin 
and  by  the  use  of  powdered  capsicum,  either  in  pill  or  upon  the  food,  for  the  purpose 
of  stimulating  the  gastric  mucous  membrane,  which  is  often  atonic  or  catarrhal 
as  a  result  of  the  impaired  hepatic  circulation. 


DISORDERS  OF  CARDIAC  ACTION  NOT  DUE  TO  VALVULAR  LESIONS. 

Neuroses. — Definition. — By  neuroses  of  the  heart  it  is  meant  to  include  a 
number  of  conditions  widely  separated  in  their  actual  causes,  but  depending  upon 
a  disorder  of  the  nerve  supply  of  this  organ,  so  that,  without  there  being  necessarily 
present  any  grave  lesions,  its  functional  activity  is  impaired  or  perverted. 

Palpitation. — Palpitation  of  the  heart  may  be  due  to  any  of  the  vahular  or  other 
lesions  that  cause  the  heart  to  beat  rapidly  or  irregularly  when  the  individual  takes 
exercise.  In  other  cases  it  arises  from  the  accumulation  of  gas  in  the  stomach  or 
colon,  which  by  its  pressure  causes  cardiac  disturbance.  In  other  instances  it  is 
due  to  intense  nervous  erethism,  and  in  still  others  it  arises  from  the  excessive  use 
of  tobacco,  or  of  coffee  or  tea.  So,  too,  sudden  nervous  shock  may  cause  repeated 
attacks  of  this  character.  Probably  the  most  frequent  cause  of  cardiac  palpitation 
is  not  connected  with  the  nerves  supplying  the  heart,  but  is  due  to  irregularities 
in  the  nervous  control  of  the  vasomotor  system,  whereby  the  tension  of  the  vessels 
is  relaxed  and  as  a  result  the  heart  beats  rapidly  because  the  ordinary  pressure 
in  the  arteries  is  suddenly  removed.  It  is  remarkable  how  cases  of  palpitation 
get  well  if  attention  is  paid  to  the  state  of  the  bloodvessels  rather  than  the  heart. 
The  so-called  "irritable  heart  of  soldiers,"  first  described  by  J.  M.  Da  Costa,  is  due 
in  all  probability  to  this  cause  as  well  as  to  the  imperfect  action  of  the  vagus. 
Associated  with  the  disordered  cardiac  action  it  will  often  be  found  that  the  periph- 
eral capillaries  suddenly  become  dilated,  so  that  the  blood  can  flow  more  rapidly 
than  normal  into  them.  Profuse  diuresis,  in  which  the  urine  is  found  to  be  pale 
and  clear,  shows  that  a  similar  relaxation  of  the  renal  vessels  has  ensued.  These 
symptoms  often  cause  the  patient  great  alarm  and  bring  him  at  once  to  the  physician 
with  the  statement  that  heart  disease  is  feared.  It  is  usually  the  case  that  a  patient 
who  says  he  has  heart  disease  has  only  a  neurosis,  unless  some  physician  has  found 
a  real  lesion  and  told  him  of  its  existence. 

Tachycardia. — Many  cases  of  neurosis  are  closely  allied,  if  not  identical,  with 
that  condition  of  rapid  heart  called  tachycardia.  This  may  be  due  to  vasomotor 
palsy,  to  a  deficient  action  of  the  vagus  nerves,  or  to  some  central  nervous  lesion. 
(The  tachycardia  of  exophthalmic  goitre  is  not  considered  here.) 

Such  attacks  occur  in  young  hysterical  women  and  are  called  "pseudo-angina," 
because  a  sense  of  cardiac  expansion  is  often  present  with  the  rapid  beating  of 
the  heart.  They  also  appear  in  women  near  the  menopause,  and  in  men  who 
have  been  guilty  of  excessive  sexual  abuse.  A  few  cases  in  men  are  apparently 
due  to  some  organic  nervous  lesion.  The  pulse  may  rise  as  high  as  220.  The 
tachycardia  may  be  paroxysmal  or  continuous.  In  a  case  under  my  care  in  1890, 
a  woman  who  had  seen  her  husband  and  sons  drowned  in  the  great  Johnstown 
flood,  and  had  been  swept  from  the  roof  of  her  floating  cottage,  presented  a  pulse 


488  DISEAS[':S  OF  THE  J1E.\RT 

rate  which  was  uncountable,  it  was  so  fast.  This  jK-rsisted  for  months  and  was 
present  two  years  after  the  catastrophe. 

Rapid,  feeble  heart  sounds,  in  which  the  first  and  second  sounds  appear  alike, 
are  met  with  in  prolonged  exhausting  fevers  such  as  severe  typhoid  fever,  and  to 
this  state  is  given  the  name  "fetal  heart  sounds"  or  "embryocardia." 

Bradycardia. — Great  slowness  of  the  heart's  action  (bradycardia)  is  caused,  to 
some  extent  at  least,  by  conditions  which  are  the  antithesis  of  those  that  cause 
tachycardia.  A  sudden  or  persistent  rise  of  arterial  pressure  may  cause  a  very 
slow  pulse,  as  the  heart  endeavors  to  force  blood  through  tightly  contracted  vessels. 
This  may  be  called  vascular  bradycardia.  Again,  it  occurs  as  the  result  of  irritation 
of  the  vagus  nerves,  by  poisons  such  as  digitalis  and  opium,  or  in  chronic  lead 
poisoning,  or  again  in  cases  of  jaundice  when  the  slowing  is  due  to  the  biliary  salts 
in  the  blood.  It  is  also  met  with  in  cases  of  cerebral  hemorrhage,  cerebral  tumor, 
and  in  the  coma  following  epilepsy. 

A  pulse  below  60,  or  even  as  low  as  40,  is  sometimes  felt  after  a  woman  has  given 
birth  to  a  child.     (Plates  VIII,  IX,  and  X.) 

Occasionally  cases  are  met  with  in  which  the  bradycardia  becomes  extraordinary. 
The  late  D.  W.  Prentiss  reported  to  the  Association  of  American  Physicians  in 
1889,  1890,  and  1891  the  case  of  a  man  whose  pulse  at  times  fell  to  11  per  minute 
and  rarely  rose  over  40  per  minute  for  two  years.  In  this  case  no  very  distinct 
morbid  lesions  were  found  at  autopsy,  although  the  patient  died  suddenly  in  an 
attack.     (See  Stokes-Adams  Disease  and  Arrhythmia.) 

Arrhythmia. — This  is  very  commonly  met  with  in  persons  who  ha\'e  taken  ex- 
cessive doses  of  digitalis,  and  it  is  also  a  common  symptom  in  mitral  stenosis  with 
ruptured  compensation.  The  so-called  gallop  rhythm  may  appear  in  these  cases. 
(See  Mitral  Stenosis.) 

Modern  studies  of  the  physiology  of  the  heart  must  be  understood  when  cases 
of  arrhythmia  are  observed.  It  is  to  be  remembered  that  the  contractility  of  the 
heart  muscle  is  inherent,  that  is  to  say,  the  muscle  contracts  by  virtue  of  its  own 
properties  and  not  as  the  result  of  a  direct  nervous  impulse,  as  do  other  muscles. 
It  must  also  be  recalled  that  the  contraction  wave  starts  in  the  sino-auricular  node 
which  exists  near  the  orifice  of  the  coronary  sinus  in  the  right  auricle,  passes  over 
the  auricular  wall  to  Tawara's  node,  and  thence  by  the  bundle  of  His,  which  mus- 
cular band  or  bundle  crosses  the  auriculoventricular  junction,  splitting  into  two 
bands,  one  for  each  ventricle.  By  this  means  the  impulse  passes  to  the  muscle 
cells  of  the  ventricles  and  the  musculi  papillares  (Fig.  91).  Although  this  con- 
traction wave  is  myogenic  in  origin  it  is  of  course  influenced  bj'  extraneous  causes, 
chiefly  nervous,  and  by  the  contents  and  heat  of  the  blood  passing  through  the 
cavities  of  the  heart.  The  auricles  and  ventricles  can,  however,  originate  con- 
traction waves  independent  of  one  another  and  such  inco-ordination  is  one  of  the 
chief  causes  of  arrhythmia.  During  systole  the  conductivity,  contractility,  and 
irritability  of  the  heart  are  abolished,  but  they  are  restored  during  diastole. 

In  some  cases  of  arrhythmia  auscultation  will  reveal  a  normal  first  and  second 
sound  followed  closely  by  another  first  sound  less  well  marked  and  by  a  second 
sound  which  is  very  feeble,  or  it  may  be  inaudible.  This  is  called  an  extrasystole. 
The  beat  is  a  feeble  one  because  the  heart  muscle  has  not  had  time  to  have  its 
vital  properties  restored.  After  this  abortive  extrasystole  there  is  a  longer  pause 
than  is  common  and  then  the  heart,  having  had  a  long  period  of  recuperation,  gives 
a  very  forcible  beat  which  often  alarms  the  patient.  The  delay  in  the  development 
of  this  powerful  systole  is  not  due  to  exliaustion  of  the  ventricle  by  reason  of  the 
first  systole  but  because  of  the  extrasystole  which  renders  the  muscle  refractory  to 
stimulation,  and  as  a  result  the  ordinary  contraction  wave  passing  over  the  auricu- 
loventricular bundle  is  unable  to  cause  contraction  of  the  ventricle.  The  response 
to  one  normal  sino-auricular  impulse  is  therefore  entirely  missed   and   the  long 


DISORDERS  OF  CARDIAC  ACTION  NOT  DUE  TO  VALVULAR  LESIONS     489 

pause  permits  the  ventricle  to  recover  its  contractility  and  to  accumulate  a 
large  amount  of  blood.  The  sequence  is  therefore  a  forcible  systole,  an  extrasystole 
arising  in  the  node  of  Tawara  or  in  the  wall  of  the  ventricle,  a  sino-auricular 
impulse  at  the  time  for  the  next  regular  systole,  which  accomplishes  nothing,  and 
then  a  regular  systole  normal  as  to  time,  but  more  forcible  than  usual,  because  of 
long  recuperation  (Fig.  91).     This  regular  systole  may  occur  slightly  before  it 


^.^:;'-> 


Centres  of  ventricular 
contraction 


Tawara's  node 
His'  bundle 


Centres  of  ventricular  contraction 


Right  side  of  the  heart  showing  diagrammatically  the  distribution  of  the  two  vagus  nerves  to  different 
parts  of  the  viscus.  The  impulse  to  contraction  originates  at  the  sino-auricular  node  and  passes  over 
the  wall  of  the  auricle  to  Tawara's  node,  and  thence  over  His'  bundle  across  the  auricuioventricular 
septuip  to  be  distributed  throughout  the  ventricular  wall.  If  the  upper,  sino-auricular,  node  is  dam- 
aged, or  if  its  impulses  fail  to  get  across  the  wall  of  the  auricle,  Tawara's  node  acts  in  its  place  to 
start  off  the  ventricle.  If  a  lesion  at  the  base  of  the  mesial  segment  of  the  tricuspid  valve  damages 
His'  bundle,  so  that  Tawara's  node  is  cut  off  from  the  ventricle,  then  the  ventricle  may  originate  its 
own  impulses  to  contraction. 


would  have  taken  place  in  a  perfect  rhythm,  because  the  irritability  of  the  muscle 
has  been  increased  by  the  missing  of  its  normal  rhythmic  contraction.  Extra- 
systole  may  arise  from  a  number  of  causes  widely  different  in  origin.  In  one  case 
the  condition  is  apparently  a  purely  functional  disorder  which  lasts  for  years,  the 
patient  seeming  to  be  in  perfect  health  and  the  contractions  of  the  heart  being 
irregular  because  the  vagus  is  irritable.     Another  case  depends  upon  the  absorption 


490  DISEASES  OF  THE  HEART 

from  the  alimentary  canal  of  certain  toxic  matters  whicli  entering  the  Ijlood  afl'eets 
tlie  heart  as  do  certain  drngs.  A  third  case  is  more  grave,  in  that  tiic  irreguhirit\- 
arises  from  a  toxemia  (hie  to  one  of  the  infectious  diseases  whicii  may  result  in  i)ureiy 
functional  disorder  or  give  rise  to  morbid  ciianges  in  tlie  bundle  of  His  or  elsewhere 
in  the  heart  muscle.  In  the  aged  there  may  be  irregularity  due  to  organic  disease 
or  irritable  vagus.  Lastly,  arrhythmia  may  be  due  to  myocardial  degeneration 
often  associated  with  syphilis,  nephritis  or  arteriocapillary  fibrosis.  (Plates  VIII, 
IX,  and  X.) 

In  still  another  type  of  cardiac  disturbance  the  systoles  are  normal  as  to  rhythm, 
but  irregular  as  to  force,  each  alternate  systole  being  less  forcible  than  the  other. 
This  gives  rise  to  the  so-called  pulsus  alternans. 

It  is  notable  that  Tawara  in  examining  112  hearts  postmortem  in  cases  in  which 
arrhythmia  had  been  present  during  life  found  no  lesions  that  could  have  been  re- 
sponsible for  the  symptoms  which  had  been  present. 

Treatment  of  Cardiac  Disorders. — In  the  treatment  of  the  various  cardiac  neuroses 
it  is  essential  that  the  physician  shall  first  determine  what  portion  of  the  circulatory 
system  is  chiefly  affected  by  disordered  innervation.  Not  infrequently,  however, 
it  will  be  found  that  both  the  heart  and  vasomotor  system  are  out  of  order,  and 
therefore  the  treatment  will  have  to  be  devoted  to  regulating  the  nerve  supply 
of  the  functions  of  both  of  these  important  vascular  areas. 

When  it  is  believed  that  attacks  of  tachycardia  have  their  origin  in  a  condition 
in  which  the  pneumogastric  nerves  fail  to  control  the  action  of  the  heart,  digitalis 
is,  of  course,  a  valuable  remedy  in  that  it  exercises  a  powerful  stimulating  influence 
upon  the  pneumogastric  nerves.  In  some  instances,  however,  the  action  of  the 
heart  is  already  sufficiently  vigorous  and  the  administration  of  digitalis,  while 
stimulating  the  pneumogastric  nerves,  also  stimulates  the  heart  to  sucli  an  excessive 
degree  that  its  action  becomes  too  violent.  Under  these  circmnstances  it  is  wtU 
to  combine  with  the  digitalis  a  little  aconite,  which  drug  also  stimulates  the  pneumo- 
gastric nerves,  and  thereby  aids  the  digitalis  in  controlling  the  heart,  and  at  tlie 
same  time  combats  the  influence  of  the  digitalis  upon  the  heart  muscle  itself, 
thereby  preventing  overstimulation.  A  prescription  made  up  as  follows  will  often 
be  of  advantage,  the  quantities  of  the  ingredients  being  varied  to  suit  the  needs  of 
the  individual  case: 

I^ — Tinot.  digitalis  (physiologically  tested) f  5j       (  4.0)  _ 

Tinct.  aconiti f  5j       (  4.0)  ' 

Tinot.  belladonna; f  oiij    (12.0) 

Tinct.  cardamom,  comp q.  s.  ad     f  Siij. 

A  teaspoonful  to  a  dessertspoonful  three  or  four  times  a  day. 

The  efficiency  of  this  prescription  may  be  increased  by  the  application  of  a  bella- 
donna plaster  over  the  lieart. 

When  by  the  use  of  the  sphygmocardiograph  it  is  found  that  there  is  obstruc- 
tion to  the  passage  of  the  impulse  over  the  bundle  of  His  large  doses  of  atropine 
are  very  useful.  When  extrasystoles  occur  digitalis  by  diminishing  the  activity  of 
Tawara's  node  and  His's  bundle  may  do  good  (Fig.  91).     (Plate  VII.) 

In  those  cases  in  which  the  cardiac  irregularity  depends  chiefly  upon  alternate 
spasm  and  relaxation  of  the  bloodvessels,  so  that  they  are  at  one  moment  offering 
too  much  resistance  and  at  another  too  little  resistance  to  the  flow  of  blood,  much 
benefit  can  be  produced  by  hydrotherapeutic  measures,  such  as  directing  that  the 
patient  shall  take  an  alternate  hot  and  cold  sponging  in  the  morning  on  getting 
up;  first,  drenching  himself  with  a  sponge  dipped  in  as  hot  water  as  he  can  bear, 
and  next  drenching  himself  with  a  sponge  dipped  in  cold  water.  In  tliis  way  he 
does  not  become  chilled,  but  the  elasticity  and  tone  of  the  bloodvessels  is  much 
improved.  The  prescription  just  recommended  is  also  beneficial  in  many  of  these 
cases,  and  not  infrequently  moderate  doses  of  tincture  of  nux  \(>niica  arc  ailvan- 


■a  8 
.2  o 


be  O 


3-2  3 

>   C3 


CSt;    >-^    SS    ^^ 

*  g  E-,„^  >  o  J5 


JISsKI 

?    o"?    1    5='C".S~ 

E,"-  =  o_-  Aa-s 

5^      o  "-s  o 
m  9  o  ^ii  *^  t,      J3 

_o  ^  ^jn        jjt^  ^ 

>■■■§  S.S  =1  S  a 

^  l:25-si5=5-s 

'^  oi3^-S  S-=  to 

-w               Cl3   ^   3   <D 

0) 

0 

01 

^i^'S'^"  SSI'S 

>> 

tfl 

m 

feHc-gE|.c^ 

-poo  o^  -t;  3-n^ 

SSo  -^  d  m  gT3 

^ 

3«-§>.^-S='^ 

bD  ty  S^  C-^  -^i 

o— :^oOc3m 

1 

.5 

■3 

(S 
o 
>> 
■0 
03 

ffl 

-^                            n-,     ^    ^'*^ 

g-g  o-g-2:g  ty^ 

f^  -^    H    C3    n-,    C    £2 

to  S5  S  3  HH-  3  5  '-^^ 

'^'^fZso'^^ 

"3  ^-2:5^      c  ,^ 

1=2  ^'^"^gSi- 

■^„&o-"fc.o 

O"^^   MI'S   ^   »3.S 

aDS"l.S«3  §-2 

■5  g.s  g^  a  §  g 

g-s  §  &  0--  s  2 

•^  ^  H^j:  ^  o  a 

«c„S*^ScD5b-„ 

^|i:-so^:| 

•5  s  S  3  I,      ag 

«  >  ^;3  j:  o       3-3 

X 

< 


f--^  ;*.  tf  =  _2  _>-,j 


.S-=  g  S  rt  '-^g'S'S 
^S  '^  "^  V  cla  e  60 


5P 
013  ^ 

J  c'aS  "-o  ^  fs  S 
3--.H  o-f  e)  cj  0  g 


i  >>S 


:2     ii^aj 


oS  g 
^-g  °  C.^  g-g  t„'K 

?? «,3   ,  s?  g  c  o 


bO 


5^ 

.S  *=" 

&  s  s 


■"  ="  ?  c_  s  uiag-2 

C3    5 


I    OO' 


1  =3  'S  -  ^ 


>j= 


15  o 


J   ^  r^    - 


m:: 


■^  g  o  ?3'o  ^--Sfg'P  c 
g  9  S  £^  oi  S;S  § 

>>a3-p  c3  a  ■?  C  c  M  2 


ANGINA  PECTORIS  491 

tageous.  When  the  disorder  depends  upon  the  excessive  use  of  tobacco,  this  drug 
must,  of  course,  be  prohibited;  and  if  the  patient  is  overworiied,  and  suft'ering  from 
nervous  strain,  he  must  be  sent  away  on  a  vacation;  or,  if  his  condition  is  grave, 
be  given  a  "rest  cure."  When  a  disordered  circulation  is  associated  with  pain 
in  the  neighborhood  of  the  heart,  small  doses  of  antipyrin,  2  to  3  grains,  are  often 
useful;  and  if  the  tension  is  high,  nitroglycerin  should  be  given. 

ANGINA  PECTORIS. 

Definition. — By  angina  pectoris  is  meant  a  condition  in  which  a  patient,  usually 
in  or  past  middle  life,  is  seized  by  a  severe,  agonizing  pain  in  the  cardiac  area, 
which  extends  in  most  cases  down  the  left  arm  even  to  the  wrist,  and  suffers  from 
intense  mental  anxiety  and  a  sense  of  impending  dissolution.  It  is  important 
that  pseudo-angina  be  not  confused  with  it.     (See  Aortitis.) 

Etiology  and  Pathology. — The  cause  of  true  angina  pectoris  is  usually  athero- 
matous change  in  the  coronary  arteries,  although  this  is  by  no  means  always  the 
case.  Thus,  Potain  found  stenosis  of  both  coronary  arteries  in  20  out  of  45  cases 
at  autopsy,  and  Huchard  in  38  out  of  70  cases.  It  is  distinctly  a  disease  of  the  brain- 
worker  rather  than  of  the  man  who  gains  his  bread  by  manual  labor.  The  laborer 
and  artisan  present  to  us  very  commonly  the  most  surprising  degenerative  changes 
in  their  arteries  in  the  way  of  calcification  of  their  radials  and  temporals,  but  they 
rarely  have  true  angina.  On  the  other  hand,  the  man  who  is  subjected  to  nervous 
strain  rarely  shows  extraordinary  calcareous  changes,  but  he  is  the  unfortunate 
victim  of  this  terrible  malady.  Physicians  are  peculiarly  prone  to  it.  The  number 
of  deaths  among  the  leaders  of  the  profession  in  Philadelphia  during  the  last  two  de- 
cades from  this  cause  is  extraordinary.  Mental  strain  with  a  sedentary  life  are,  there- 
fore, causes.  Gout,  syphilis,  and  renal  disease  are  also  causes.  The  disease  affects 
men  much  oftener  than  women.  Out  of  65  cases  collected  by  me  only  4  occurred 
in  women,  and  out  of  290  cases  collected  by  Forbes,  Huchard,  and  Lartigue  only 
47  occurred  in  women.  Aside  from  the  narrowed  and  thickened  coronary  arteries 
and  the  fibroid  changes  in  the  heart  which  result  from  their  state,  there  are  no 
characteristic  lesions  of  true  angina  pectoris.  Among  the  exciting  causes  of  an 
attack  are  to  be  named  nervous  wear  and  tear,  anger,  or  muscular  exertion,  par- 
ticularly if  it  be  made  in  the  face  of  a  cold  wind,  which  contracts  the  capillaries 
and  so  increases  still  more  the  labor  of  the  heart.  So,  too,  errors  in  diet,  by  causing 
gastric  disorder,  may  reflexly  cause  an  attack. 

Sir  Douglas  Powell  and  Merklen  give  the  age  incidence  for  true  angina  at  twenty 
to  forty  years.     This  is  probably  too  young.     The  actual  age  is  forty  to  sixty  years. 

Symptoms. — When  angina  pectoris  is  well  developed  there  is  no  sj-mptom-complex 
so  characteristic  and  dramatic.  Seized  on  a  sudden  or  with  but  a  few  moments' 
warning,  the  patient  stands  or  siU  transfixed  with  pain  and  fear.  It  is  difficult 
to  tell  whether  his  arrested  respiration  is  controlled  by  the  disease  or  his  own  will- 
power. The  sense  of  dissolution  or  of  impending  death  is  so  real  that  the  patient 
expresses  the  belief  that  death  is  at  hand,  if  he  can  find  breath  to  speak.  The 
expression  of  the  face  is  one  of  intense  anxiety  or  horror,  the  skin  is  pallid  to  the 
degree  of  cadaveric  hue,  and  the  brow  is  marble  white  and  perhaps  bedewed  with 
sweat  as  the  attack  advances.  The  pulse  during  an  attack  is  usually  slow,  sviall, 
and  very  tense,  becoming  feebler  and  more  relaxed  as  the  paroxysm  passes  away. 
The  pain  is  often  beyond  the  patient's  power  of  description  after  his  recovery, 
both  as  to  severity  and  character.  Some  patients  say  that  the  heart  feels  as  if  it 
were  being  crushed  in  a  vise;  others  that  a  huge  stone  is  crushing  the  chest  wall; 
others  that  a  heavy  bar  of  steel  is  laid  across  the  thorax.  At  times  the  pain  riot 
only  extends  down  the  left  arm  to  the  fingers,  but  to  the  right  arm  as  well.  As 
the  attack  passes  oft'  the  patient's  expression  of  keen  suft'ering  is  modified.     A  flush 


492  DISEASES  OF  rilE  HEAh'T 

may  supplant  the  pallor  and  a  sigh  reveals  that  the  seizure  has  passed.  At  this 
time  the  patient  not  rarely  belches  up  large  volumes  of  gas,  and  this  seems  to  give 
much  relief.  It  is  this  which  gives  rise  to  the  euphemistic  diagnosis  of  "acute 
indigestion"  in  some  of  these  cases.  Sometimes  more  than  one  attack  may  occur 
in  an  hour,  but  this  is  rare. 

Modified  forms  of  severe  angina  are  constantly  met  with  in  which  the  pain 
is  not  so  severe  as  in  the  cases  just  described.  The  degree  of  modification  may  be 
so  great  that  little  or  no  pain  is  felt,  this  form  being  called  angina  pectoris  sine  dohrc. 

Diagnosis. — When  angina  pectoris  presents  itself  in  its  well-developed  form, 
there  cannot  be  much  doubt  as  to  its  true  character.  The  question  of  the  character 
of  an  attack  is,  however,  often  in  doubt  when  the  symptoms  are  not  all  present. 
While  it  is  a  rule  that  valvular  disease  of  the  heart  rarely  causes  pain,  it  is  a  fact 
that  attacks  of  anginoid  pain  are  occasionally  met  with  in  cases  of  aortic  regurgita- 
tion, particularly  if  dilatation  of  the  heart  is  marked.  This  state  can  be  determined 
by  the  diastolic  murmur  and  the  "Corrigan  pulse."  Again,  aortitis  may  cause 
symptoms  practically  identical  with  those  of  true  angina,  and  it  may  be  impossible 
to  separate  the  disease  of  the  aorta  from  that  of  the  coronary  arteries  because  the 
lesion  spreads  from  the  aorta  to  the  openings  of  these  vessels.  That  is  the  angina 
may  be  due  to  aortitis. 

It  is  of  some  importance  to  differentiate  the  angina  pectoris  due  to  ordinary 
coronary  sclerosis  and  secondary  myocardial  change  from  that  due  to  syphilis. 
This  is  probably  impossible  by  the  physical  signs  in  the  circulation,  but  can  be 
made  if  a  history  of  late  syphilis  can  be  obtained,  or  if  the  patient  is  prematurely 
aged  or  if  he  gi\'es  a  Wassermann  or  Ruelin  reaction.  AMiile  these  changes,  when 
due  to  syphilis,  cannot  be  treated  as  successfully  as  can  secondary  syphilis,  for  they 
are  of  the  nature  of  late  syphilitic  affections,  more  aid  can  be  given  by  the  use  of  the 
iodides  of  mercury  and  salvarsan  than  in  those  cases  which  present  changes  in  the 
coronary  arteries  from  other  causes. 

A  form  of  pseudo-angina  is  occasionally  seen  in  ner\'ous  women  and  in  men 
who  resort  to  wine,  tobacco,  and  women  to  excess.  It  differs  from  true  angina 
pectoris  in  the  facts  that  the  man  is  usually  under  thirty  years  rather  than  over 
forty  years  of  age;  his  vessels  are  usually  in  fair  condition;  there  is  a  history  of 
neurosis  or  excessive  venery  and  of  the  excessive  use  of  tobacco,  and  the  sensation 
al)out  the  heart  is  that  of  distention  instead  of  constriction. 

Prognosis. — From  what  has  been  said  as  to  the  state  of  the  vessels  and  the  heart 
muscle  in  true  angina  pectoris  it  must  be  evident  that  the  prognosis  is  most  grave, 
for  death  may  ensue  in  any  attack  and  an  attack  may  come  on  at  any  time.  On 
the  other  hand,  patients  sometimes  go  long  periods  without  a  fatal  attack,  partic- 
ularly if  the  mode  of  life  can  be  quiet  and  the  pulse  tension  can  be  reduced  by  the 
iodides  and  nitroglycerin.  Much  depends  in  prognosis  upon  the  degree  of  vascular 
and  myocardial  change  which  can  be  found.  In  many  of  these  cases  the  feeble  first 
sound  shows  how  weak  and  dilated  the  ventricles  have  become. 

Treatment. — The  treatment  of  angina  pectoris  may  be  divided  into  that  which  is 
de\otcd  to  the  improvement  of  the  circulatory  condition  with  the  object  of  pre- 
venting paroxysms  of  the  disease,  and  to  that  which  is  devoted  to  the  relief  of  the 
patient  during  the  paroxysm.  As  the  treatment  of  a  paroxysm  requires  very  active 
procedures,  it  will  be  considered  first.  If  seen  as  a  paroxysm  is  commencing,  the 
patient  should  inhale  from  3  to  5  minims  of  nitrite  of  amyl,  or  if  this  drug  is  not  at 
hand  a  few  whift's  of  chloroform  should  be  used.  Nitroglycerin  should  also  be 
given  hypodermically  in  the  dose  of  y ', „-  or  even  ^V  of  a  grain.  If  the  patient  has 
become  accustomed  to  this  remedy,  larger  doses  are  indicated.  Sometimes  it  is 
advantageous  to  give  simultaneously  with  the  nitroglycerin  j  of  a  grain  of  morphine; 
but  in  those  cases  in  which  the  paroxysm  is  not  of  long  duration,  the  attack  com- 
monlj-  passes  away  before  the  morphine  has  an  opportunity  to  exercise  its  pain- 


ANGINA  PECTORIS  493 

relieving  influences.  If  the  patient  can  swallow,  a  very  useful  remedy  is  1  or  2 
drachms  of  Hoffmann's  anodyne  given  in  a  little  cracked  ice  and  water;  or,  if 
this  is  not  at  hand,  §  to  1  drachm  of  spirit  of  chloroform  may  be  given  in  a  similar 
manner.  The  employment  of  nitrite  of  amyl,  nitroglycerin,  and  chloroform  is 
useful  in  direct  proportion  to  the  degree  of  arterial  spasm  which  is  present.  In 
that  somewhat  unusual  class  of  cases  in  which  attacks  of  angina  occur  with  a  state 
of  low  arterial  tension,  these  drugs,  manifestly,  cannot  be  of  the  same  value  as  in 
those  patients  in  which  the  systemic  arteries  are  tightly  contracted.  Should  the 
patient  be  seen  in  a  paroxysm  and  the  physician  possesses  none  of  the  remedies 
just  named  for  his  relief,  a  drink  of  hot  water,  containing  some  capsicum,  or  some 
brandy,  may  be  given,  since  this  not  infrequently  causes  the  belching  up  of  a 
considerable  quantity  of  gas  followed  by  some  degree  of  relief  to  the  patient. 

The  treatment  between  the  paroxysms  is  dietetic,  hygienic,  and  medicinal. 

The  patient  must  take  a  sufficient  quantity  of  food  for  the  purpose  of  maintaining 
his  nutrition,  and  must  be  forbidden  to  eat  anything  more  than  is  absolutely  neces- 
sary for  this  purpose.  Sweet  and  fatty  articles  of  diet  should  be  entirely  avoided, 
as  should  be  champagne  and  all  sweet  wines.  If  any  alcoholic  stimulant  is  required, 
Scotch  or  rye  whiskey,  or  a  dry  gin  with  lime-juice  and  sparkling  water  should  be 
ordered.  There  is  no  objection  to  the  diet  being  largely  one  of  meat,  if  the  kidneys 
are  in  a  fairly  healthy  state;  the  more  so,  as  starchy  foods  are  prone  to  cause  the 
formation  of  gas  in  the  stomach  and  bowels,  which  may  reflexly  upset  the  cardiac 
balance  and  precipitate  an  attack. 

As  distention  in  the  stomach  sometimes  causes  an  attack,  it  is  often  necessary 
to  feed  the  patient  with  small  quantities  of  food  four  or  five  times  a  day  rather 
than  to  permit  him  to  eat  two  or  three  hearty  meals. 

The  hygienic  treatment  consists  in  having  the  patient  take  as  much  sunshhie 
and  fresh  air  as  possible;  in  forbidding  him  to  expose  himself  to  blustermg  winds, 
and  to  warn  him  that  if  his  peripheral  circulation  is  chilled  the  consequent  contrac- 
tion of  his  capillaries  may  result  in  an  attack  of  heart  pang.  Flannel  should  be 
worn  next  the  skin  both  winter  and  summer.  Sudden  effort,  as  going  up  stairs 
rapidly  or  running  for  a  car,  or  entering  into  any  heated  debate,  either  in  court  or 
in  a  business  argument,  should  be  avoided. 

Care  must  be  taken  that  the  bowels  do  not  become  overloaded  with  feces,  and 
that  they  be  moved  every  day  by  some  vegetable  laxative  or  one  of  the  mild  saline 
waters. 

The  medicinal  treatment  consists  in  the  administration  of  iodides  in  as  large 
doses  as  the  patient  can  readily  bear  without  danger  of  disordering  his  digestion. 
If  there  is  a  history  of  sj^jhilis  in  the  case,  larger  doses  are  needed  than  if  the  history 
is  not  specific.  The  patient  should  take  at  least  60  grains  a  day  of  the  iodide  of 
sodium  or  iodide  of  strontium  if  possible,  divided  into  four  doses,  which  should  be 
taken  one  hour  after  food.  In  some  cases  syrup  of  hydriodic  acid,  in  the  dose  of 
2  to  4  drachms  three  or  four  times  a  day,  maj'  be  given  with  advantage,  well  diluted 
with  water.  The  iodides  under  these  circiunstances  lower  arterial  tension  and  do 
whatever  can  be  done  toward  arresting  the  process  of  fibroid  overgrowth  in  the 
bloodvessels.  The  patient  will  also  be  much  benefited  if  he  receives  nitrite  of 
sodium  in  the  dose  of  1  grain  four  or  five  times  tlirough  the  twenty-four  hours,  the 
dose  being  controlled,  not  by  the  number  of  doses  administered,  but  by  the  effects 
which  it  produces  upon  arterial  tension.  In  some  instances  it  is  wise  to  alternate 
the  nitrite  and  iodide.  If  the  heart  muscle  is  very  feeble,  full  doses  of  nux  vomica, 
10  or  20  drops  of  the  tincture,  or  moderate  doses  of  digitalis — say,  5  minims  of  the 
tincture — may  be  given  three  times  a  day.  The  patient  should  be  instructed  to 
carry  glass  pearls  of  nitrate  of  amyl  in  his  pocket  and  to  crush  one  and  inhale  its 
contents  if  at  any  time  he  feels  threatened  by  an  attack. 

Symptoms  of  gastro-intestinal  dyspepsia  are  to  be  relieved  not  only  by  regulating 


494  DISEASES  OF  THE  HEART 

the  diet  in  the  way  indicated,  l)ut  by  the  use  of  pancreatin  and  taka-diastase  to 
aid  digestion.  A  very  useful  capsule  under  these  circumstances  is  one  which  con- 
tains 2  grains  of  taka-diastase,  2  grains  of  pancreatin,  1  grain  of  capsicum,  and  | 
grain  of  extract  of  nux  vomica.  This  shoiild  be  taken  thrice  daily.  Donovan's 
solution  is  often  useful. 

CONGENITAL  CARDIAC  DEFECTS. 

Two  abnormal  conditions  may  arise  in  the  lieart  of  the  ffctus  and  persist  after 
birth,  namely,  defects  of  development  and  defects  produced  by  an  attack  of  endo- 
carditis. In  some  instances  the  endocarditis  is  responsible  for  the  defect  in  develop- 
ment. The  most  common  of  these  defects  is  the  persistence  of  the  foramen  ovale, 
which  permits  the  blood  to  make  a  short  circuit  through  the  interauricular  septum 
instead  of  passing  into  the  right  ventricle  and  thence  through  the  lungs.  Some- 
times this  opening  is  partly  guarded  by  a  membrane,  but  in  other  cases  no  such 
membrane  is  present.  If  the  opening  is  large  and  entirely  unguarded  by  a  mem- 
brane the  patient  is  apt  to  present  intense  cyanosis,  particularly  if  any  efi'ort  is 
made;  but  in  some  cases  the  defect  does  not  produce  this  symptom  and  the  patient 
lives  to  adult  j'ears,  no  one  suspecting  the  presence  of  such  a  defect,  the  existence 
of  which  is  revealed  only  at  autopsy.  Thus,  my  colleague,  Coplin,  made  an  autopsy 
upon  a  woman,  dead  of  croupous  pneiunonia.  During  her  life  and  in  her  final 
illness  there  were  no  signs  of  cardiac  disease,  but  at  the  autopsy  a  twenty-five-cent 
piece  could  be  dropped  flatwise  through  the  foramen  ovale.  More  or  less  oblique 
communications  between  right  and  left  auricles  are  present  in  about  2  to  5  per 
cent,  of  adult  hearts. 

A  very  rare  congenital  defect  is  a  patent  ductus  arteriosis  whicli  produces  no 
definite  symptoms,  save  that  it  is  sometimes  associated  with  stunted  development, 
but  definite  physical  signs,  namely  a  distinct  thrill  and  pulsation  in  the  second 
left  interspace  close  to  the  sternum  with  a  loud,  rasping,  prolonged,  humming-top 
murmur  extending  all  over  the  precordium,  to  the  vessels  of  the  neck,  to  the  scapula, 
and  along  the  vertebral  column.     The  second  pulmonic  sound  is  also  accentuated. 

A  much  more  rare  condition  is  that  in  which  there  is  an  absence  of  the  septiun 
between  the  right  and  left  sides  of  the  heart,  and  as  a  result  "bilocular  heart"  is 
present.  In  others  again  the  absence  of  an  interventricular  septum  produces  a 
"trilocular  heart."  At  times  a  condition  is  met  with  in  which  a  perforation  exists 
in  the  upper  part  of  the  ventricular  septum,  in  the  so-called  "  undefended  space." 
A  perforated  interventricular  septum  is  characterized  by  a  systolic  murmur  and 
an  absence  of  marked  cyanosis. 

Stenosis  of  the  right  conus  arteriosus,  of  the  pulmonary  artery,  and  of  the  pul- 
monary orifice  are  often  associated,  and  form  a  large  proportion  of  the  congenital 
lesions  seen  at  autopsy  in  persons  who  have  suffered  from  these  defects,  but  lived 
for  years.  It  is  a  noteworthy  fact  that  these  lesions  are  not  rarely  complicated 
by  a  patulous  interventricular  septum,  an  open  foramen  ovale,  and  an  open  ductus 
arteriosus.  Considerable  hypertrophy  of  the  right  ventricle  is  naturally  found  in 
these  cases  if  life  is  prolonged.  Congenital  pulmonary  stenosis  when  severe  enough 
to  produce  marked  circulatory  disorder  in  early  infancy  is  characterized  by  cyanosis 
and  enlargement  of  the  area  of  cardiac  dullness  and  often  a  well-marked  thrill  on 
palpation. 

Valvular  anomalies  also  occur.  The  three  aortic  semilunar  valves  may  be 
replaced  by  two  leaflets.  This  state  while  not  at  all  incompatible  with  life  is, 
nevertheless,  prone  to  become  grave,  in  that  the  semilunar  valves  usually  become 
thickened  and  distorted.  The  pulmonary  valves  are  much  more  rarely  abnormal, 
and  the  valves  protecting  the  auriculoventricular  orifices  on  both  sides  of  the  heart 
are  even  more  rarely  anomalous  from  defective  development.     These  valves  may. 


AORTITIS  495 

however,  be  the  subject  of  endocardial  disease  prior  to  birth,  and  the  result  is, 
in  one  sense,  not  very  different  from  that  met  with  in  the  heart  of  the  ordinary 
individual  who  suffers  from  rheumatic  endocarditis;  for  we  find  the  auriculoventricu- 
lar  valves  thickened  and  the  chorda;  tendinese  broadened  and  shortened  so  that  they 
interfere  with  the  free  action  of  the  valves.  That  form  of  acute  or  chronic  endo- 
carditis which  results  in  the  production  of  granular  or  warty  nodules  on  the  valves 
is  rarely  encountered  in  fetal  endocarditis. 

The  orifice  of  the  pulmonary  artery  is  very  commonly  found  to  be  in  a  state 
of  stenosis,  as  a  result  of  gluing  together  of  the  valves  and  contraction  of  the  ring 
around  the  orifice  itself.  The  agglutination  of  the  segments  may  be  so  perfectly 
accomplished  as  to  leave  a  smooth,  funnel-like  opening,  or  the  valves  may  be  rough- 
ened by  vegetations.  Patients  with  this  defect  may  live  for  years,  but  it  is  a 
curious  fact  that  they  are  very  prone  to  die  of  pulmonary  tuberculosis. 

Narrowing  of  the  aortic  orifice  is  a  rare  congenital  defect.  Malposition  or  trans- 
position of  the  heart  is  sometimes  seen.  Transposition  is  always  associated  with 
transposition  of  the  other  viscera. 

Occasionally  ectopia  cordis,  a  state  in  which  the  heart  is  not  protected  by  the 
chest-wall,  is  met  with.  The  heart  has  also  been  found  in  the  abdominal  cavity. 
Peacock  reported  one  such  case  in  a  man  of  forty-seven  years,  and  Rezek  one  in  a 
man  of  thirty-two  years.  It  is  important  to  bear  in  mind  that  congenital  cardiac 
defects  are  often  multiple. 


DISEASES  OF  THE  ARTERIES. 

The  tubes  carrying  blood  are  subject  to  many  alterations,  some  of  which  depend 
upon  changes  in  the  perivascular  tissues,  including  with  these  peri-arterial  inflam- 
mations, infection,  trauma,  etc.  The  most  important  group  of  vascular  changes, 
however,  result  from  alterations  in  stress  and  tension  under  whicli  the  circulation 
is  maintained,  and,  to  a  greater  degree,  are  the  results  of  the  irritant  action  of 
poisons  circulating  in  the  blood.  The  intravascular  irritants  may  be  bacterial 
or  of  bacterial  origin  (toxins),  unusual  quantities  of  normal  salts,  or  the  presence 
of  abnormal  compounds  that  irritate  the  endothelium. 

With  the  acute  and  subacute  inflammations  involving  the  intima  (endarteritis), 
and  the  relation  of  this  change  to  later  alterations  in  the  vessels,  we  are  at  present, 
through  the  studies  of  Thayer  and  others,  becoming  more  familiar.  The  clinical 
importance,  however,  of  these  alterations  is  not  as  yet  fully  appreciated.  Hyaline 
and  fatty  degenerative  changes  occur  in  the  intima  and  subintimal  tissues  in  a 
number  of  pathological  processes.  The  deposit  of  pigment  in  the  vessel  walls, 
infiltration  by  lime  salts  (calcification),  and  amyloid  disease  are  rarely,  if  ever, 
primary  in  the  vessels,  but  depend  upon  a  number  of  primary  conditions,  and  there- 
fore are  rarely,  if  ever,  recognized  independently  of  the  conditions  by  which  they 
are  caused.  Infections  acting  within  the  vessels  give  rise  to  proliferative  or  necrotic 
changes  in  the  endothelium  with  the  formation  of  thrombi  (thrombo-arteritis  and 
thrombophlebitis),  which,  by  mechanical  interference  of  the  circulation,  influence 
the  nutrition  of  the  organs,  or,  by  causing  embolism  and  distribution  of  infectious 
material  through  the  system  at  large,  constitute  the  basis  of  septicemia  and  pyemia 
as  already  considered. 

AORTITIS. 

Closely  allied  in  its  symptomatology  and  pathology  with  angina  pectoris  and 
arteriosclerosis  is  aortitis,  a  condition  usually  due  to  an  old  syphilitic  infection  or 


496  DISEASES  OF  THE  ARTERIES 

to  gout.  It  is  characterized  by  the  morbid  changes  descril)ed  under  Arteriosclerosis 
and  by  the  presence  of  more  or  less  constant  distress  or  gnawing  pain  under  the 
upper  sternum.  There  are  often  acute  exacerbations  of  this  pain  particularly  at 
night,  and  on  exertion  and  this  pain  may  extend  down  one  or  both  arms. 

The  treatment  consists  in  rest  and,  when  there  is  a  specific  history,  in  the  use  of 
salvarsan  and  mercury,  particularly  the  latter,  associated  with,  or  followed  by, 
iodide  of  potassiimi  in  large  doses.  If  the  general  arterial  system  is  degenerated 
the  use  of  salvarsan  must  be  cautious  or  avoided. 

ARTERIOSCLEROSIS. 

Definition. — Arteriosclerosis,  as  we  understand  it  today,  evidently  comprises 
a  number  of  pathological  processes,  the  exact  relation  of  which,  one  to  the  other, 
is  still  somewhat  uncertain.  Two  important  processes,  often,  if  not  constantly, 
associated,  are,  first,  an  affection  involving  particularly  the  smaller  arteries  (arteri- 
oles), and  commonly  termed  arteriocapillary  fibrosis;  and,  second,  a  type  of  arterial 
change  involving  particularly  the  larger  vessels  and  called  atheroma,  or,  on  account 
of  the  changes  in  the  conformation  of  the  affected  vessels,  arteritis  deformans. 
Writers  are  not  agreed  that  these  two  processes  are  independent,  for  they  are 
very  constantly  associated,  and  the  clinical  picture  embraced  under  the  term 
arteriosclerosis  includes  them  both. 

Etiology. — Certain  individuals,  and  often  whole  families,  seem  peculiarly  liable 
to  arteriosclerosis.  The  change  is  often  a  manifestation  of  age,  and  the  trite 
but  true  saying  "  that  a  man  is  as  old  as  his  vessels"  indicates  the  belief  in  premature 
aging  of  those  in  whom  arterial  change  occurs  in  early  life.  Alcohol,  and  intem- 
perance in  work  and  eating,  and  overexertion,  mental  or  physical,  are  also  causes. 
The  auto-intoxications,  lead  poisoning,  sj^jhilis,  and  gout  are  important  factors 
in  the  production  of  arterial  disease.  The  demonstration  of  the  Treponema  palUdvm 
in  aortic  lesions  has  substantiated  some  of  the  earlier  claims  as  to  the  frequency 
of  syphilitic  aortitis.  There  is  not  unanimity  of  opinion,  however,  that  sjTDhilitic 
aortitis  is  always  to  be  differentiated  anatomically  from  the  ordinary  atheroma 
or  that  the  former,  as  some  assert,  is  the  cause  of  the  great  majority  of  aneurysms 
of  the  aorta.  Certain  forms  of  chronic  interstitial  nephritis  may  precede,  accom- 
pany, or  follow  arterial  change.     (See  Etiologj'  of  Chronic  Interstitial  Nephritis.) 

Some  studies,  experimental  and  pathological,  seem  to  indicate  that  possibly 
arteriosclerosis  may  bear  some  definite  relation  to  morbid  processes  afl'ecting  the 
adrenals.  Josue,  Ziegler,  Erb,  Pearce,  and  others  have  produced  atheroma,  or  a 
closely  allied  lesion,  by  the  intravenous  injection  of  adrenalin.  'Wiquez  reported 
an  instance  of  adenoma  of  the  adrenal  associated  with  heightened  arterial  tension, 
and  Josue  and  Bernard,  and,  my  colleague,  Coplin,  have  shown  that  in  patients 
having  arteriosclerosis  the  adrenal  is  rarely,  if  ever,  a  normal  organ.  The  observa- 
tions are  not,  however,  as  yet  conclusive,  since  similar  lesions  have  been  produced 
in  animals  by  the  use  of  agents  other  than  adrenalin,  agents  moreover  that  do  not 
cause  increased  blood  pressure.  Steinbiss  has  recently  secured  lesions  he  describes 
as  identical  with  the  adrenalin  cases  by  feeding  animals  on  liver  albumin,  on  which 
they  will  li\-e  for  about  tliree  months. 

The  relation  of  heightened  stress  to  arteriosclerosis  is  one  of  the  problems  upon 
which  authorities  are  not  agreed.  Allbutt  recognizes  a  mechanical  arteriosclerosis 
depending  upon  prolonged  high  tension  of  whatsoever  origin.  There  can  be  no 
doubt  that  in  some  cases  prolonged  stress  is  an  important  etiological  factor,  as  is 
shown  by  the  fact  that  typical  arteriosclerosis  is  rare  in  the  pidmonary  artery 
and  its  branches,  except  when  mitral  disease  or  pulmonary  lesions  increase  the 
tension  in  this  vessel,  imder  which  circumstance  sclerotic  changes  are  not  of  infre- 
quent occurrence.     Heightened  stress  in  the  veins  also  tends  toward  the  develop- 


ARTERIOSCLEROSIS  497 

ment  of  phlebosclerosis,  as  is  shown  by  the  occurrence  of  this  lesion  in  the  veins 
of  the  lower  extremity,  when  for  any  reason  tlie  tension  in  these  tubes  is  lieightened, 
and  also  by  the  development  of  similar  changes  in  the  portal  area  in  cirrhosis  of  the 
liver  with  venous  obstruction. 

Pathology  and  Morbid  Anatomy. — Leswns  in  the  Terminal  or  Small  Arteries. — 
The  change  in  the  arterioles  is  characterized  by  proliferation  of  the  endothelium 
and  subendothelial  tissues,  fragmentation  of  the  elastica,  and  alterations  in  the 
media.  There  has  been  much  dispute  as  to  the  primary  alteration  in  the  muscle 
layer,  some  holding  that  there  is  evidence  of  a  distinct  hypertrophy,  which  others 


/■'-' 


) 

I 

II 

r 


/' 


^^  / 


\ 


Left  coronai-y  artery.  Advanced  arteriosclerosis,  from  a  case  of  fatal  angina  pectoris.  Magnified  30 
diameters.  But  little  of  the  adventitia  is  shown.  The  media  is  thinned  and  at  points  encroached  upon, 
but  the  most  conspicuous  change  is  in  the  intima,  beneath  the  endothelial  layer  of  which  there  has 
been  extensive  proliferation  and  leukocytic  accumulation,  most  marked  in  the  upper  segment,  greatly 
altering  the  lumen  of  the  vessel,  lessening  its  carrying  capacity,  and  rendering  it  practically  inelastic. 
There  was  a  marked  fibroid  myocarditis  in  the  area  supplied  by  the  vessel. 

fail  to  recognize.  Whether  or  not  there  be  an  initial  increase  in  the  muscle  layer 
of  the  arteriole,  there  is,  sooner  or  later,  if  the  condition  persists,  a  degenerative 
change,  hyaline  in  tendency,  with  loss  of  elasticity,  thickening  of  the  intimal  and 
subintimal  tissues,  and  narrowing  of  the  lumen,  and  hence  increased  peripheral 
resistance. 

Lesions  in  the  Larger  Arterial  Trunks. — In  the  second  conspicuous  alteration 

of  arteriosclerosis  there  develops  in  the  larger  arteries  a  succession  of  changes 

greatly   influencing   the   elasticity   of   these   structures.     Councilman   recognizes 

at  least  three  divisions  of  this  type  of  arterial  change.     In  the  nodular  form  a 

32 


498 


DISEASES  OF  THE  ARTERIES 


cellular  infiltration  occurs  around  the  vasovasorum,  as  originally  pointed  out 
by  Martin,  extending  into  the  media  and  subintimal  layers.  Fragmentation  of 
the  elastica  with  efforts  at  production  of  new  elastic  tissue  occurs.  Later  necrotic 
and  degenerative  changes  weaken  the  wall  and,  as  pointed  out  by  Tlioma,  endothe- 
lial proliferation  tends  to  restore  the  smooth  lumen.  The  cells  forming  the  node 
undergo  hyaline  and  fatty  degeneration,  giving  rise  to  a  mass  of  cellular  detritus 
constituting  the  so-called  atheromatous  abscess.  Should  the  overlying  endothelium 
give  way  an  atheromatous  ulcer  is  formed;  these  areas  are  particularly  prone  to 
develop  around  smaller  branches  given  off  by  relatively  large  trunks,  and  lessen 
the  blood-carrying  capacity  of  the  affected  branches. 


Atheromatous  plaques  on  the  lining  of  the  aorta.     (Graupner  and  Zimmermann.) 


The  nodules,  seen  on  the  vascular  surface  of  the  larger  arteries,  are  elevated, 
yellowish,  and  often  soft  from  degenerative  changes,  and,  later,  arc  infiltrated 
by  calcareous  material,  becoming  rigid  so  that  they  break  when  bent.  Often 
associated  with  this  nodular  form  is  a  diffuse  arteriosclerosis,  which  n:ay  also  occur 
independently.  The  affected  vessels  are  dilated,  thin-walled,  with  irregular 
elevations  at  points,  taking  on  more  or  less  fully  the  character  of  the  nodules 
already  described.     Sometimes  the  intima  is  almost  unchanged. 

The  senile  arteriosclerosis,  so  classified  by  Councilman,  would  ajipear  to  represent 
that  late  stage  of  the  nodular  type  in  which  so-called  atheromatous  ulcers  and 
abscesses  form  with  calcareous  scales,  giving  rise  to  rigid  "pipe-stem"  or  "slate- 
pencil"  vessels  that  can  be  rolled  under  the  fingers  as  tortuous,  inelastic,  rigid 
tubes.  The  blood-carrying  capacity  of  such  vessels  is  materially  diminished,  and 
the  resistance  ofl'ered  to  the  circulation  proportionately  increased. 

These  briefly  described  alterations  in  the  arteries  may  be  associated  with  similar, 
though  usually  much  less  marked,  changes  in  the  veins  (phlebosclerosis),  the 
combined  arterial  and  A'cnous  lesions  constituting  what  Thoma  has  called  angio- 
sclerosis. 

The  thoracic  aorta  is  the  one  large  vessel  which  usually  presents  the  greatest 
atheromatous  change,     Its  entire  inner  surface  may  be  so  roughened  that  it  no 


ARTERIOSCLEROSIS  499 

longer  presents  any  of  the  appearances  seen  in  health.  In  other  cases,  in 
which  the  process  has  not  gone  so  far,  we  find  patches,  or  plaques,  of  atheromatous 
change  all  over  its  lining.  These  patches  may  cover  areas  of  softening  or  areas 
of  calcification,  and  on  them  thrombi  may  form.  They  are  particularly  prone  to 
appear  about  the  origin  of  branch  vessels,  and  this  is  the  reason  that  fatal  disease 
of  the  coronary  arteries  so  often  occurs  as  part  of  the  aortic  changes. 

In  vessels  of  the  intermediate  class  and  in  the  aorta  these  changes  may  so  weaken 
the  resistance  of  the  vessel  wall  that  it  yields  to  pressure  and  an  aneurysm  de\-elops. 

When  changes  occur  in  the  small  vessels  their  intima  becomes  thickened  by  an 
outgrowth  of  the  endothelial  cells,  and  the  connective-tissue  cells  in  the  media 
also  proliferate,  so  that  the  vessel  becomes  fibroid,  the  elastic  coat  being  rendered 
rigid  and  the  calibre  of  the  vessel  diminished.  If  this  process  proceeds  far  it 
causes  an  obliterative  endarteritis. 

The  secondary  effects  of  these  vascular  changes  have  already  been  largely  con- 
sidered when  discussing  the  causes  of  cardiac  hypertrophy  and  myocardial  degenera- 
tion. The  heart,  if  its  own  tissues  are  not  invaded,  undergoes  hypertrophy  to 
enable  it  to  pump  blood  through  rigid,  unyielding  vessels,  and  finally,  when  the 
pressure  becomes  too  high,  develops  a  leak  at  the  mitral  valve  to  relieve  pressure, 
or  breaks  down  and  fails,  suddenly  or  gradually,  under  the  strain  thrown  upon  it. 
The  hypertrophy  chiefly  aft'ects  the  left  ventricle,  because  it  is  upon  this  part 
that  the  strain  falls. 

Symptoms. — If  the  heart  is  examined  the  apex  may  be  found  displaced  a  little 
downward  and  to  the  left,  and  palpation  will  show  that  the  impulse  against  the 
chest  wall  is  forcible  if  hypertrophy  is  present. 

A  symptom  of  greater  importance  is  the  accentuation  of  the  aortic  second 
sound  at  the  second  right  costal  cartilage,  and,  indeed,  wherever  it  is  heard  else- 
where in  the  chest.  If  the  radial  or  temporal  arteries  are  palpated  they  may  be  found 
thickened  and  corded,  often  elongated  and  tortuous  and  so  rigid  it  is  difficult  to 
extinguish  the  pulse  by  pressure.  This  high  arterial  tension  is  one  of  the  most 
important  clinical  conditions  that  can  be  estimated  by  the  physician.  While 
it  is  true  that  the  degenerative  process  is  practically  universal  nevertheless  in  some 
cases  the  palpable  vessels  may  seem  so  soft  that  far-advanced  sclerosis  of  important 
deep  vessels  is  not  suspected. 

A  patient  presenting  these  signs  and  symptoms  may  continue  in  apparently 
excellent  health  for  several  years,  but  as  life  progresses  the  cardiovascular  changes 
also  progress,  and  cardiac  failure,  attacks  of  angina  pectoris,  or  renal  disease  ensue. 
Much  depends  in  these  cases  upon  how  widespread  the  lesions  are  and  where  they 
are  most  developed.  If  the  coronary  arteries  are  the  parts  chiefly  aft'ected,  anginoid 
attacks  soon  come  on.  If  the  cerebral  arteries  are  calcareous  apoplexy  ends 
existence,  or,  if  the  stroke  be  mild,  it  were  better  for  the  patient  if  death  ensued. 
Not  rarely  attacks  of  vertigo,  of  fleeting  monoplegia  or  hemiplegia,  and  aphasia 
may  take  place  as  the  result  of  the  arteriocapillary  fibrosis,  without  being  due 
necessarily  to  rupture  of  a  cerebral  vessel.  If,  again,  the  renal  vessels  are  involved, 
then  the  general  manifestations  of  chronic  contracted  kidney  are  produced. 

Among  the  complications  may  be  named  cerebral  and  pulmonary  embolus,  and 
gangrene  of  the  extremities  from  the  same  cause. 

Treatment. — The  treatment  consists  in  the  use  of  the  iodides,  whether  there 
be  a  history  of  syphilis  or  not,  in  the  administration  of  nitrites  to  lower  that  part 
of  the  arterial  tension  due  to  spasm  and  so  relieve  the  heart  of  labor,  and  in  the 
use  of  gentle  exercise  and  electric  cabinet  baths  in  moderation  to  flush  the  capillaries 
with  blood.  After  the  circulation  begins  to  fail  in  the  advanced  stages  of  the 
disease  strychnine  and  digitalis  may  be  urgently  required.  Highly  seasoned  dishes 
are  also  to  be  avoided.  If  the  heart  is  tired,  atrophanthus  is  to  be  given  to  sup- 
port this  organ.    High  altitudes  are  dangerous  for  such  patients.     Great  muscular 


500  DISEASES  OF  THE  ARTERIES 

and  mental  strain  are  daiij];erous  because  the  Increased  arterial  pressure  may  rupture 
a  vessel  or  weary  the  heart. 

As  chronic  interstitial  nephritis  is  nearly  always  present  the  treatment  for  that 
state  should  be  instituted  if  any  sign  of  renal  disease  can  be  discovered.  (See 
Chronic  Interstitial  Nephritis.) 

ANEURYSM. 

Definition. — An  aneurysm  is  a  localized  dilatation  of  an  artery  and  depends 
u])on  a  weakening  of  its  wall  so  that  it  is  unable  to  withstand  the  pressure  of  the 
blood.  This  dilatation  may  involve  the  entire  circumference  of  the  vessel,  forming 
a  cylindrical  or  fusiform  aneurysm,  or  it  may  chiefly  affect  only  a  part  of  the  cir- 
cumference, forming  a  sacculated  aneurysm.  The  walls  of  the  aneurysm  are 
composed  of  the  thinned  coats  of  the  vessel,  but  as  the  sac  develops  some  of  these 
may  in  part  disappear. 

The  term  "dissecting  aneurysm"  is  applied  to  that  form  in  which  the  blood 
escapes  through  the  intima  and  forces  a  passage  for  itself  into  the  middle  area 
of  the  vessel  wall,  between  the  media  and  the  adventitia.  By  "false  aneurysm" 
is  meant  a  state  in  which  ail  the  coats  of  the  vessel  give  way  so  that  the  blood 
escapes  into  the  surrounding  tissues,  where  a  pulsating  sac  usually  forms,  owing 
to  the  development  of  fibrous  tissue  around  it.  An  "aneurysmal  vari.v,"  or  "vari- 
cose aneurysm,"  is  one  in  which  the  artery  communicates  with  a  ^■ein  through  an 
abnormal  opening,  so  that  the  vein  and  its  neigliboring  veins  are  distended  with 
pulsating  blood.  An  "embolic  aneurysm"  is  one  in  which  a  vessel  is  plugged  liy  an 
embolus  and  then  undergoes  dilatation  in  its  proximal  part.  "Mycotic  aneurysm" 
is  often  multiple  and  occurs  as  a  result  of  the  infection  of  the  vessel  by  micro- 
organisms, as  in  ulcerative  endocarditis. 

Etiology. — Aneurysm  is  due  to  arterial  degenerative  changes  whereby  the  normal 
elasticity  of  the  vessel  is  impaired  and  its  lining  membrane  injured.  (See  Arterio- 
sclerosis.) The  primary  causes  of  aneurysm  are,  therefore,  identical  with  those  of 
ordinary  arterial  disease,  and  consist  in  syphilis,  alcoholism,  and  excessive  toil 
or  sudden  strain.  Thus  syphilis,  for  example,  weakens  the  vessel  and  a  strain 
causes  it  to  give  way.  There  are  also  cases,  not  so  commonly  met  with,  in  which 
congenital  defects  seem  to  exist  in  the  vessel  walls.  Thus,  I  saw  a  few  years  ago 
a  young  man  of  about  twenty-eight  years,  who  developed  a  po])liteal  aneurysm 
and  then  a  thoracic  aneurysm  and  finally  died  of  cerebral  aneurysm,  but  who  at 
no  time  suffered  from  syphilis  or  from  strain.  It  may  also  arise  from  injury,  as 
when  a  vessel  is  damaged  by  a  stab  wound  or  by  a  bullet,  and  these  injuries  may 
result  in  the  dcA'clopment  of  the  aneurysm  many  years  after,  and  only  when  the 
arterial  changes  of  advancing  age  still  further  weaken  the  area  which  was  damaged. 
In  other  cases  the  acute  infectious  diseases,  without  causing  general  or  widespread 
arterial  cliange,  may  j^roduce  localized  vascular  inflammation  and  necrosis. 

Pathology  and  Morbid  Anatomy. — In  fusiform  aneurysm  the  wall  of  the  vessel 
dilates  in  its  full  circumference,  but  certain  .spots  give  way  more  rapidly  than  others, 
so  that  the  surface  of  the  dilated  vessel  is  slightly  nodular  or  uneven.  As  it  increases 
in  size  its  walls  become  thinner,  but  if  an  inflammatory  process  is  set  up  in  the 
surrounding  tissues  the  actual  thickness  of  the  wall  may  be  increased,  and  finalh' 
a  marked  deposit  of  lime  salts  may  take  place. 

In  sacculated  aneurysm  the  dilatation  may  originate  in  at  least  two  ways.  In 
one,  the  entire  vessel  having  become  weakened,  dilates,  and  the  middle  coat  atro- 
phies. This  process  of  atrophy  becomes  further  advanced  in  one  area  than  in 
another,  and  here  bulging  rapidly  progresses.  In  other  cases  the  low-grade  inflam- 
matory process  results  in  degeneration  of  the  tissues  lying  imder  the  intima,  thereby 
greatly  weakening  the  sustaining  lamina,  which  eventually  yields,  so  that  the 


ANEURYSM 


501 


fibrous  sheath  of  the  vessel  may  be  all  that  is  left  of  the  arterial  wall.  In  either 
case,  however,  a  process  of  compensation  or  repair  may  develop  and  the  sac 
become  filled  with  a  clot,  which  is  usually  laminated  and  remarkably  tough.  Such 
aneurysmal  sacs  often  grow  to  an  enormous  size,  becoming  as  large  as  a  child's 
head. 

Frequency. — The  relative  frequency  of  aneurysm  as  compared  to  other  diseases 
is  not  of  much  interest,  and  there  are  no  very  large  statistics  which  deal  with  this 
point.     There  is,  however,  interesting  information  at  hand  in  regard  to  the  relative 


Eun.' 


Double  sacculated  aneurysm  of  the  thoracic  aorta,  the  upper  sac  rupturing  into  the  pleura.  On  the 
right  is  the  aorta,  in  which  can  be  seen  the  two  oval  openings  communicating  with  the  aneurysmal  sacs. 
The  inferior  margin  of  the  lower  sac  has  been  pushed  upward,  showing  the  erosion  of  the  body  of  the 
vertebra,  which,  above  the  point  shown,  has  exposed  the  spinal  canal,  but  had  not,  in  this  case,  com- 
pressed the  cord. 


frequency  of  the  most  frequent  and  important  forms  of  aneurysm.  Thus,  at  St. 
Bartholomew's  Hospital,  Browne  found  that  in  thirty  years  there  were  468  cases 
of  aortic  aneurysm,  80  of  popliteal  aneurysm,  21  of  femoral  aneurysm,  14  of  sub- 
clavian aneurysm,  8  of  carotid  aneurysm,  and  6  of  external  iliac  aneurysm. 

Aneurysm  of  the  Thoracic  Aorta. — Not  only  is  aortic  aneurysm  the  most  com- 
mon lesion,  but  it  is,  by  reason  of  the  importance  of  this  vessel  and  of  the  tissues 
about  it,  capable  of  causing  very  characteristic  and  also  very  obscure  symptoms, 
both  by  disturbing  the  circulation  and  by  pressure  on  neighboring  organs. 


502  DISEASES  OF  THE  ARTERIES 

For  convenience  of  study  tlie  aorta  is  usually  divided  into  three  parts:  the 
ascending,  the  transverse,  and  the  descending.  Each  of  these  may  be  the  seat  of 
an  aneurysm,  but  the  ascending  portion  is  most  frecjuently  affected.  Some  years 
ago  one  of  my  assistants.  Holder,  and  m\self  studied  the  statistics  derived  from 
953  cases  of  aortic  aneurysm,  and  obtained  the  following  results.  No  less  than 
570  of  these  were  cases  of  aneurysm  of  the  ascending  portion  of  the  arch.  Of  these, 
544  were  sacculated  and  46G  occurred  in  males  and  7S  in  females.  The  remaining 
26  cases  were  fusiform,  and  all  of  these  26  cases  occurred  in  males.  These  statistics 
emphasize  very  forcibly  the  far  greater  frequency  of  sacculated  aneurysm  than 
the  fusiform  variety.  When  we  consider  that  of  nearly  1000  cases  analyzed, 
aneurysm  of  the  ascending  aorta  occurred  no  less  than  570  times,  while  aneurysm 
of  the  trans\'erse  portion  occurred  only  104  times,  and  of  the  descending  portion 
110  times,  the  great  difference  in  the  relative  freciuency  of  the  lesion  in  different 
parts  of  the  aorta  is  also  marked. 

Of  the  466  cases  of  sacculated  aneurysm  occurring  in  males,  it  is  interesting 
to  note  that  the  great  majority  of  them  occurred  in  persons  between  thirty-five 
and  forty-five  years  of  age,  that  the  next  greatest  frequency  was  in  persons  between 
twenty-five  and  thirty-five,  then  between  forty-fi^'e  and  fifty-five. 

When  we  come  to  the  consideration  of  aneurysms  involving  the  second  or  trans- 
verse portion  of  the  aorta  we  find,  once  again,  that  the  most  common  age  for  the 
development  of  this  lesion  is  between  thirty-five  and  forty-five;  for  out  of  88  males 
suft'ering  from  this  lesion  37  were  between  these  ages,  21  between  forty-five  and 
fifty-fi\-e,  14  between  twenty-five  and  thirty-fi^•e,  10  between  fifty-five  and  seventy, 
and  2  between  fifteen  and  twenty-fi\e.  The  same  facts  as  to  age  also  hold  true 
for  aneurysm  of  tJie  descending  arch.  It  is  evident,  therefore,  that  aneurysm  is 
not  a  disease  of  old  age,  but  of  the  middle  period  of  life.  As  Coats  has  well  expressed 
it,  "  aneurysm  occurs  when  the  period  of  greatest  bodily  vigor  overlaps  the  period 
of  occurrence  of  atheroma." 

Symptoms. — Aneurysm  of  the  aortic  arch  not  infrequently  lasts  for  some  time 
before  producing  any  symptoms,  and  is  then  spoken  of  as  a  "latent  aneurysm." 
In  other  instances  it  causes  symptoms  almost  as  soon  as  it  develops,  and  the  differ- 
ence in  the  promptness  with  which  the  signs  appear  depends  largely  upon  the  site 
of  the  growth  and  the  parts  pressed  upon. 

When  the  convex  surface  of  the  ascemUncj  arch  is  invohed  we  find  the  patient 
presenting  engorgement  of  the  veins  of  the  head,  nech,  and  arm  on  the  right  side, 
and  the  voice  is  often  altered  or  lost  from  the  pressure  upon  the  recurrent  laryngeal 
nerve  of  the  right  side.  The  impil  of  the  right  eye  may  be  dilated,  due  to  irritation 
of  the  s,\Tnpathctlc;  or  it  may  be  contracted  because  the  ciliospinal  nerves  are  para- 
lyzed by  pressure.  There  is  often  severe  imin  due  to  pressure,  and  attacks  of 
anginoid  pain  may  be  present. 

The  physical  signs  are  dulness  on  percussion  over  the  second  right  interspace, 
a  bruit,  or  roaring  sound,  produced  by  the  passage  of  blood  through  the  sac,  and 
perhaps  bulging  of  the  first,  second,  or  third  interspace  on  the  right  side.  If  the 
hand  is  placed  over  the  area  of  bulging,  a  distinct,  expansile,  heaving  movement 
is  felt.  Some  displacement  and  hypertrophy  of  the  heart  is  often  present,  and, 
if  the  sac  is  a  large  one,  the  apex  beat  of  the  heart  may  be  far  below  and  outside 
the  normal  spot  near  the  nipple.  If  the  sac  develops  on  the  concave  part  of  the 
arch,  then  the  downward  displacement  of  the  heart  is  still  greater,  for  oln-ious 
reasons. 

Hypertrophy  of  the  heart  is  by  no  means  a  constant  sequel  of  aneurysm. 
Not  rarely  the  heart  is  not  increased  in  size  at  all,  but  its  apex  may  be  displaced 
and  tiie  impidse  transmitted  to  the  chest  wall  more  markedly  than  normal  because 
of  the  pressure  produced  by  the  aneurysmal  sac. 

When  we  come  to  the  consideration  of  the  direction  in  which  sacculated  aneurysms 


ANEURY.W 


503 


of  the  ascending  arch  most  commonly  rupture,  or,  in  other  words,  when  we  study 
the  neighboring  tissues  into  which  the  blood  forces  its  way  when  the  wall  of  the 
aneurysm  bursts,  we  find  that  the  vast  majority  rupture  into  the  pericardium. 
Thus,  out  of  289  cases  in  which  death  was  stated  to  have  been  due  to  rupture  in 
males,  75  ruptured  into  the  pericardium  and  58  into  the  pulmonary  artery;  23 
ruptured  into  the  right  auricle,  3  of  these  taking  place  some  time  before  death; 
23  ruptured  externally;  14  ruptured  into  the  superior  vena  cava ;  11  into  the  esopha- 
gus; 9  into  the  left  auricle;  8  into  the  right  ventricle;  8  into  the  trachea;  6  into  the 
left  ventricle;  6  into  the  left  pleura,  and  5  into  the  right  lung;  3  burst  in  the  posterior 
mediastinum  and  1  burst  simultaneously  into  the  trachea  and  esophagus;  in  20 
others  no  statement  was  made  as  to  the  direction  of  the  rupture.  It  is,  moreover, 
a  fact  that  death  is  much  more  commonly  due  to  pressure  symptoms  than  to 
rupture. 


Aneurysm  of  the  ascending  and  transverse  part  of  the  aortic  arch,  with  erosion  of  the  chest  wall. 


Aneurysm  of  the  transverse  portion  of  the  arch  usually  causes  a  ringing,  brassy 
cough,  dysphagia,  expansile  pulsation  in  the  suprasternal  notch,  and  dithiess  on  per- 
cussion on  the  first  and  second  left  intercostal  spaces.  Its  pressure  on  the  innomi- 
nate vein  may  cause  congestion  of  the  left  side  of  the  face  and  neck.  Dyspnea 
from  tracheal  pressure  may  be  present,  and  there  may  be  aphonia  from  paralysis 
of  the  left  vocal  cord,  arising  from  pressure  on  the  left  recurrent  laryngeal 
nerve.  If  the  growth  is  so  situated  that  it  presses  upon  the  left  bronchus  it 
may  cause  bronchiectasis  and  even  bronchial  suppuration  by  preventing  drainage. 
Again,  if  the  sac  be  a  large  one,  it  may  involve  the  innominate  artery,  the  left 


504  DISEASES  OF  THK  ARTERIES 

carotid,  and  even  the  subclavian,  and  in  this  manner  the  radial  pulse  may  be  absent 
on  one  side.  Even  the  pulse  in  the  arteries  of  the  trunk  and  lower  extremities  may 
be  greatly  lessened  in  -vigor.  The  hmit  may  be  loud  and  angry,  but  if  the  lammated 
clot  be  large  it  is  often  absent.  The  aortic  second  xouud  is  usually  accentuated  or 
ringing  in  character  unless  aortic  regurgitation  is  present. 

When  the  descending  arch  is  aft'ected  it  often  occurs  that  the  aneur\sni  extends 
posteriorly,  and  the  bruit  and  pulsation  are  found  in  the  back,  between  the  scapula 
and  the  spinal  column  on  the  left  side.  In  these  cases  severe  pain  due  to  pressure 
on  the  intercostal  nerves  is  often  present,  and  the  pressure  on  the  ^•ertebr£P  may 
cause  erosion  and  even  paraplegia  by  destroying  the  spinal  cord. 

Aneurysms  of  the  ascending  and  transverse  portions  of  the  aorta  often  produce 
an  extraordmary  degree  of  erosion,  and  so  pass  through  the  wall  of  the  chest  by 
causing  the  absorption  of  the  bony  tissues,  and  by  pushing  the  fragments  of  the 
ribs  to  one  side.  This  is  well  shown  in  the  accompanying  cut.  The  surface  of 
this  tumor  is  often  shining  from  distention  of  the  skin,  it  is  discolored  by  blood, 
and  the  surface  may  weep  bloody  serum  for  days  as  the  end  approaches. 

Under  the  name  tracheal  tugging  a  s\Tuptom  of  aortic  aneurysm,  which  consists 
in  the  transmission  of  a  tugging  sensation  to  the  trachea,  has  been  described  by 
Oliver  and  studied  by  MacDonnell.  To  make  this  test,  the  patient  stands  erect 
with  his  head  slightly  tipped  backward,  so  as  to  stretch  the  tissues  of  the  front  of 
the  neck.  The  cricoid  cartilage  is  now  grasped  by  the  thmnb  and  finger  and 
drawn  toward  the  chin,  when  if  aneurysm  is  present  a  tugging  sensation  will  some- 
times be  felt  with  each  beat  of  the  heart.  I  have  seen  many  cases  and  have  met 
this  sign.  Sewall  has  shown  that  this  sign  is  present  in  cases  which  have  adhesions 
in  the  left  pleura,  and  in  some  healthy  persons  when  they  take  a  deep  inspiration. 

Occasionally  in  aortic  aneurysm  incurvation  of  the  finger-nails  and  clubbing 
of  the  finger-tips  on  one  side  may  be  present. 

Blood-spitting  is  due  to  the  formation  of  an  erosion  of  the  mucosa  at  the  spot 
in  the  bronchial  tube  where  the  timior  causes  pressure.  Such  a  cause  produces 
only  a  slight  blood  stain  of  the  sputum,  ^^'hen  the  blood  passes  by  a  process  of 
leakage  through  the  wall  of  the  sac  and  escapes  into  a  bronchus  it  may  be  in  con- 
siderable amount,  and  death  may  be  due  to  a  free  hemorrhage  of  this  sort. 

V^ery  rarely  there  de\'elops  in  the  chest,  as  the  result  of  aortic  aneurysm,  an 
adhesion  between  the  sac  and  the  superior  vena  cava,  so  that  on  the  de\elopment 
of  ulceration  a  communication  between  the  two  vessels  is  established,  forming  on 
a  large  scale  an  arteriovenous  aneurysm.  The  most  exliaustive  study  of  this 
state  has  been  made  by  Pepper  and  GrifBth,  and  was  reported  to  the  Association 
of  American  Physicians  in  1890.  They  could  find  only  28  cases  in  literature  in 
addition  to  the  one  they  observed.  Less  commonly  the  aneurysm  communicates 
with  the  pulmonary  artery. 

Diagnosis. — The  symptoms  of  aneurysm,  on  which  the  diagnosis  must  be  chiefly 
based;  have  already  been  mentioned.  They  may  be  briefly  named  as  follows: 
The  presence  of  bruit,  expansile  pulsation,  pressiu-e  symptoms,  dulness  on  percussion 
over  the  second  and  third  interspace  anteriorly  on  either  side,  unilateral  sweating, 
and  mydriasis  or  myosis,  and  thoracic  pain.  Swellings  due  to  aneurysm  nearly 
always  are  expansile,  but  care  must  be  taken  that  swellings  which  pulsate  by 
reason  of  transmitted  impulse  are  not  mistaken  for  a  true  dilated  vessel. 

Nothing  is  more  difficult  to  diagnosticate  correctly  than  the  early  manifestations 
of  aortic  aneurysm.  Scarcely  a  physician  of  experience  can  look  back  and  not 
recall  cases  in  which  its  early  signs  completely  misled  him.  The  mconstant  pain 
in  the  chest  is  often  thought  to  be  rheumatic  or  neiu'algic.  In  other  instances 
dyspneic  seizures  are  thought  to  be  asthmatic,  or  attacks  of  severe  cardiac  pain 
are  considered  to  be  due  to  true  angina  pectoris.  The  persistence  of  symptoms 
like  these,  despite  treatment,  the  age  of  the  patient,  the  degenerated  state  of  the 


ANEURYSM  505 

palpable  arteries,  the  sounds  of  the  heart,  and  the  history  of  syfjhilis,  of  alcoholism, 
and  of  strain  or  blow  or  wounds,  are  all  at  least  capable  of  arousing  suspicion  of 
the  real  condition.  The  pain  of  aneurysm  is  often  dull,  gnawing,  and  constant, 
but  in  some  cases  pain  may  be  absent.  Occasionally  an  unsuspected  aneurysm 
may  cause  an  attack  of  stridor  or  paroxysmal  dyspnea,  resembling  somewhat  a 
laryngeal  crisis  in  locomotor  ataxia.  This  should  excite  suspicion  of  aneurysm 
causing  pressure  on  the  recurrent  laryngeal  ner\-es.  A  hemorrhage  from  the 
lungs  in  the  absence  of  tuberculosis  should  also  be  regarded  as  significant.  This 
hemoptysis  may  be  frothy  and  mucoid,  or  rusty,  like  that  of  pneumonia,  or  prune- 
juice  in  hue. 

A  very  valuable  aid  in  the  diagnosis  of  thoracic  aneurysm  is  the  use  of  the  x-rays, 
either  the  fluoroscope  being  used  or  .T-ray  pictures  being  taken.  The  chest  should 
be  x-rayed  not  only  anteroposteriorly  but  laterally  to  discover  the  direction  in 
which  sacculation  is  occurring.  The  advantage  of  the  fluoroscope  is  the  fact  that 
the  physician  can  see  the  expansile  movement  of  the  mass. 

Prognosis. — The  prognosis  of  aortic  anem-ysm  is,  in  the  vast  majority  of  cases, 
inevitably  fatal,  but  in  some  cases  life  is  preserved  for  many  years  if  nature  succeeds, 
by  the  deposition  of  laminated  clot,  in  walling  off  the  sac.  An  old  scrub-woman 
presented  herself  to  my  clinic  during  thirteen  years,  each  season,  with  a  massive 
aneurj'sm  of  the  aorta  which  had  eroded  the  sternum  years  before,  and  which  had 
not  grown  since  to  any  extent.  She  worked  hard  for  her  li^"ing  and  had  little  dis- 
comfort. Her  case  is  the  exception  that  proves  the  rule,  howe\-er.  If  the  gro^si;!! 
is  of  any  size,  life  rarely  lasts  more  than  a  few  months.  Even  when  it  is  small 
a  rupture  may  occur.  As  already  stated,  death  from  aortic  aneurysm  is  usually 
due  to  pressiu-e  on  adjacent  parts,  and  not  most  commonly  to  rupture,  as  is 
generally  thought. 

Treatment. — iVneurysm  of  the  peripheral  arteries  is  best  treated  by  compression 
and  ligation,  and  the  methods  to  be  employed  will  be  found  discussed  in  works 
devoted  to  surgery. 

In  aortic  aneurysm  there  are  two  plans  of  treatment  which  may  be  insti- 
tuted, namely,  medicinal  and  dietetic,  on  the  one  hand,  and  operative  on  the 
other. 

The  medicinal  treatment  depends  to  some  extent  upon  the  underlying  cause  of 
the  aneurysm.  If  it  be  due  to  sjTphilis,  in  the  sense  that  this  disease  is  chiefly 
responsible  for  the  vascular  degeneration,  it  is  hardly  necessary  to  state  that  the 
iodides  in  full  doses  are  advisable,  not  that  they  can  cure  the  aneurysm  in  the  sense 
of  regenerating  an  old  vessel,  but  that  they  may,  by  their  specific  influence,  arrest 
the  degenerative  influence  in  the  vessel  wall,  and  so  delay  the  progress  of  the  malady. 
Even  if  there  is  no  history  of  sj^jhilis  in  the  case,  the  iodides  are  often  of  value  in 
that  they  seem  to  arrest  in  some  imknown  manner  degenerative  changes  in  the 
vessels.  They  should  be  given  in  sufficiently  large  dose  to  produce  some  evidence 
of  iodism,  but  not  in  sufiicient  dose  to  seriously  disorder  digestion. 

The  second  point  in  the  treatment  of  the  case  is  the  institution  of  the  greatest 
degree  of  rest  which  is  compatible  with  comfortable  existence.  The  patient  should 
be  placed  in  bed  and  required  to  use  a  bedpan  in  order  that  he  may  not  disturb 
his  circulatory  equilibrium  by  getting  up.  He  should  also  be  given  small  doses 
of  the  bromides,  if  necessary,  to  overcome  nervous  irritation  and  restlessness, 
and  if  the  action  of  his  heart  is  exceedingly  tumultuous  and  fails  to  become  more 
quiet,  by  rest  in  bed,  I  have  known  small  doses  of  aconite,  such  as  10  minims  of 
the  tincture,  three  or  four  times  a  day,  to  be  advantageous.  In  other  cases  tincture 
of  veratrum  viride  is  useful.  Such  a  plan  of  rest  treatment  is  useless  unless  it 
is  carried  out  for  weeks,  and  sufficient  time  must  be  allowed  for  a  laminated  clot 
to  form  in  the  aneurysm  and  reinforce  its  walls. 

The  so-called  Tufnell  treatment  of  aneurysm  consists  in  a  more  rigorous  method 


506  DISEASES  OF  THE  ARTERIES 

than  that  just  described.  The  patient  is  not  only  put  at  absohitc  rest,  but  he 
is  also  given  considerable  quantities  of  iodide  of  potassium  and  as  low  a  diet  as  is 
compatible  with  existence.  Indeed,  the  treatment  may  be  called  the  starvation 
plan  of  treatment,  for  it  is  the  deliberate  purpo.se,  when  this  plan  is  instituted, 
to  lower  the  activity  of  the  circulation  by  the  depression  which  is  associated  with 
semistarvation.  I  have  seen  this  plan  instituted  in  only  a  few  cases,  and  I  have 
never  seen  good  results  from  it.  Surely,  no  advantage  can  accrue  except  by 
diminishing  the  activity  of  the  circulation,  and  this  can  be  obtained  by  the  use 
of  aconite  or  veratrum  viride. 

The  use  of  digitalis  in  these  cases  is  not  advisable  because,  while  the  drug  steadies 
the  heart,  it  increases  arterial  tension  and  so  tends  to  increase  the  pressure  upon 
the  aneurysmal  sac. 

The  operative  treatment  of  thoracic  aneurysm  is  only  possible  when  the  tumor 
is  of  the  sacculated  type.  The  fusiform  type  of  aneurysm  contra-indicates  its 
employment.  A  large  number  of  operative  procedures  have  been  suggested, 
but  there  is  only  one  which  has  at  the  present  time  received  general  recognition 
by  the  profession,  namely,  the  so-called  Corradi  method,  in  which  there  is  intro- 
duced into  the  aneurysmal  sac  several  feet  of  fine  platinum-gold  wire  which  has 
been  previously  wound  about  a  glass  spool,  both  the  spool  and  the  wire  being 
carefully  sterilized  by  boiling  before  they  are  used.  After  the  skin  over  the  sac 
has  been  carefully  sterilized,  the  greatest  gentleness  being  used  lest  it  be  damaged, 
a  hollow  needle,  which  is  insulated  by  being  coated  with  porcelain,  is  pushed  into 
the  sac,  and  then  through  it  is  passed  from  ten  to  thirty  feet  of  wire,  according  to 
the  size  of  the  growth.  A  larger  number  of  feet  have  been  used,  but  ten  or  fifteen 
feet  will  be  sufficient  in  the  vast  majority  of  cases.  As  soon  as  all  the  wire,  save 
about  six  inches  has  passed  into  the  sac,  the  external  end  of  the  wire  is  made  fast 
to  an  electrode  which  is  attached  to  the  positive  pole  of  a  galvanic  battery.  A 
large,  wet,  clay  electrode  attached  to  the  negative  pole  is  placed  under  the  back 
to  complete  the  circuit  and  by  means  of  a  "current  controller"  the  electricity 
is  gently  turned  on.  At  first  about  5  milliamperes  are  used;  at  the  end  of  five 
minutes  the  current  is  raised  to  10  milliamperes,  and  after  this  the  current  is  in- 
creased every  five  minutes  by  5  milliamperes  until  about  50  milliamperes  are 
employed.  A  higher  number  of  milliamperes  have  been  used,  but  with  increasing 
experience  I  am  confident  that  they  are  unnecessary  and  perhaps  harmful.  As 
the  result  of  this  method  of  procedure  it  not  infrequently  happens  that  by  the  end 
of  the  first  twenty  minutes  or  half-hour  the  sac  is  found  to  be  somewhat  more  firm 
than  before,  and  that  pulsation  in  it  has  diminished  owing  to  the  fact  that  the 
acid  reaction  produced  by  electrolysis  about  the  gold  wire  has  resulted  in  the  for- 
mation of  a  clot,  wliich,  as  time  goes  by,  becomes  more  and  more  firm  and  solid. 
At  the  end  of  from  thirty  minutes  to  an  hour  the  wire  is  disconnected  from  the 
battery,  its  external  end  is  pushed  underneath  the  skin,  and  the  external  womid 
is  closed  by  collodion.  Absolute  quiet  must  be  maintained  for  ten  days  or  two 
weeks  after  the  operation,  in  order  that  the  clot  may  become  thoroughly  con- 
solidated. 

I  have  now  performed  this  operation  twenty-nine  times,  and  my  experience 
has  been  that  in  no  instance  did  the  patient  sufi'er  much  pain.  Indeed  the  relief 
of  pain  is  one  of  the  chief  advantages  of  the  procedure.  In  several  instances 
the  patient  has  stated  during  the  operation  that  he  had  less  pain,  and  in  every 
instance  he  has  voluntarily  expressed  his  pleasure  at  the  subsequent  impro\ement. 
Unfortunately,  the  conditionof  the  aorta  is  often  such  that  when  we  close  one  bulging 
spot  in  this  way,  it  is  not  long  before  another  area  gives  way  under  pressure,  and 
so  another  aneurysm  is  formed.  In  most  of  my  cases  this  accident  has  ultimately 
occurred.  One  patient  operated  on  the  first  time  five  years  ago  and  a  second  time 
three  years  ago  is  alive  and  at  work  as  I  write.     One  case  a  year  after  operation 


ANEURYSM  507 

lost  his  life  not  by  the  disease  but  because  he  was  struck  by  a  freight  car  as 
he  was  walking  along  the  track  in  very  excellent  health.  In  one  case  operated 
on  by  Stewart  some  years  ago  the  patient  lived  in  comparative  health  for  a  period 
of  three  years,  and  then  died  from  pneumonia  following  an  alcoholic  debauch, 
although  at  the  time  of  operation  the  aneurysm  could  be  seen  as  large  as  a  fist 
outside  the  chest  wall.  Considering  the  slight  pain  of  the  operation,  it  is  indicated 
in  many  cases,  if  only  for  the  relief  which  it  gives. 

Aneurysm  of  the  Abdominal  Aorta. — Aneurysm  of  the  abdominal  aorta  usually 
occurs  near  the  diaphragm,  and  it  is  far  more  rare  than  aneurysm  of  the  thoracic 
aorta.  Out  of  325  cases  of  aortic  aneurysm  collected  at  Guy's  Hospital  in  forty- 
six  years,  54  involved  the  abdominal  aorta.  Of  these  63  per  cent,  occurred  between 
the  ages  of  twenty-one  and  forty  years  and  77  per  cent,  between  twenty-one  and 
fifty  years;  over  90  per  cent,  occurred  in  men.  The  growth  usually  arises  from  the 
neighborhood  of  the  celiac  axis.  Like  that  in  the  thorax,  its  sacculated  form  is 
more  common  than  its  fusiform  type.  It  usually  projects  forward,  but  it  may 
extend  backward  and  cause  erosion  of  the  vertebrae,  followed  by  pressure  on  the 
spinal  cord.  Pain  is  usually  a  constant  symptom,  which  is  often  referred  to  the 
region  of  the  heart  or  to  the  back.  On  inspecting  the  abdomen  distinct  jiuJsation 
may  be  seen  at  once,  but  care  must  be  taken  that  the  transmitted  pulsation  of 
the  aorta  in  a  state  of  health  is  not  mistaken  for  true  expansion.  These  two  states 
can  be  separated  by  careful  palpation.  In  some  instances  the  aorta  can  be  clearly 
felt  through  the  belly  wall;  in  other  cases  a  morbid  growth  in  the  stomach  or  in 
the  omentum  can  be  felt,  but  although  it  pulsates  it  is  not  expansile.  If  the  patient 
is  placed  in  the  knee-elbow  position  so  that  the  growth  falls  away  from  the  aorta, 
the  diagnosis  may  be  readily  made.  Auscultation  may  reveal  a  bruit  if  aneurysm 
is  present,  but  if  a  stethoscope  is  used  it  is  easy  by  pressure  on  the  aorta  to  narrow 
its  lumen  and  cause  a  humming  sound,  which  is  not  a  sign  of  aneurysm.  Again, 
in  hysterical  persons  a  very  marked  pulsation  of  the  aorta  may  be  complained  of 
by  the  patient  and  felt  by  the  physician.  I  have  seen  an  hysterical  male  who  had 
rhythmical  contraction  of  his  abdominal  rectus  muscles  synchronous  with  his 
pulse.  It  was  only  possible  to  diagnose  his  case  by  giving  him  ether  to  the  point  of 
relaxation. 

A  larger  proportion  of  these  cases  end  by  rupture  than  is  the  case  in  aneurysm 
of  the  thoracic  aorta.     Thus,  out  of  these  54  cases  no  less  than  43  died  from  ruptiu-e. 

Aneurysm  of  the  abdominal  aorta  may  rupture  into  the  retroperitoneal  tissues, 
through  the  diaphragm  into  the  pleural  spaces,  or  into  the  general  peritoneal 
cavity,  or  more  rarely  into  an  intraperitoneal  viscus,  as,  for  example,  the  stomach. 
Rarely  death  ensues  from  the  vessel  becoming  closed  bj'  a  thrombus. 

Abdominal  sacculated  aneurysms  may  be  treated  by  wiring  and  electricity. 
(See  Aortic  Aneurysm.) 

Even  more  rare  than  aneurysm  of  the  abdominal  aorta  is  aneurysm  of  its  branches. 
Cases  have  been  reported  in  which  a  blow  upon  the  belly  has  caused  aneurysm 
of  the  hepatic  artery,  and  in  a  case  seen  by  the  writer  it  followed  ulceration  produced 
by  a  malignant  growth  of  the  gallbladder.  That  this  condition  is  very  rare  is 
shown  by  the  fact  that  up  to  1898  only  26  cases  had  been  recorded.  The  sj-mptoms 
are  usually  mistaken  for  hepatic  colic,  and  this  error  is  all  the  more  easy  because 
jaundice  from  pressure  is  often  present.  In  most  of  the  recorded  cases  the  ante- 
mortem  diagnosis  has  been  "gallstones"  or  "duodenal  ulcer." 

Aneurysm  of  the  splenic  artery  is  rarer  than  aneurysm  of  the  hepatic  artery, 
and  causes  symptoms  like  those  of  gastric  ulcer. 

Aneurysm  of  the  superior  mesenteric  artery  is  also  rare.  Rolleston  has  collected 
20  cases.  Embolism  is  the  usual  cause,  and  uijury  may  be  responsible  for  it. 
This  growth  may  cause  jaundice  by  pressure  on  the  gall-duct,  as  in  a  case  reported 
by  J.  A.  Wilson;  or  it  may  press  on  the  renal  arteries  and  cause  uremia,  as  in  a  case 


508  DISEASES  OF  THE  A  UTERI ES 

recorded  by  Barney  Yeo.     Aneurysin  of  tlie  inferior  iiu'scnteric  artery  is  ]jraetieally 
unknown. 

Aneurysm  of  the  renal  artery  is  also  rare,  although  small  nuiltij)le  saes  are  some- 
times seen.  If  the  sac  be  very  large  hematuria  may  occur,  or  wasting  of  the  kidney 
may  ensue.  Sometimes  by  the  sudden  rupture  of  an  aneurysm  of  this  vessel  the 
retroperitoneal  space  has  been  filled  with  blood.  In  the  surgical  clinic  of  the 
Jefferson  College  Hospital,  my  colleague,  Dr.  W.  W.  Keen,  cut  down  on  a  kidney 
because  of  severe  renal  symptoms,  and  found  a  large  aneurysm  of  the  artery. 
He  was  forced  to  remove  the  aneurysm  and  the  kidney. 


DISEASES  OF  THE  DIGESTIVE  TRACT. 


DISEASES  OF  THE  MOUTH. 


STOMATITIS. 


Definition. — As  its  name  implies,  stomatitis  is  an  inflammation  of  the  mouth. 
Of  the  many  forms  that  have  been  described  three  are  important:  catarrhal  stoma- 
titis, aphthous  stomatitis,  and  ulcerative  stomatitis.  All  these  forms  of  stomatitis 
usually  occur  in  childhood.  The  catarrhal  and  aphthous  forms  are  more  common 
in  early  infancy,  but  the  ulcerative  type  is  practically  never  met  with  in  children 
who  have  not  as  3'et  gotten  teeth,  and  is  more  common  in  those  past  puberty  than 
are  the  other  forms. 

Catarrhal  Stomatitis. — In  catarrhal  stomatitis  there  is  hyperemia  of  the  mucous 
membrane  of  the  tongue  and  cheeks,  with  an  increase  in  secretion  on  the  part  of 
the  mucous  and  salivary  glands.  It  arises  from  injury,  as  by  some  foreign  body 
being  taken  into  the  mouth  which  acts  as  a  mechanical  irritant,  or  by  hot  or  irrita- 
ting liquids.  These  are,  however,  only  predisposing  causes.  DifBcult  dentition, 
or  the  use  of  a  rubber  nursing  nipple  which  is  dirty,  are  more  common  factors. 
It  also  occurs  as  one  of  the  manifestations  of  the  acute  eruptive  diseases,  as  in 
scarlet  fever  and  measles,  and  it  may  be  a  symptom  of  some  metallic  poisoning,  as 
mercury,  lead,  or  arsenic. 

Symptoms. — The  symptoms  of  catarrhal  stomatitis  are  intense  hyperemia  of  the 
mucous  membrane  of  the  mouth  with  some  swelling  which  is  particularly  visible 
on  the  gums.  If  the  finger  be  placed  in  the  mouth  a  sense  of  increased  heat  is  felt. 
The  child  evidently  suffers  a  good  deal  of  -pain.  When  given  the  breast  or  bottle 
it  eagerly  seizes  it  because  of  hunger  and  thirst,  and  then,  as  the  nipple  touches 
the  tender  mucous  membrane,  gives  a  cry  of  pain  and  disappointment.  Cool 
water  is  usually  taken  with  avidity  if  given  from  a  cup  or  spoon.  The  flow  of  saliva 
is  so  free  that  constant  dribbling  on  the  chin  is  present  or  the  excess  is  swallowed 
and  disturbs  digestion.  If  the  mouth  be  carefully  examined  it  may  be  that  tiny 
blisters  at  the  opening  of  the  mucous  glands  will  be  seen  and  the  papillae  of  the  tongue 
will  be  found  enlarged,  swollen,  and  unduly  red  in  hue.  Some  digestive  disturbance 
and  diarrhea  are  nearly  always  present.  Whether  these  symptoms  are  the  result 
of  the  condition  of  the  mouth,  or  whether  the  state  of  the  mouth  is  secondary  to 
disturbed  digestion,  is  often  difficult  to  determine. 

Prognosis. — Recovery  from  catarrhal  stomatitis  is  usually  rapid,  the  condition 
rarely  lasting  for  more  than  a  few  days  after  the  disordered  digestion  is  corrected 
and  proper  cleanliness  of  the  mouth  is  obtained. 

Aphthous  Stomatitis. — The  aphthous  form  of  stomatitis,  sometimes  called  fol- 
licular or  vesicular  stomatitis  or  canker,  may  be  considered  as  a  still  further  develop- 
ment of  the  catarrhal  form.  In  this  condition  we  not  only  have  a  diffuse  hyperemia 
of  the  mucous  membrane  of  the  mouth,  but  in  addition  small  spots  appear  which 
look  as  if  the  superficial  epithelium  had  been  snipped  off  with  curved  scissors. 
These  spots  are,  of  course,  exquisitely  sensitive.  All  the  symptoms  of  the  catarrhal 
form  are  much  exaggerated,  and  in  addition  to  more  marked  digestive  disturbance 

(509) 


510  DISEASES  OF  THE  MOV  Til 

the  patient  often  lias  systemic  disturbance,  as  is  shown  by  some  fever  and  general 
wretchedness.  Nutrition  is  interfered  with  materially  only  by  the  inability  to 
take  food. 

Ulcerative  Stomatitis. — The  ulcerative  form  of  stomatitis,  sometimes  called 
fetid  stomatitis,  or  putrid  sore  mouth,  is  a  much  more  serious  type,  but  it  is  often 
so  mild  that  the  dividing  line  between  it  and  tlie  aphthous  form  is  not  readily 
made.  When  well  developed,  the  mucous  membrane  is  seen  to  be  studded  by 
small  ulcers  which  may  coalesce,  forming  rather  large  areas  of  superficial  necrosis. 
If  the  child  is  badly  nourished,  or  suffering  from  some  malady  which  impairs  its 
general  nutrition,  ulcerative  stomatitis  may  become  a  very  serious  affection,  causing 
great  suffering,  interfering  seriously  with  proper  feeding  and  rapidly  undermining 
the  strength  of  the  patient.  The  ulcers  are  situated  chiefly  along  the  edges  of  the 
gums  which  recede  from  the  teeth,  or  on  the  margins  of  the  tongue,  on  the  buccal 
membrane,  and  even  on  the  lips.  The  breath  is  often  very  fovl  and  the  corners  of 
the  mouth  become  excoriated  from  the  salivary  flow.  When  the  patient  is  a 
suft'erer  from  scurvy,  it  may  be  an  important  factor  in  preventing  recovery.  In 
adults  it  is  usually  due  to  mercurialism. 

In  many  cases  the  condition  arises  from  carious  teeth  and  occasionally  the 
disease  occurs  epidemically.  On  the  other  hand,  I  have  repeatedly  seen  mild 
ulcerative  stomatitis  occur  in  otherwise  healthy  young  girls  past  puberty,  in  whom 
none  of  these  causes  was  apparent. 

In  severe  cases  the  ulceration  may  be  very  deej)  and  may  even  cause  loosening 
of  the  teeth  or  superficial  necrosis  of  the  lower  jaw. 

Treatment. — The  treatment  of  all  these  forms  of  stomatitis  may  be  considered 
simultaneously.  All  of  them  are  to  be  treated  by  careful  attention  to  cleanliness 
of  the  mouth  itself  and  of  all  objects  entering  the  mouth,  by  careful  regulation  of 
the  bowels  and  the  food,  and  by  a  mouth-wash  of  chlorate  of  potash  and  myrrh  in 
the  following  formula: 

3^ — Potassii  chlorat gr.  xxx. 

Tinct.  myrrha; Ill  x. 

Elix.  calisayse .      .  f  5'ii- — M 

Sig. — Dilute  one  tablespoonful  with  two  of  water,  and  use  as  a  mouth-wash. 

When  very  young  children  are  treated  this  solution  may  be  applied  to  the  mucous 
membrane  by  means  of  a  swab  tied  to  a  small  stick  or  pencil.  These  measures  are 
usually  efficient  in  the  catarrhal  and  aphthous  type. 

In  the  ulcerative  form  it  may  be  necessary  in  addition  to  touch  each  ulcer  with 
a  solid  stick  of  nitrate  of  silver  or  with  a  solution  of  tbis  drug  of  the  strength  of  60 
grains  to  the  ounce.  This  is  painful,  but  efficacious.  Only  a  few  spots  should  be 
touched  at  each  sitting.  When  the  teeth  are  not  carious  pero.xide  of  hydrogen 
may  be  used  locally.  The  system  should  be  well  supported  by  nutritious  foods 
such  as  cold  consomme  or  cold  chicken-jelly,  by  ordinary  foods  if  they  can  be  taken 
into  the  mouth,  and,if  anemia  is  present,  by  the  use  of  iron  and  quinine  in  moderate 
doses. 

When  for  any  reason  chlorate  of  potash  cannot  be  applied  locally  the  physician 
may  give  the  drug  internally  in  the  dose  of  2  grains  every  three  hours,  since,  as  it 
is  eliminated  by  the  salivary  glands,  the  saliva  bathes  the  diseased  mucous  mem- 
brane with  the  drug.  This  plan  of  treatment  is  contra-indicated  if  any  renal 
irritation  or  marked  gastric  disturbance  is  present. 

In  scorbutic  cases  fresh  vegetables,  fruit,  and  beef-juice  are  absolutely  needful 
in  the  treatment  of  the  patient. 

There  still  remain  to  be  discussed  in  this  connection  two  forms  of  sore  mouth 
which  do  not,  strictly  speaking,  fall  under  any  of  the  headings  just  given,  since 
in  each  of  them  definite  specific  causes  have  been  isolated,  namely,  so-called  thrush 
or  parasitic  stomatitis  and  gangrenous  stomatitis. 


STOMATITIS  511 

Thrush. — Thrush,  or  parasitic  stomatitis  (Soor  or  Muguet),  is  flue  to  the  pres- 
ence in  the  mouth  of  a  parasite  variously  named  Saccharomyces  albicans,  or  Oidmm 
albicans  or  Endomyces  albicans.  This  parasite  has  been  classed  with  yeasts,  and 
grows  with  branching  filaments  at  the  ends  of  which  egg-shaped,  torula  cells  are 
produced.  Thrush  is  distinctly  associated  with  impaired  health  of  the  mucous 
membrane,  and  in  children,  in  whom  it  is  most  commonly  met  with,  it  is  due,  as  a 
rule,  to  the  use  of  dirty  nursing  nipples  or  nursing  bottles,  or  to  general  impairment 
of  health.  When  the  latter  cause  is  present,  thrush  may  appear  in  the  mouth  of 
adults,  and  for  this  reason  it  sometimes  aids  in  increasing  the  miseries  of  those 
whose  vitality  is  impaired  by  tuberculosis,  diabetes,  and  by  prolonged  exliausting 
fevers.  It  is  also  seen  in  children  suffering  from  marasmus.  The  parasite  can  be 
readily  convej^ed  from  one  person  to  another  by  utensils. 

Symptoms. — The  subjective  symptoms  of  thrush  consist  in  the  same  discomfort 
in  the  mouth  which  is  met  with  in  aphthous  stomatitis.  The  objective  symptoms 
are,  however,  to  be  carefully  separated  from  that  state.  Instead  of  denudation 
or  depression  of  the  surface  of  the  mucous  membrane  there  is  seen  on  the  tongue 
small  particles  or  specks  in  the  form  of  tiny  pearly  white  spots,  which  are  raised 
and  may  gradually  coalesce  and  seem  to  form  a  membrane  that  is  usually  easily 
removed,  although  its  removal  may  leave  a  bleeding  surface.  From  the  tongue 
the  growth  may  extend  to  the  entire  mucous  membrane  of  the  mouth  and  the  soft 
and  hard  palate.  Very  rarely  it  even  spreads  to  the  pharynx  and  esophagus,  and 
even  into  the  stomach  and  small  intestine.  Holt  states  that  the  fungus  has  been 
found  in  the  lungs  of  babies  suffering  from  bronchopneumonia.  Thrush  is  separated 
from  aphthous  stomatitis  by  the  fact  that  the  profuse  salivation  of  the  latter  is 
replaced  by  great  dryness  of  the  mouth,  and  by  the  aid  of  a  microscopic  examination 
of  the  growth. 

Prognosis. — The  prognosis  depends  upon  the  health  of  the  patient.  In  the 
robust  the  condition  may  last  but  a  few  days,  but  in  the  feeble  and  impoverished 
it  may  persist  for  weeks.  It  does  not  materially  influence  the  general  health 
except  by  interfering  with  the  taking  of  nourishment. 

Treatment. — The  treatment  consists  in  cleanliness,  good  feeding,  the  use  of  a 
mouth-wash  of  borax  in  the  strength  of  10  grains  to  the  ounce,  or  of  a  mouth-wash 
of  permanganate  of  potash,  1  grain  in  8  ounces  of  water,  or  by  diluting  peroxide 
of  hydrogen,  1  part  in  5  of  water.  Any  underlying  disorder  of  nutrition  should 
be  carefully  removed  if  it  be  possible.  All  sweets  and  syrups  should  be  carefully 
avoided. 

Gangrenous  Stomatitis,  Cancrum  Oris,  or  Noma. — Noma  is  a  term  applied  to 
all  forms  of  severe  ulceration  of  a  localized  character  attacking  mucous  membranes, 
but  the  state  may  be  present  without  the  mucous  membrane  being  broken,  the 
tissues  of  the  cheek  being  chiefly  affected.  The  condition  occurs  so  rarely  in  those 
who  are  past  puberty  that  it  may  be  said  to  be  a  disease  of  early  childhood.  It 
affects  the  buccal  mucous  membrane  and  cheek  so  constantly  that  the  word  "  noma" 
has  come  to  mean  a  malignant  and  sometimes  a  perforating  gangrenous  process 
involving  the  cheek,  although,  strictly  speaking,  noma  may  affect  the  ear,  the 
vagina,  the  buttock,  the  nose,  or  the  external  genitalia. 

In  the  vast  majority  of  cases  noma  results  in  the  death  of  the  patient,  not  so 
much  because  it  is  in  itself  a  fatal  disease  as  that  it  is  a  terminal  infection;  that  is, 
one  which  develops  only  in  a  child  or  adult  whose  vital  resistance  is  so  lowered  by 
disease  or  poor  nutrition  that  the  pathological  process  known  as  noma  is  possible. 

The  disease  is  rarely  seen  in  private  practice,  but  has  its  greatest  frequency 
in  institutions  for  poor  children,  where  because  of  mismanagement,  or  of  the 
wretched  state  of  the  child  on  admission,  it  readily  falls  a  victim  to  infections  of 
all  kinds. 

Noma  more  commonly  follows  measles  than  any  of  the  other  eruptive  diseases, 


512  DISEASES  OF  THE  MOUTH 

but  it  also  sometimes  complicates  or  follows  scarlet  fe\'er,  typlioid  fever,  wliooping- 
cough.  It  is  practically  never  a  primary  lesion  at  the  i)oint  of  dcveloi)nient,  but 
begins  in  a  solution  of  continuity  such  as  an  ulcer  due  to  a  carious  tfioth  or  as  a 
sequence  of  ulcerative  stomatitis.  In  all  probability  it  is  not  due  to  an  infection 
by  any  single  micro-organism,  but  to  several  organisms  which  may  be  associated. 
Cases  have  been  recorded  in  which  the  ulceration  seemed  to  be  due  to  the  bacillus 
of  diphtheria,  but  niLxed  infection  is  the  rule.  An  attempt  to  establish  specificity 
for  any  single  organism  has  been  futile. 

Not  only  has  the  ulcerati\-e  process  a  tendency  to  rapidly  become  deep  and  so 
to  perforate  the  cheek,  but  it  lacks  the  sharp  line  of  demarcation  marking  the  wall 
often  built  by  nature  to  prevent  the  spread  of  gangrene.  That  is  to  say,  the  ulcer 
is  bounded  by  an  e.xtending  area  of  necrosis,  often  branching  and  discolored,  which 
spreads  from  day  to  day,  with  no  apparent  effort  on  the  part  of  the  system  to 
limit  its  progress.  The  soft  parts  melt  into  the  fetid  ulcer,  and  cartilage  and  bone 
undergo  necrosis.  When  recovery  does  occur,  which  is  exceedingly  rare,  a  line 
of  demarcation  forms,  and  the  extension  of  the  disease  is  arrested  in  this  way;  the 
ulcer  clears  up  and  repair  slowly  takes  place. 

Symptoms. — The  local  symptoms  of  noma  are  a  foul  breath,  a  state  of  localized 
ulceration  with  deep  indvration  of  the  tissues  near  by,  and  the  speedy  de\elopnient 
in  the  centre  of  the  ulcer,  of  a  dirty-looking  slough  of  necrotic  tissue.  The  side 
of  the  face  is  usually  much  swollen  and  distorted,  and  when  felt  by  the  fingers  the 
tissues  feel  brawny  and  hard.  If  the  ulceration  extends  to  the  gums,  the  teeth 
become  loosened.  So  great  may  be  the  destructive  process  that  the  teeth  and 
alveoli  may  be  seen  through  the  perforated  cheek. 

The  systemic  symptoms  are  not  characteristic  of  any  specific  state,  but  are  those 
of  profound  systemic  poisoning,  depression,  and  exhaustion.  The  2>"/''e  is  rapid 
and  feeble,  the  appearance  of  the  patient  markedly  septic  and  cachectic,  and  the 
temperature  mildly  febrile.  The  height  of  the  temperature  depends,  hov,-e\-er,  to  a 
considerable  degree,  upon  the  vitality  of  the  patient.  When  the  sufi'erer  is  i)ro- 
foundly  exhausted  and  the  vital  state  is  very  low  marked  febrile  movement  does 
not  occur. 

Treatment. — From  the  description  just  given  it  is  evident  that  the  treatment 
of  noma,  to  be  successful,  must  depend  upon  its  early  institution  and  thorough 
character.  It  must  also  consist  in  the  use  of  such  nutritious  food  and  such  medicines 
as  will  serve  to  support  the  strength  of  the  patient.  The  local  treatment  consists 
in  the  early  and  complete  cauterization  of  the  part  affected  by  the  electrocautery 
or  its  excision  by  the  knife,  so  that  the  necrotic  mass  is  at  once  destroyed  and 
removed.  The  physician  must  not  limit  the  operation  to  the  dead  tissues,  but 
extend  the  excision  to  the  living  tissues  as  well  in  order  that  none  of  the  infected 
tissue  may  remain.  The  local  process  may  be  temporarily  treated  by  swabbing 
the  part  with  peroxide  of  hydrogen  or  by  using  permanganate  of  potash.  In 
cases  in  which  the  streptococcus  or  the  bacillus  of  diphtheria  are  present,  the  serum 
therapy  needed  for  these  specific  infections  should  be  used. 

ECZEMA  OF  THE  TONGUE. 

Under  this  tlistinctly  erroneous  term  is  described  a  condition  in  which  there 
is  a  superficial  overgrowth  and  desquamation  of  the  epithelium  covering  the  tongue. 
As  a  rule,  the  centre  of  each  spot  of  descjuamation  begins  to  heal  while  the  periphery 
is  still  si)reading,  so  that  the  appearance  of  the  inflammatory  zone  is  distinctly 
circinate.  Its  irregular  outline  has  given  it  the  name  of  "geographical  tongue." 
In  other  instances  the  appearance  of  the  tongue  is  that  of  a  worm-eaten  leaf.  In 
some  patients  it  i)roduces  no  discomfort  whatever.  In  others  the  patient  may 
have  some  itching  and  tingling,  and  on  examining  the  tongue  is  surprised  to  find 


FUNCTIONAL  DISOKDKliS  OF   THE  SALIVARY  GLANDS  5i;5 

the  curious  outlines  which  have  been  described.  Not  infrequently  nervous  patients 
are  wont  to  consider  that  it  is  an  evidence  of  syphilis,  or  perhaps  of  a  malignant 
growth.  A  modified  form  of  this  condition  is  very  frequently  seen  in  children  as  a 
result  of  catarrhal  condition  of  the  stomach  and  bowels. 

Treatment. — In  adults  it  is  best  treated  by  the  local  application  of  nitrate  of 
silver,  20  grains  to  the  ounce.  In  children  the  correction  of  the  gastro-intestinal 
disorder  usually  results  in  a  normal  growth  of  epithelium,  so  that  the  condition 
is  relieved.  As  a  rule,  such  children  require  some  simple  bitter  such  as  tincture 
of  gentian  with  5  or  10  grains  of  bicarbonate  of  soda. 

LEUKOPLAKIA  BUCCALIS. 

Leukoplakia  buccalis  is  sometimes  called  smoker's  tongue,  ichthyosis  lingualis, 
and  buccal  psoriasis.  It  is  characterized  by  the  development  of  white  spots  of 
considerable  size  on  the  mucous  membrane  of  the  mouth  and  tongue,  which  are 
due  to  cellular  infiltration  of  the  subepithelial  connective  tissue  and  a  thickening 
of  the  epithelium.  When  the  spots  occur  on  the  edge  of  the  tongue  and  are  indented 
by  the  teeth  they  sometimes  look  like  the  scars  or  puckerings  which  are  seen  on 
the  edges  of  the  tongue  in  cases  of  advanced  sj'phihs.  Occasionally  these  areas 
maj'  be  slightly  ulcerated,  and  in  some  cases  are  thought  to  be  the  seat  of  epithelio- 
matous  degeneration.  In  the  majority  of  instances,  however,  they  are  benign, 
and  after  removal  of  the  cause  require  no  treatment  unless  the  surface  is  ulcerated, 
in  which  case  they  may  be  touched  with  nitrate  of  silver  and  the  patient  directed 
to  avoid  taking  hot,  irritating  substances  into  the  mouth,  and  particularly  to 
avoid  smoking  or  chewing.  Leukoplakia  is  sometimes  looked  upon  as  a  precancer- 
ous condition,  and  this  is  probably  true  in  the  sense  that  the  state  if  permitted  to 
continue  it  may  lead  to  cancer. 

MUCOUS  PATCHES. 

Mucous  patches  are  opaque,  white,  flattened  swellings  on  the  mucous  membrane 
of  the  mouth  and  lips,  and  are  characteristic  of  secondary  syphilis.  (See  Syphilis.) 
From  them  the  Trepoiiema  'pallidum  is  readily  communicated.  Not  infrequently 
their  surface  is  somewhat  ulcerated. 

Treatment. — The  treatment,  of  course,  consists  in  the  active  employment  of 
salvarsan  and  the  use  of  nitrate  of  silver  locally. 


DISEASES  OF  THE  SALIVARY  GLANDS. 

FUNCTIONAL  DISORDERS  OF  THE  SALIVARY  GLANDS. 

Ptyalism. — Ptyalism,  or  salivation,  occurs  as  the  result  of  poisoning  by  mer- 
cury or  the  iodides.  It  is  also  produced  by  such  drugs  as  jaborandi,  and  occasionally 
occurs  because  of  irritation  of  the  mucous  membrane  of  the  mouth  by  the  develop- 
ment of  stomatitis  in  one  of  its  severe  forms.  Rarely  a  form  of  idiopathic  ptyalism 
is  met  with  in  young  children.  Under  these  conditions  the  salivation  is  probably 
the  result  of  a  neurosis. 

When  due  to  the  influence  of  a  drug,  the  condition  is  to  be  arrested  by  stopping 

the  use  of  that  substance  and  aiding  in  its  elimination  by  the  employment  of  sodium 

bicarbonate  if  the  iodides  have  been  taken,  and  mild  saline  purgatives  if  mercury 

has  been  used.     A  mouth-wash  containing  10  grains  of  chlorate  of  potassium  and 

33 


514  DISEASES  OF   Till':  SALIVA  UY  i;LA\l)S 

2  drachms  of  fluidextract  of  rliiis  glabra  in  an  ounce  of  water  will  he  useful  to 
improve  the  condition  of  the  mucous  membrane  and  arrest  the  How  of  saliva. 
Sometimes  moderate  doses  of  atropine  are  useful.  In  other  cases,  10  to  1.5  grain 
doses  of  camphoric  acid  given  thrice  a  day  may  be  used. 

DRY  MOUTH. 

Dry  mouth,  or  xerostomia,  is  frequently  met  with  in  all  fevers,  but  sometimes 
occurs  as  an  independent  condition.  Under  these  circumstances  the  tongue  is 
seen  to  be  red  and  dry,  with  lessened  superficial  epithelium,  so  that  it  is  smooth 
and  shiny.  It  is  said  to  be  most  frequent  in  women  after  great  nervous  excitement 
or  in  those  sufl'ering  from  hysteria. 

Treatment. — Temporary  relief  from  dryness  of  tlie  mouth  may  be  produced 
by  washing  it  with  a  mixture  of  1  part  of  glycerin  to  2  of  water,  to  wliich  has  been 
added  a  little  lemon-juice. 

INFLAMMATION  OF  THE  SALIVARY  GLANDS. 

The  most  important  and  most  common  inflammation  of  the  salivary  glands  is 
the  swelling  of  the  parotid  gland  in  mumps,  which  has  already  been  considered. 
The  next  most  frequent  cause  of  inflammation  of  the  salivary  glands  is  a  septic 
condition  of  the  mouth  in  the  course  of  one  of  the  prolonged  adynamic  fevers,  such 
as  typhoid  fever,  and  in  persons  who  are  sufl'ering  from  cerebral  softening.  In 
these  cases  it  would  seem  that  infection  may  pass  through  the  salivary  duct,  and 
so  cause  inflammation  of  the  gland  itself.  Occasionally  a  similar  accident  occurs 
in  pyemia,  pneumonia,  syphilis,  and  scarlet  fever.  In  some  of  these  diseases 
the  infection  undoubtedly  enters  the  glands  by  way  of  the  blood\'essels  and  Ijtii- 
phatics.  Pyogenic  infection  of  the  parotid,  whether  hemal,  lymphatic,  or  by  a 
duct,  produces  a  suppurative  interstitial  parotitis,  or  parotid  abscess,  also  called 
"parotid  bubo."  A  curious  form  of  inflammation  of  tlie  parotid  gland  witli  stenosis 
of  Steno's  duct  is  sometimes  seen  in  cases  of  sulphuric-acid  poisoning.  AVhile  it  is 
possible  for  the  sublingual  and  submaxillary  glands  to  be  involved,  the  parotid 
is  the  gland  which  nearly  always  suffers. 

The  inflammation  may  be  treated  in  its  earh-  stages  by  cold  compresses,  by  the 
application  of  leeches,  and  by  the  administration  of  circulatory  sedatives  like 
aconite,  provided  the  patient  is  not  already  depressed  by  disease.  So  far  as  possible 
the  treatment  should  also  be  addressed  to  the  relief  of  the  underlying  cause  of  the 
condition.  If  the  gland  is  sufl'ering  from  a  subacute  inflammation,  mercurial 
ointment,  iodine  ointment,  or  ichthyol  ointment  may  be  thoroughly  rubbed  into 
the  skin  over  it,  unless  perchance  the  gland  is  swollen  as  the  result  of  mercurial 
or  iodide  influence.  AVhen  an  abscess  forms  it  must  not  be  forgotten  that  it  should 
be  opened  promptly,  but  with  great  care.  Not  infrequently  a  parotid  abscess  is 
so  closely  associated  with  an  important  bloodvessel,  or  indeed  with  the  external 
carotid  artery,  that  a  careless  incision  may  produce  disaster.  Such  an  abscess 
should  always  be  opened  by  careful  dissection. 

Chronic  indurative  or  sclerosing  parotitis  is  a  well-known  pathological  condition, 
the  clinical  features  of  which  are  still  obscure.  It  has  been  observed  in  diabetes 
with  and  without  pancreatic  disease,  but  the  exact  relationship,  if  any,  is  not 
known. 

Mikulicz's  Disease. — Bilateral  Salivary  Swelling. — This  is  a  condition  character- 
ized by  bilateral  swelling  of  the  salivary  glands,  often  associated  with  an  involve- 
ment of  the  lachrvTiial  glands  and  sometimes  accompanied  by  a  considerable  degree 
of  anemia.  In  some  instances  the  blood  changes  are  closely  allied  to  or  identical 
with  leukemia  and  in  still  others  there  may  be  swelling  of  the  spleen  and  lymph 


ACUTE  PHARYNGITIS  515 

nodes  with  the  picture  of  lymphatic  pseudoleukemia.  According  to  Thursfield 
there  are  at  least  eight  groups  of  these  cases.  In  one  group  it  appears  in  a  con- 
genital or  hereditary  family  affection;  in  another  group  it  occurs  in  a  single  in- 
dividual; in  still  a  third  there  is  involvement  of  the  lymphatic  apparatus;  in  the 
fourth  there  is  leukemia;  in  the  fifth  it  is  associated  with  tuberculosis;  in  the  sLxth 
with  syphilis;  in  a  seventh  with  gout;  while  the  eighth  form  manifests  an  inter- 
mittent or  periodic  salivary  swelling,  the  so-called  sialodochitis  fibrinosa.  The 
prognosis  in  the  simple  form  without  involvement  of  the  lymph  nodes  is  good  as 
to  life,  although  some  years  may  elapse  before  a  cure  de\'elops.  In  the  leukemic 
cases  the  prognosis  is  evil  for  obvious  reasons.  In  the  tuberculous  and  syphilitic 
the  prognosis  depends  upon  the  treatment  usually  carried  out  for  these  maladies. 


DISEASES  OF  THE  PHAKYNX. 

ACUTE  PHARYNGITIS. 

Definition. — Acute  pharyngitis  is  an  acute  catarrhal  inflammation  of  the  mucous 
membrane  lining  the  pharynx  in  which  there  is  hyperemia  and  congestion,  with 
some  infiltration  of  the  submucous  tissues,  and,  later,  an  increased  secretion  of 
mucus. 

Etiology. — Acute  pharyngitis  is  caused,  as  a  rule,  by  simultaneous  exposure  to 
cold  and  infectious  dust.  Cold  and  damp  air  first  impair  the  vital  resistance  of 
the  pharyngeal  mucous  membrane,  and  then  dust,  laden  with  micro-organisms, 
falling  upon  it  speedily  produces  infection.  There  can  be  no  doubt  that  systemic 
conditions  also  favor  the  development  of  this  state. 

Aside  from  the  fact  that  lowered  vitality  always  permits  infection  to  take  place 
readily,  there  can  be  no  doubt  that  the  excessive  use  of  alcohol,  tobacco,  or  rich 
foods,  or  the  presence  of  a  torpid  liver,  or  a  catarrh  of  the  nose,  mouth,  or  stomach 
aid  materially  in  permitting  the  condition  to  arise.  Pharyngitis  also  arises  as  a 
result  of  lithemic  states.  Sometimes  infection  seems  to  come  from  a  chronic 
tonsillitis  or  is  an  extension  from  the  nares.  The  condition  is  particularly  prone 
to  arise  in  those  who  work  for  a  number  of  hours  a  day  in  imperfectly  ventilated 
rooms. 

Pathology. — After  a  preliminary  dry  stage  the  engorgement  of  the  bloodvessels 
of  the  mucous  membrane  and  the  inflammation  of  the  mucous  glands  results  in 
the  pouring  out  of  considerable  quantities  of  mucus,  marked  epithelial  desquama- 
tion, and  in  severe  cases  some  fibrin.  If  pyogenic  organisms  are  present  the  secre- 
tion may  be  distinctly  mucopurulent.  In  some  instances  the  swelling  of  the 
submucous  tissues  is  very  marked.  In  others,  although  severe,  it  may  be  superficial 
In  very  rare  cases  the  exudate  may  be  so  fibrinous  as  to  form  a  false  membrane 
which  is  not  alwaj's  due  to  the  presence  of  the  bacillus  of  diphtheria.  Not  rarely 
in  such  cases  the  uvula  and  the  tonsils  are  also  involved. 

Symptoms. — Acute  pharyngitis  usually  comes  on  suddenly,  with  the  sjinptoms 
of  what  is  popularly  called  "sore  throat,"  so  that  the  patient  feels  that  the  mucous 
membrane  is  swollen  and  sore,  and  there  is  some  pain  on  swallowing.  On  inspection 
it  will  be  found  that  the  posterior  wall  of  the  pharynx  and  neighboring  parts  are 
dry  and  red,  with  the  capillaries  injected.  After  secretion  is  established  the  parts 
are  thoroughly  moistened  by  serum  and  mucus.  In  some  instances,  if  the  infiltra- 
tion of  the  submucous  tissues  is  marked,  the  patient  may  complain  of  a  sense  of 
constriction  in  the  throat,  and  at  times  a  good  deal  of  pain  may  extend  along  the 
Eustachian  tube  into  the  ear.     If  the  pain  is  not  too  great,  the  patient  may  con- 


516  DISEASES  OF  THE  I'lIARYXX 

tinually  clear  his  throat  in  an  effort  to  relieve  the  irritatif)n.  Constitutional 
sj'mptoms  are  usually  mild,  but  the  tongue  is  coated  and  the  patient  may  be  some- 
what depressed. 

Prognosis. — Recovery  always  ensues  unless  some  unforeseen  complication  arises. 

Treatment. — The  treatment  consists,  if  the  patient  is  seen  in  the  early  stages, 
ill  the  ai)])lication  of  a  cold  compress  to  the  neck  below  the  angle  of  the  jaw.  This 
comjiress  is  made  by  dipping  cloths  in  ice-water,  wringing  them  out,  and  then 
binding  them  against  the  part.  They  should  not  be  allowed  to  become  warm 
and  so  produce  the  relaxing  effects  of  a  poultice.  Internally,  if  the  patient  is  an 
adult,  he  may  be  given  from  10  to  1.5  drops  of  the  tincture  of  aconite  with  a  drachm 
of  sweet  spirit  of  nitre  in  a  glassful  of  hot  lemonade.  Before  taking  this  he  should 
be  put  to  bed  in  order  that  when  perspiration  de\-elops  he  will  not  be  chilled. 
Small  pieces  of  ice  may  be  held  in  the  mouth,  but,  as  a  rule,  better  results  will  be 
obtained  if  the  patient  gargles  with  as  hot  water  as  he  can  bear.  This  water  may 
be  fortified  by  adding  to  it  an  equal  quantity  of  the  distilled  extract  of  witch-hazel. 
If  the  bowels  are  at  all  constipated,  saline  purgatives,  such  as  citrate  of  magnesia, 
should  be  used  to  unload  them.  If  there  is  any  rheumatic  or  gouty  tendency,  the 
patient  will  do  best  if,  in  addition  to  the  purgatives,  he  is  given  20  grains  of  bicar- 
bonate of  potash  in  large  draughts  of  water  every  four  or  five  hours;  or,  instead, 
10  grains  of  aspirin  may  be  given  every  three  hours  until  40  grains  have  been  used. 

Local  treatment  aside  from  the  use  of  the  gargle  is  usually  unnecessary.  If  the 
condition  is  due  to  a  gouty  tendency,  the  use  of  any  one  of  the  oily  substances 
commonly  employed  in  atomizers  produces  increased  discomfort,  in  the  writer's 
experience.  If  it  is  not  due  to  this  cause,  some  relief  may  be  obtained  by  spraying 
the  parts  with  3  drops  each  of  oil  of  sandal-wood  and  oil  of  sassafras  in  an  ounce 
of  liquid  albolene.  In  other  cases,  when  the  oils  cause  discomfort,  my  colleague. 
Dr.  Kyle,  strongly  recommends  applying  hydrochloric  acid,  in  the  proportion  of 
5  to  10  drops  of  the  dilute  acid  in  an  ounce  of  water,  for  the  purpose  of  contracting 
the  dilated  bloodvessels. 

When  the  second  stage  is  reached  .5  to  10  grains  of  chloride  of  ammonium  may 
be  given  in  equal  parts  of  fluidextract  of  licorice  and  water  four  or  five  times  a  day. 
Or,  instead,  10  grains  of  benzoate  of  ammonium  may  be  given  in  capsule  four 
times  a  day. 

ULCERATIVE  OR  PHLEGMONOUS  PHARYNGITIS. 

Etiology. — This  condition,  sometimes  called  ulcerated  sore  throat,  or  phlegmonous 
pharyngitis,  is  due  to  an  infection  of  the  mucous  membrane  of  the  throat  by  micro- 
organisms. It  is  not  uncommonly  seen  in  physicians  and  nurses  who  are  attending 
children  suffering  from  scarlet  fever  and  diphtheria.  Many  years  ago  it  was 
frequently  met  with  in  medical  students  who  were  dissecting  cadavers  which  had 
been  imperfectly  preserved.  This  form  of  pharyngitis  is  exceedingly  painful 
in  its  early  stages,  and  is  characterized  by  changes  much  like  those  just  described 
in  acute  catarriial  pharyngitis,  except  that  a  superficial  necrosis  of  the  mucous 
membrane  rapidly  occurs,  so  that  in  a  few  hours  small,  irregular  ulcers  may  be 
seen  upon  the  soft  palate,  the  half-arches,  and  the  pharyngeal  wall.  If  the  infection 
is  severe,  so  that  the  submucous  tissues  are  involved,  it  becomes  a  phlegmonous 
pharyngitis. 

Symptoms. — A  patient  with  infectious  pharyngitis  usually  complains  of  much 
pain  in  the  throat  and  in  the  viii.scles  of  the.  neck.  This  is  greatly  increased  when 
ho  attempts  to  swallow.     There  may  be  si iri lit  febrile  movement  and  depression. 

Treatment. — The  treatment  consists  in  spraying  the  inflamed  mucous  membrane 
with  a  normal  salt  solution,  and  following  this  by  a  gargle  or  spray  of  1  per  cent, 
solution  of  carbolic  acid  and  water  or  albolene.     This  in  turn  is  followed  by  a 


FOLLICULAR  PHARYNGITW  517 

spray  of  menthol,  4  grains  to  the  ounce.  Cold  compresses  applied  under  the  jaw 
are  advantageous.  If  one  or  two  ulcers  are  particularly  active,  they  may  be  touched 
with  nitrate  of  silver.  Usually  it  is  advisable  to  give  the  patient  a  moderate 
purgative  dose  of  calomel  and  to  follow  it  by  a  saline  purge,  such  as  a  Seidlitz 
powder. 

CROUPOUS  PHARYNGITIS. 

Etiology. — Croupous  pharyngitis  occurs  in  two  forms;  as  diphtheria,  which  has 
already  been  described,  and  as  a  simple  membranous  pharyngitis,  which  commonly 
is  due  to  infection  by  the  Pyieumococcus  or  Streptococcus  yyogcnes.  The  chief 
difference  between  this  form  of  pharyngitis  and  diphtheria  is  that  the  mucous 
membrane  is  not  deeply  involved,  that  true  ulceration  never  occurs,  and  the  Klebs- 
Loeffler  bacillus  is  absent.  The  inflammation  is,  however,  of  such  a  character 
that  a  false  membrane  develops  with  desquamation  of  the  epithelium.  If  the 
membrane  is  removed,  the  tissues  beneath  may  bleed,  very  much  as  they  do  in 
diphtheria.  Although  there  is  usually  a  slight  chill  and  some  fever,  the  degree  of 
systemic  disturbance  is  by  no  means  as  marked  as  in  the  well-developed  case  of 
true  diphtheria. 

Treatment. — The  treatment  consists  in  washing  the  infected  parts  thoroughly 
by  a  spray  of  normal  salt  solution,  and  following  this  by  a  solution  of  hydrogen 
peroxide  and  water  half  and  half,  and  this  in  turn  by  gargling  and  spraying  with 
distilled  extract  of  witch-hazel.  Usually  this  treatment  is  sufficient.  If  the 
condition  persists  Loeffler's  solution  may  be  applied  locally.  Antitoxin  is  to  be 
used  if  diphtheria  is  present.     (See  Diphtheria.) 

CHRONIC  PHARYNGITIS. 

Etiology. — A  condition  of  chronic  inflammation  of  the  pharyngeal  mucous  mem- 
brane is  frequently  met  with  in  certain  climates,  particularly  that  of  the  Atlantic 
seaboard.  It  is  also  found  in  persons  who  continually  use  the  voice,  and  so  it 
has  obtained  the  name  of  "auctioneer's"  or  "clergymen's"  sore  throat.  It  is 
also  met  with  in  persons  who  use  tobacco  to  excess,  and  sometimes  in  those  who 
take  too  much  alcohol.  Obstructions  in  the  nasal  passages  seem  distinctly  to 
predispose  to  this  state. 

Pathology. — The  pathological  condition  consists  in  a  thickening  of  the  mucous 
membrane  of  the  pharynx  and  an  increase  in  the  connective  tissues  of  the  mucous 
membrane  itself,  and  of  the  submucous  tissues.  This  may  result  in  a  secondary 
atrophy  of  the  glands  in  the  mucous  membrane. 

Symptoms. — The  symptoms  consist  in  a  thickening  of  the  pharyngeal  secretions 
and  irritation  of  the  mucous  membrane,  so  that  the  patient  is  continually  attempting 
to  clear  the  throat,  which  often  feels  dry  and  harsh.  The  cough  is  spasmodic, 
unproductive  in  its  result,  and  is  made  much  worse  by  exposure  to  cold  and  dust. 

Treatment. — The  treatment  consists  in  a  regulation  of  the  digestive  system, 
in  giving  tone  to  the  circulation  if  it  is  feeble,  in  rest  for  the  nervous  system  if  the 
patient  is  overworked,  and  in  the  internal  administration  of  benzoate  of  ammonium 
in  10  grain  doses  several  times  a  day.  Before  going  to  bed  at  night  the  patient 
should  gargle  his  throat  with  hot  water  or  with  hot  salt  solution,  and  if  the  blood- 
vessels are  much  dilated  a  spray  of  dilute  hydrochloric  acid,  10  drops  to  the  ounce 
of  water,  should  be  used. 

FOLUCULAR  PHARYNGITIS. 

Etiology. — Under  the  name  of  follicular  pharyngitis  a  closely  related  condition 
to  that  just  described  exists,  in  which  an  annoying  cough  is  persistent,  and  in 


518  DISEASES  OF  THE  TOXSILS 

which  a  considerable  number  of  enlarged  follicles,  surrounded  by  an   injected 
mucous  meml)rane,  can  be  seen  on  the  posterior  wall  of  the  pharynx. 

Treatment. — The  treatment  is  of  the  same  character  as  that  just  described  for 
clironic  ])luiryngitis.  Occasionally  it  is  necessary  to  cauterize  the  follicles.  An 
excellent  api)iication  is  tincture  of  iodine  1  part  in  2  parts  of  glycerin. 

EPIDEMIC  SORE  THROAT. 

Definition. — This  very  general  term  is  applied  to  a  form  of  more  or  less  severe 
pharyngitis  and  tonsillitis  occurring  in  epidemic  form,  sometimes  causing  death. 
The  earliest  reports  deal  with  an  epidemic  in  England  in  1875.  Very  noteworthy 
outbreaks  have  occurred  in  Boston  in  1910  and  1911,  in  Chicago  and  Baltimore  in 
1911  and  1912,  and  in  Jacksonville,  Illinois,  in  1913.  In  Chicago  no  less  than  10,000 
persons  suffered  from  it. 

Etiology. — The  cause  exists  in  infected  milk  derived  from  cows  suffering  from 
an  acute  inflammation  of  the  udder  due  to  a  streptococcus,  which  organism  is 
found  to  be  identical  in  the  milk  and  in  the  throat  of  the  patient.  The  micro- 
organism is  easily  destroyed  in  sour  milk,  but  may  be  found  in  ice-cream  after 
three  weeks. 

Symptoms. — These  consist  in  more  or  less  severe  inflammation  of  the  jjharyn.x 
and  tonsils  with  swelling  of  the  cervical  lymph  nodes,  fever  as  high  as  105°  F.,  and 
great  prostration.  When  death  has  ensued  it  has  been  due  to  erysipelas,  septic 
pneumonia,  peritonitis,  appendicitis,  or  general  septicemia. 

Treatment. — This  consists  in  preventing  further  infection  by  excluding  the  milk 
previously  used  and  using  only  pasteurized  or  boiled  milk  and  in  the  general  plan 
of  treatment  carried  out  in  combating  any  one  of  the  conditions  named. 


DISEASES  OF  THE  TONSILS. 

ACUTE  TONSILLITIS. 

Definition. — As  its  name  implies,  this  disease  consists  in  an  acute  inflammation 
of  the  tonsils,  accompanied  by  great  swelling  of  their  tissues,  and  an  associated 
pharyngitis.  It  occurs  in  two  forms,  the  follicular  and  diffuse.  The  follicular 
form  is  distinctly  infectious. 

Etiology. — Acute  tonsillitis  is  the  result  of  an  infection  by  pathogenic  micro- 
organisms, which  are  practically  always  present  in  the  crypts  of  the  tonsils,  but 
do  not  penetrate  the  mucous  membrane  until  its  permeability  is  increased  by  con- 
gestion, or  by  general  causes  afl'ccting  perhaps  the  vital  resistance  of  the  entire 
body.  In  many  instances  the  suppurating  form  arises  because  the  organisms 
attempt  to  enter  the  general  system  by  way  of  the  tonsils,  and  the  suppurative 
process  is  the  result  of  an  ett'ort  to  prevent  such  an  entrance.  The  streptococcus 
is  a  cause  in  some  cases.  In  other  cases  the  organism  which  Poynton  and  Payne 
think  is  the  cause  of  acute  articular  rheumatism  is  responsible,  and  the  bacillus 
of  diphtheria  is  also  a  common  factor. 

Follicular  tonsillitis  is  more  common  in  the  period  of  life  from  five  to  twenty 
years  than  at  any  other  time,  and  is  rare  in  infancy.  Some  individuals  sufl'er 
from  frequent  attacks  until  they  reach  forty  or  fifty  years  of  age.  After  this  time 
of  life  it  is  very  rare. 

Although  follicular  tonsillitis  is  rare  in  adults,  the  suppurating  form  is  frequently 
met  with  in  this  class  of  patients.     Persons  who  have  a  lymphatic  temperament 


ACUTE  TONSILLITIS  519 

are  far  more  susceptible  than  persons  of  the  wiry  type,  and  it  is  particularly  prone 
to  occur  in  those  who,  because  of  obstruction  of  the  nasal  passages,  are  "mouth 
breathers,"  or  who  sufi'er  from  subacute  or  chronic  hypertrophic  catarrh  of  the 
nasopharynx.  One  attack  distinctly  jjredisposes  to  another.  My  exjjerience 
leads  me  to  believe  that  it  is  distinctly  infectious,  for  I  have  repeatedly  seen  healthy 
persons  develop  the  malady  after  being  exposed  to  the  breath  of  those  who  were 
ill  with  it.  Another  predisposing  cause  is  the  Ijreathing  of  vitiated  air,  and  air 
that  is  contaminated  by  sewer  gas  or  smoke.  How  much  these  influences  act 
directly  as  sources  of  infection  and  how  much  as  agents  which,  by  diminishing 
vital  resistance,  make  infection  possible,  is  difficult  to  determine. 

Pathology  and  Morbid  Anatomy. — In  acute  follicular  tonsillitis  there  is  an  inflam- 
matory swelling  of  the  parenchyma  of  the  gland.  The  mucous  membrane  covering 
the  gland  is  intensely  hyperemic  and  may  even  show  vesicles  on  its  surface.  Each 
follicle  exudes  a  cheesy-looking  mass,  and  these  masses  dot  the  surface  of  the  tonsil 
or  coalesce  and  produce  a  tonsillar  coating,  which  at  first  glance  closely  resembles 
the  false  membrane  of  diphtheria.  If  some  of  this  material  is  examined  micro- 
scopically it  is  found  to  consist  of  dead  epithelial  cells,  micro-organisms,  and  pus 
cells.  In  addition  to  these  superficial  changes  there  is  hyperemia  of  the  tonsillar 
capillaries,  and  proliferation  of  the  lymphoid  cells  in  the  deeper  tissues  of  the  glands. 
In  the  more  deeply  situated  and  intense  inflammations  of  the  gland,  sometimes 
called  quinsy,  there  is  a  necrosis  of  the  tissues,  suppuration  takes  place,  and  the 
pus  escapes  from  the  tonsillar  abscess,  either  by  the  aid  of  the  surgeon's  knife  or 
by  rupture  of  the  abscess  w'all.  In  any  of  these  conditions  the  passage  of  bacteria 
or  their  toxins  into  the  lymphatics  may  produce  glandular  enlargement  in  the  neck. 

As  general  systemic  infection  often  enters  the  body  by  way  of  the  tonsils  it  is 
wise  to  be  on  the  watch  for  signs  of  endocarditis.  Doubtless  the  association  of 
rheumatism  with  tonsillitis  by  many  practitioners  is  due  more  to  the  development 
of  septic  arthritis  from  the  entrance  of  pathogenic  germs  by  these  pathways  than 
to  any  real  relationship  between  acute  rheumatism  and  tonsillitis.  I  have  seen 
many  cases  of  severe  endocarditis  and  acute  arthritis  follow  an  acute  tonsillitis. 

Symptoms. — A  patient  suffering  from  the  earliest  stages  of  acute  tonsillitis  may 
first  feel  soreness  of  the  throat,  with  a  sense  of  local  swelling  or  constriction,  or  the 
systemic  signs  of  the  infection  may  first  be  manifested.  Creeping,  chilly  sensations, 
or  even  a  true  rigor,  may  develop,  and  there  is  very  frequently  an  amount  of  aching 
and  fain  in  the  limbs  which  is  extraordinarily  severe,  so  that  the  patient  complains 
most  bitterly,  not  only  of  this  symptom,  but  of  the  degree  of  illness,  so  that  he 
fears  a  serious  malady.  Violent  headache  is  often  a  prominent  symptom,  and  the 
temperature  soon  becomes  very  high,  mounting  to  103°  or  104°  or  even  105°  in  a  few 
hours.  Rarely  nausea  and  vomiting  may  occur.  An  examination  of  the  throat 
will  show  the  presence  of  distinct  swelling  of  the  tonsils,  which  not  rarely  extend 
as  far  across  the  fauces  as  the  uvula,  and  even  press  against  one  another.  These 
swellings  are  intensely  congested  and  frequently  covered  with  exudate,  and  are 
often  very  foul  in  appearance.  The  breath  of  the  patient  is  often  exceedingly /om?,  and 
unless  ventilation  is  very  good  the  odor  may  fill  the  room.  Owing  to  the  swelling 
of  the  tonsils  and  adjacent  glands  and  stiffness  of  the  muscles  of  the  sides  of  the 
neck,  an  examination  of  the  patient's  throat  may  be  very  painful.  It  is  a  note- 
worthy fact  that  acute  follicular  tonsillitis  is  practically  alwaj's  bilateral,  while  the 
deeper  form,  sometimes  called  quinsy,  is  often  unilateral. 

In  the  suppurating  form  of  the  disease  the  systemic  manifestations  are  often 
less  severe  than  in  the  follicular  types  just  described,  but  the  local  pain  is  often 
very  severe,  and  opening  the  mouth  may  be  very  painful.  The  tonsil  is  often 
enormously  enlarged,  but  is  rarely  dotted  with  follicular  spots.  Instead  it  may 
be  smooth  and  shining  in  appearance.  The  inflammation  often  extends  to  the 
uvula,  which  may  be  so  swollen  and  elongated  as  to  cause  great  distress. 


520  DISK  ASKS  OF  THE  TOXSILS 

Treatment. — The  treatment  of  botli  forms  of  tonsillitis  is  largely  identieal.  To 
the  surface  of  the  tonsil,  in  the  first  twenty-four  hours  of  the  inflammation,  there 
is  nothing  better  to  arrest  the  process  and  relieve  pain  than  pure  guaiacol  applied 
by  a  cotton  applicator.  This  often  causes  great  pain  for  the  moment;  but  it  is 
remarkably  efficacious.  Externally,  over  the  gland,  a  small  ice-bag  is  a  valuable 
application.  It  should  be  kept  constantly  applied  for  several  days.  Internally 
in  the  very  early  stages  the  use  of  biniodide  of  mercury  is  very  useful  in  the  dose 
of  -5~o  0  oi  a  grain  every  half-hour  till  ,-,'„  grain  has  been  taken. 

After  the  stage  of  onset  is  past  the  Ijest  internal  treatment  is  10  to  20  minims 
of  tincture  of  iron  chloride  well  diluted  with  water  every  three  or  four  hours  and 
potassium  bicarbonate,  or  citrate,  in  copious  draughts  of  water  to  flush  the  kidneys 
and  diminish  the  backache. 

Many  practitioners  rely  largely  on  aspirin  or  salicin  at  this  time,  giving  them  in 
full  doses.  They  are  efficacious,  but  they  increase  headache,  disorder  the  diges- 
tion, and  may  irritate  the  kidneys,  which  are  prone  to  irritation  in  this  disease. 

Some  cases  get  relief  from  gargling  with  very  hot  water  or  by  holding  ice  in  the 
mouth. 

When  the  tonsils  are  chronically  enlarged  and  repeated  attacks  of  tonsillitis 
occur  they  should  be  removed  between  attacks.  The  application  of  caustics  like 
nitrate  of  silver  often  makes  them  larger  than  before. 

In  the  suppurating  form  the  pus  should  be  evacuated  as  soon  as  it  is  formed, 
the  tonsils  being  punctured  by  a  bistoury  or  a  tenotome,  the  tip  of  which  is  exposed 
after  being  run  through  a  small  cork  so  as  to  guard  it  and  present  any  movement 
of  the  patient  from  causing  the  physician  to  injure  an  important  bloodvessel. 

In  all  cases  of  follicular  tonsillitis  cultures  of  the  secretions  from  the  throat 
should  be  examined  for  the  Klebs-LoefHer  bacillus,  for  in  all  cases  before  making 
a  diagnosis  of  follicular  tonsillitis  the  physician  should  carefully  exclude  diphtheria. 
(See  Diphtheria.)  When  children  are  in  the  household  the  patient  should  be 
carefully  isolated. 

LUDWIG'S  ANGINA. 

In  1836  Ludwig  described  a  condition  in  which,  in  association  with  an  acute 
inflammation  of  the  mucous  membrane  of  the  mouth,  cheek  or  tonsillar  region  there 
developed  a  phlegmonous  cellulitis  resembling  that  produced  in  other  portions  of 
the  body  by  virulent  infections.  This  cellulitis  is  particularly  prone  to  involve 
the  tissues  under  the  tongue.  It  may  spread  with  great  rapidity  and  rapidly  reach 
a  fatal  termination  in  ten  days.  The  sub-maxillary  area  is  intensely  swollen,  the 
lower  jaw  almost  immovable.  The  extension  of  the  swelling  posteriorly  may 
produce  suffocation.  Whether  Ludwig's  angina  is  a  specific  infection  is  not  as 
yet  determined,  but  almost  every  bacteriological  investigator  has  found  one  or 
more  common  pathogenic  germs  present.  Some  have  isolated  the  streptococcus, 
others  the  bacillus  of  malignant  edema,  and  sometimes  the  streptococcus  and 
staphylococcus  have  both  been  present.  The  pneumococcus  has  also  been 
found  in  the  pus.  E\en  when  fluctuation  cannot  be  found  if  pressure  symp- 
toms exist  free  drainage  should  be  obtained.  Ludwig  considered  the  following 
symptoms  as  characteristic  of  the  disease:  More  or  less  inflammation  of  the  throat 
which  often  disappears  early.  A  board-like  hardness  of  the  sub-maxillary  swelling; 
a  condition  also  characteristic  of  the  sub-lingual  swelling  so  that  the  same  sensation 
is  given  to  the  finger  both  inside  and  outside  the  lower  jaw.  There  is  a  sharp 
line  of  demarcation  between  the  indurated  tissues  and  the  siurounding  healthy 
ones,  and  this  is  true  even  when  the  loose  connective  tissue  is  involved.  There 
is  an  irregular  septic  fever,  profuse  sweats,  delirium  and  a  rapidly  developing 
typhoid  state  if  free  drainage  is  not  given  early.  The  swelling  may  rupture  in 
the  floor  of  the  mouth  discharging  a  tliin  grayish  or  reddish-brown  offensive  fluid, 


CHRONIC  HYPERTROPHIC  TONSILLITIS  521 

more  like  a  putrefactive  process  than  ordinary  suppuration.  Aside  from  free  drain- 
age the  patient  should  be  supported  by  good  food,  administered  through  a  tube,  by 
stimulants  and  if  possible  by  the  use  of  autogenous  vaccine.  If  the  chief  swelling 
is  sublingual  the  incision  may  be  made  between  the  tongue  and  the  teeth,  or  a 
median  incision  may  be  carried  through  the  mylohyoid  muscle  under  the  jaw. 

VINCENT'S  ANGINA. 

Vincent's  angina  is  an  acute  inflammatory  diphtheroid  inflammation  of  one  or 
both  tonsils,  which  condition  in  severe  cases  extends  to  peritonsillar  tissues  and  is 
often  accompanied  by  marked  swelling  of  the  cervical  lymph  nodes.  Two  asso- 
ciated microorganisms  are  present,  a  spirillum  and  a  fusiform  bacillus  readily 
differentiated  by  Gram's  method  of  staining.  These  organisms  do  not  grow  on 
ordinary  culture  media  and  can  only  be  found  by  using  a  smear.  It  is  probably 
far  more  common  than  supposed,  being  diagnosed  as  acute  tonsillitis.  The  false 
membrane  when  removed  leaves  a  bleeding  surface.  The  blood  shows  a  marked 
lymphocytosis.  There  is  little  fever  but  considerable  prostration.  If  the  peri- 
tonsillar tissues  are  involved  and  the  patient  is  already  feeble  death  may  occur. 
The  treatment  consists  in  the  local  use  of  tincture  of  iodine,  hydrogen  peroxide  or 
nitrate  of  silver,  and  good  food  with  iron  and  arsenic.  RoUeston  and  others 
advise  dipping  a  cotton  applicator  in  glycerin  which  is  in  turn  dipped  in  salvarsan 
and  applied  to  the  lesion.     The  results  are  remarkably  good. 

CHRONIC  HYPERTROPHIC  TONSILLITIS. 

Definition. — Chronic  hypertrophic  tonsillitis  is  a  condition  of  overgrowth,  or 
hyperplasia  of  the  tonsils,  which  affects  all  parts  of  both  tonsils  and  usually  involves 
the  so-called  pharjaigeal  tonsil.  In  some  instances  the  lymphoid  tissue  of  the 
glands  is  chiefly  affected,  while  in  others  it  is  the  connective  tissue.  In  the  one 
instance  the  enlarged  tonsils  present  themselves  as  projecting  masses,  soft  in  tex- 
ture. In  the  other  they  are  remarkably  hard  and  cut  with  a  resistance  almost 
cartilaginous  in  character.  In  some  instances  there  is  overgro^'th  of  the  tonsils 
without  the  adenoid  of  the  pharynx  being  involved.  Nearly  always  patients 
with  this  affection  suffer  from  associated  nasal  catarrh,  often  from  secondary 
middle-ear  disease,  and  they  present  a  peculiar  expression  of  stupiditj'  or  lack 
of   intelligence. 

Symptoms. — Aside  from  organic  disease  of  the  great  viscera  there  is  no  chronic 
malady  which  produces  such  extraordinary  changes  in  the  physical  appearance, 
growth,  and  mental  development  as  does  this  one.  The  obstruction  to  free  nasal 
breathing  results  in  mouth  breathing,  and  this  in  turn  causes  the  child  to  hold  the 
mouth  open  in  a  silly  manner,  which  detracts  from  its  facial  appearance.  So, 
too,  the  lack  of  free  respiration  results  in  a  failure  of  physical  development,  so 
that  the  chest  is  often  poorly  developed,  and  even  the  entire  body  is  dwarfed.  Finally, 
this  same  cause  produces  restless  nights  and  so  causes  loss  of  physical  rest,  which 
may  be  emphasized  by  attacks  of  spasmodic  croup  or  night  screaming.  Constant 
cough  at  night  on  lying  down  is  also  often  a  troublesome  symptom  and  is  due  to 
undue  dryness  of  the  nasopharynx  or  to  thickening  of  the  uvula  by  the  edges  of 
of  the  projecting  tonsils. 

After  the  disease  has  lasted  for  years  the  child  is  often  stupid,  morose,  and 
apathetic  to  a  degree,  and  the  open  mouth,  stunted  nose,  and  heavy  eyes  make  a 
diagnosis  of  the  tonsillar  state  easy.  When  the  child  is  stripped  the  chest  is  often 
found  to  be  barrel-shaped  or  the  patient  is  pigeon-breasted,  or  it  presents  the 
Trichterbrust  of  the  Germans,  or  the  so-called  funnel  chest  of  English  writers,  in 
which  there  is  a  deep  depression  of  the  lower  part  of  the  breast-bone.     These 


522  DISEASES  OF  THE  ESOPIIAdUS 

tlioracic  changes  are  due  to  two  chief  causes:  first,  the  general  impairment  of 
nutrition  produces  mahiutrition  of  tlie  thoracic  walls  as  in  rickets,  and,  second,  in 
the  efi'ort  at  sufficient  respiration  the  chest  walls  undergo  faulty  de\clopment. 
The  breath  is  often  quite  fetid,  due  to  retained  secretions  and  particles  of  food  in 
the  crypts  of  the  tonsils,  and  if  the  tonsils  be  pressed  upon  a  surprisingly  large 
amount  of  material  can  be  expelled  from  their  cavities. 

The  nasopharyngeal  spaces  of  such  children  are  first-rate  culture  fields  for  the 
growth  of  bacteria  of  all  sorts  and  for  acute  infections,  such  as  diphtheria  and 
scarlet  fever. 

Treatment. — AVhen  the  tonsils  are  ragged  and  clironically  enlarged  this  does 
not  in  itself  indicate  operative  interference.  There  can  be  no  doubt,  as  J. 
Noland  Mackenzie  points  out,  that  there  has  been  a  massacre  of  the  tonsil  in  the 
last  decade.  If  the  enlargement  obstructs  breathing,  causes  night  cough,  or  results 
in  frequent  attacks  of  acute  tonsillitis  the  tonsils  should  be  removed,  particularly 
if  they  induce  peritonsillar  abscess.  Mere  enlargement  of  the  tonsils  does  not 
necessarily  predispose  the  child  to  the  severe  complication  of  the  acute  infectious 
diseases,  such  as  diphtheria  and  scarlet  fever.  If,  however,  the  tonsils  are  so 
large  as  to  obstruct  breathing,  and  particularly  if  the  postnasal  adenoids  are  greatly 
enlarged,  making  the  child  a  mouth-breather,  then  operative  interference  is  essential. 
If  we  except  the  effects  produced  by  the  use  of  thyroid  gland  in  cretinism  it  is  not 
possible  to  find  any  state  in  which  the  physician  can  cause  such  a  complete  meta- ' 
morphosis  in  his  patient  as  to  health  of  mind  and  body  as  in  this  type  of  case. 
The  removal  of  the  enlarged  tonsils  by  tonsillotomy  and  the  scraping  away  or 
curetting  of  the  pharyngeal  adenoid  results  in  free  and  easy  breathing  and  in  an 
extraordinary  change  in  growth  and  spirits.  Children  who  have  been  stunted  in 
mind  and  body  for  years  gain,  it  may  be,  thirty  pounds  in  a  few  months,  become 
rosy  and  bright-looking,  and  are  able  for  the  first  time  to  keep  up  with  their  fellows 
in  school  and  in  sport. 

The  use  of  cod-liver  oil  and  syrup  of  the  iodide  of  iron  after  the  operation  is  a 
great  aid  to  speedy  recovery. 


DISEASES  (W  THE  ESOPHAGUS. 

ESOPHAGITIS. 

An  acute  inflammation  of  the  esophagus  often  ensues  after  the  ingestion  of 
irritant  poisons,  such  as  concentrated  lye,  ammonia-water,  carbolic  acid,  and 
similar  substances.  Under  these  conditions  it  is  but  a  part  of  the  general  inflamma- 
tion of  the  gastrointestinal  tract  which  all  irritant  poisons  induce,  and  has  little 
interest  except  from  a  toxicological  standpoint  and  the  strictures  that  commonly 
follow.  When  esophagitis  is  due  to  disease  it  may  arise  from  an  extension  of  a 
diphtheria  from  the  pharynx  or  from  an  extension  of  the  inflammation  in  the 
pharynx  in  cases  of  scarlet  fever.  So,  too,  in  certain  cases  of  tyj)ht)id  fever  the 
esophagus  may  undergo  inflammatory  changes,  and  these  may  progress  to  such 
an  extent  that  ulceration  ensues.  (See  Typhoid  Fever.)  Sometimes,  too,  the 
esophagus  is  involved  in  cases  of  aphthous  stomatitis  and  in  thrush. 

A  membranous  esophagitis  occurs,  but  it  is  rare.  It  may  follow  the  swallowing 
of  escharotics  and  is  occasionally  seen  after  prolonged  alcoholic  excess.  A  cast 
of  the  entire  esophagus  may  be  expelled. 

The  mucous  membrane  in  ordinary  inflammations  of  the  esophagus  is  reddened 
and  hyperemic.     There  may  be  some  pain  beneath  the  breastbone,  which  is  in- 


DILATATION  OF  THE  ESOPHAGUS  523 

creased  by  the  swallowing  of  food  or  drink,  but  in  the  milder  types  no  symptoms 
are  present,  and  unless  ulceration  is  followed  by  cicatrization,  neither  the  physician 
nor  the  patient  may  be  aware  of  the  fact  that  the  esophagus  has  suft'ered  from  an 
inflammatory  process. 

Should  symptoms  of  pain  and  discomfort  exist,  they  may  be  relie\-ed  by  the 
use  of  demulcent  drinks,  of  which  perhaps  the  best  is  emulsion  of  sweet  almonds, 
or  milk  with  arrowroot.     Sometimes  swallowing  small  pieces  of  ice  gives  relief. 

In  cases  of  heart  disease  and  cirrhosis  of  the  liver  a  form  of  chronic  esophagitis 
sometimes  develops,  in  which  the  mucous  membrane  sutlers  from  a  chronic  catarrh 
and  the  smaller  bloodvessels  become  varicose  and  rupture,  causing  the  vomiting 
of  blood. 

ORGANIC  STRICTURE  OF  THE  ESOPHAGUS. 

As  has  already  been  intimated,  stricture  of  the  esophagus  usually  follows  the 
healing  of  an  ulcer  which  is  produced  by  the  ingestion  of  some  corrosive  substance, 
or  by  ulceration  developing  in  the  course  of  typhoid  fe\'er  or  syphilis.  Stricture 
may  be  cylindrical  or  annular,  symmetrical  or  asymmetrical,  single  or  multiple. 
The  usual  sites  are  behind  the  cricoid  cartilage,  opposite  the  bifurcation  of  the 
trachea,  and  at  the  hiatus  esophagei.  Occasionally  inflammation  of  a  lymphatic 
gland,  the  pressure  of  a  tumor  in  the  mediastinum,  or  of  an  aneurysm,  causes  a 
narrowing  of  the  gullet,  and,  more  rarely  still,  a  polypoid  tumor  may  grow  from 
the  mucous  membrane.     Malignant  stricture  will  be  discussed  later. 

Symptoms. — The  symptoms  consist  in  difficulty  in  swallowing  food,  the  patient 
stating  that  it  lodges  part  way  down  to  the  stomach,  and  that  if  any  considerable 
quantities  are  taken  regurgitation  takes  place,  the  regurgitated  materials  containing 
no  trace  of  gastric  juice  or  the  products  of  digestion.  If  an  esophageal  bougie 
is  passed  it  is  found  to  be  arrested  at  the  level  of  the  stricture,  and  it  may  be  im- 
possible to  push  it  past  this  point. 

Treatment. — The  treatment  consists  in  the  use  of  a  small  bougie  to  dilate  the 
stricture,  followed  by  the  employment  of  larger,  graduated  bougies.  If  the  stricture 
is  so  tight  that  food  cannot  pass  and  the  life  of  the  patient  is  endangered  by  inani- 
tion, and  if  the  use  of  a  bougie  fails  to  overcome  the  obstruction,  surgical  interference 
will  be  necessary. 

Sometimes  stricture  of  the  esophagus  is  a  congenital  condition,  in  which  case  the 
child  rarely  lives,  and  little  can  be  done  for  its  relief. 

DILATATION  OF  THE  ESOPHAGUS. 

Etiology. — Dilatation  of  the  esophagus  occurs  in  two  forms,  namely,  the  diffuse 
and  the  localized.  In  the  diffuse  form  the  entire  tube  is  dilated,  and  there  may 
be  some  overgrowth  of  the  muscular  fibres,  which  has  occurred  in  an  endeavor 
on  the  part  of  the  esophagus  to  force  food  past  an  obstruction  which  exists  near 
the  cardiac  orifice  of  the  stomach. 

When  a  localized  dilatation  occurs  it  takes  the  form  of  a  diverticulum,  which 
may  be  divided  into  two  types,  namely,  "pressure  diverticula"  and  "traction 
diverticula."  The  pressure  diverticula  are  very  rare  and  are  found  usually  at 
the  junction  of  the  pharynx  and  the  esophagus,  where  the  muscular  fibres  are 
weakest.  Their  origin  is  supposed  to  depend  upon  pressure  upon  this  point  of 
the  gullet  in  deglutition,  and  they  are  thought  to  develop  in  those  who  are  in  the 
habit  of  bolting  their  food.  The  diverticulum  arising  from  this  cause  is  lined 
with  mucous  membrane,  its  submucous  tissues  are  thickened,  and  the  muscular 
coat  is  atrophied  so  that  the  mucous  coat  bulges  through  it  as  a  hernia-like  pro- 
jection. The  lesion  always  occurs  in  the  posterior  or  posterolateral  wall  of  the 
esophagus. 


524  DISEASES  OF  THE  ESOPHAGUS 

Traction  diverticula  occur  more  frequently  than  the  type  just  mentioned,  but 
are  very  seldom  recognized  during  lite.  They  are  thought  to  be  due  to  contraction 
of  tissues  which  have  become  attached  to  the  esoj)liagus  hy  inflammatory  adhesions, 
as  in  cases  in  which  inflammation  of  the  bronchial  lymph  glands  has  taken  place. 
This  lesion  is  usually  found  in  the  anterior  wall  of  the  gullet,  and  a  number  of 
diverticula  may  be  present  in  a  single  case. 

Atonic  dilatation  of  the  esophagus  is  occasionally  observed;  the  dilated  tube 
may  be  fusiform  or  flask-shaped,  the  part  of  the  organ  corresponding  to  the  neck 
of  the  flask  being  upward.  Such  dilatation  occurs  independently  of  organic  disease 
below,  and  has  been  attributed  to  spasm  of  the  cardia.  The  dilated  esophagus 
may  be  extremely  capacious,  holding  a  pint  or  more  of  fluid. 

Symptoms. — The  symptoms  of  difl'use  dilatation  of  the  esophagus  due  to  stenosis 
are  those  produced  by  stricture  of  the  gullet,  and  consist  chiefly  in  difficulty  in 
swallowing.  It  is  a  condition  rarely  recognized  during  life.  The  small  diverticula 
due  to  traction  by  adhesions  are  also  rarely  recognized,  unless  one  of  them  becomes 
so  large  that  it  forms  a  pocket  in  which  food  accumulates,  until  by  reason  of  its 
decomposition  or  fermentation  it  produces  so  much  irritation  and  inflammation 
that  the  stomach,  esophagus,  and  all  the  muscles  of  the  chest  and  abdomen  endeavor 
to  expel  it  by  a  process  akin  to  that  of  vomiting.  Sometimes  a  diverticulum  of 
this  character  is  capable  of  holding  a  very  considerable  quantity  of  fluid. 

Diagnosis. — The  diagnosis  of  a  diverticulmn  is  reached  by  the  use  of  a  stomach 
tube,  which  is  passed  as  far  as  it  will  go  and  then  used  as  it  would  be  in  la\'age,  or  as 
a  stomach  pump  would  be  employed.  Under  these  circumstances  liquids  which 
have  been  swallowed  are  brought  up  when  the  tube  has  not  been  passed  far  enough 
to  make  it  possible  that  the  liquids  are  obtained  from  the  stomach.  Such  large 
diverticula  are  usually  of  the  traction  type.  A  diverticulum  may  be  discovered  by 
filling  the  cavity  with  bismuth  and  syrup  of  acacia  and  using  the  .r-rays. 

Treatment. — The  treatment  consists  in  the  use  of  a  stomach  tube  for  the  purpose 
of  feeding  the  patient,  provided  the  physician  or  the  patient  is  successful  in  passing 
the  tube  past  the  diverticulum.  In  those  cases  in  which  the  diverticulum  is  so 
large  that  it  prevents  the  ingestion  of  food,  by  pressure  on  the  esophagus,  and  so 
interferes  with  the  patient's  nutrition,  the  only  resort  is  a  surgical  operation  and 
rectal  alimentation. 

SPASM  OF  THE  ESOPHAGUS. 

This  affection,  sometimes  called  "  esophagisiimts,"  is  rarely  met  with  except  in 
persons  sufl'ering  from  hysteria  or  insanity.  It  is  sometimes  seen  in  hydrophobia, 
and  it  is  this  difficulty  in  swallowing  water,  rather  than  an  actual  dread  of  water, 
which  has  given  that  disease  its  name;  for  with  the  thought  of  swallowing,  at  the 
sight  of  water,  the  spasm  develops.  The  difficulty  in  swallowing  usually  points 
to  the  presence  of  spasm  or  stricture,  and  if  there  is  no  history  of  the  ingestion  of 
an  irritant  some  time  before,  or  other  causes  which  would  be  likely  to  produce 
ulceration  and  stricture,  the  strong  possibility  of  spasm  is  to  be  considered.  L  sually 
in  spasm  it  is  much  easier  to  pass  an  esophageal  bougie  than  it  is  in  cases  of  stricture. 
But  occasionally  the  spasm  is  sufficiently  tight  to  oppose  the  passage  of  the  bougie, 
and  to  give  to  the  hand  guiding  the  bougie  the  sensation  which  is  produced  by  the 
end  of  the  instrument  commg  in  contact  with  a  true  organic  obstruction. 

Treatment. — The  treatment  consists  in  the  passage  of  a  bougie  once  or  twice  a 
day;  in  the  administration  of  nervous  sedatives  if  the  patient  is  in  a  condition  of 
nervous  excitation;  of  stimulants,  if  she  is  in  a  condition  of  profound  dei)ression, 
and  of  measures  devoted  to  the  improvement  of  the  general  health,  both  mental 
and  physical,  if  it  is  impaired.  As  the  spasm  may  be  due  to  a  fissure,  ulcer,  or 
other  tender  spot  the  food  should  not  be  bulky,  but  preferably  liquid  and  never 
taken  in  large  amounts. 


ACUTE  GASTRIC  CATARRH  525 


CANCER  OF  THE  ESOPHAGUS. 


Cancer  of  the  esophagus  usually  occurs  in  the  form  of  squamous  epithelioma, 
and  affects  men  more  frequently  than  women.  Occasionally  a  medullary  cancer 
is  found  in  this  region.  The  growth  soon  undergoes  ulceration,  and  not  infrequently 
the  entire  circumference  of  the  tube  may  be  involved,  and  in  this  manner  a  stenosis 
may  be  developed  with  dilatation  of  the  esophagus  above  the  point  of  growth. 
The  disease  is  quite  rare,  for  of  7290  cases  of  cancer  collected  by  'Williams  but  G 
per  cent,  were  primary  in  the  esophagus.  Tanchon  in  9118  cases  of  cancer  found 
only  1.3  in  the  esophagus.  Cases  have  been  recorded  as  early  in  life  as  nineteen 
years,  but  most  patients  are  past  forty.  The  disease  is  about  equally  divided  as 
to  its  occurrence  in  different  levels  of  the  tube.  Thus,  if  the  statistics  of  Kraus, 
von  Hacker,  and  Newmann  are  added  together,  making  1477  cases,  we  find 
that  582  were  near  the  cardia,  453  near  the  middle  third,  and  440  at  the  upper 
third. 

Symptoms. — The  symptoms,  as  in  cases  of  ordinary  stenosis  due  to  stricture, 
consist  in  difficult  deghdition  and  not  infrequently  considerahJe  jpain,  both  at  the 
time  of  swallowing  and  when  the  esophagus  is  at  rest.  The/oocZ  is  often  regurgitated 
almost  as  soon  as  it  leaves  the  pharynx,  and  sometimes  the  effort  at  regurgitation 
is  followed  by  the  appearance  of  some  blood  and  mucus.  Blood  and  mucus  also 
very  frequently  appear  if  a  bougie  is  used  to  pass  the  stricture.  The  age  of  the 
patient,  the  absence  of  a  history  of  the  ingestion  of  a  corrosive  poison,  the  emaciation 
and  weakness,  and  the  presence  of  primary  or  secondary  growths  elsewhere  render 
the  diagnosis  possible.  Sometimes  an  aneurysm  of  the  thoracic  aorta  by  pressing 
on  the  esophagus  may  produce  somewhat  similar  sjmptoms,  but  under  these 
circumstances  the  physical  signs  of  aneurysm  may  be  found. 

Prognosis. — The  prognosis  in  esophageal  cancer  is,  of  course,  exceedingly  bad. 
Death  comes  from  exhaustion  and  starvation,  from  pneumonia  due  to  the  inhala- 
tion of  septic  materials,  or  to  ulceration  of  a  large  bloodvessel.  Sometimes  the 
lymphatic  glands  of  the  neck  are  secondarily  involved.  Occasionally  the  phjsician 
is  chagrined  at  the  autopsy  to  find  that  an  unsuspected  esopliageal  cancer  has 
been  present  for  weeks  without  presenting  symptoms,  and  without  his  having 
recognized  its  existence. 

Treatment. — ^Medicinal  measures  are  of  course  fruitless  except  for  the  relief  of 
pain.  Surgical  measures  are  of  little  value,  since  the  patient  is  usually  so  exhausted 
by  the  time  that  the  diagnosis  is  confirmed  and  he  is  willing  to  resort  to  an  operation, 
that  life  is  prolonged  but  little  by  the  operative  interference.  Exner  has  recently 
reported  a  ca:se  in  which  improvement  followed  the  use  of  radium  in  a  tube  attached 
to  a  bougie. 


DISEASES  OF  THE  STOMACH. 

ACUTE  GASTRIC  CATARRH. 

Definition. — Acute  gastric  catarrh,  or  acute  catarrhal  gastritis,  as  its  name  indi- 
cates, is  a  state  in  which  the  mucous  membrane  of  the  stomach  becomes  hj'peremic 
and  then  swollen,  with  lessened  secretion,  followed  by  excessive  production  of 
mucus  and  reduction  in  the  quantity  of  digestive  ferments.  The  term  acute 
gastritis  is  sometimes  employed  to  describe  this  state.  This  is  unfortunate  because 
a  true  inflammation  of  all  the  coats  of  the  stomach  is  not  present  except  when 
irritating  foods  have  been  taken  in  excess,  or  when  some  irritant  poison  has  been 
swallowed. 


520  DISEASES  OF  THE  STOMACH 

Etiology. — The  causes  of  acute  gastric  catarrh  are  very  various.  In  children 
it  is  often  a  sequel  to  taking  cold,  with  some  resulting  interference  with  the  activity 
of  the  liver.  It  also  follows  the  excessive  use  of  sweets  in  this  class  of  patients. 
In  older  persons  it  is  nearly  always  due  to  the  taking  of  an  excessive  amount  of 
indigestible  food  or  overloading  the  viscus  with  ordinary  foodstuft's,  particularly 
if  alcoholic  drinks  and  highly  seasoned  articles  have  been  swallf)\vc(l. 

Symptoms. — The  symptoms  of  acute  gastric  catarrh  in  children  are  c|uitc  dillcrent 
from  those  met  with  in  adults  in  most  instances.  The  child  has  nausea  and  vomiting, 
and  some  epu/astric  discomfort.  Fever,  varying  from  100°  to  102°,  often  develops 
and  persists  for  several  days.  The  bowels  may  be  constipated  or  several  loose  vtove- 
ments  may  occur  daily.  The  appearance  of  the  tongue  in  this  class  of  cases  is  very 
characteristic.  It  is  evenly  coated  by  a  thin  white  fur  which  is  dotted  by  many 
tiny  red  spots  where  the  enlarged  papillae  exist.  The  tongiie  is  also  somewhat 
drier  than  normal  and  the  breath  slightly /ow/  and  hot.  The  urine  is  usually  decreased 
in  amount  and  high  colored. 

In  adults  acute  gastric  catarrh  presents  somewhat  different  symptoms.  There 
is  often  some  pain  or  tenderness  on  pressure  in  the  epigastrium  and  a  loss  of  appetite 
amounting  to  disgust  for  food.  Navsea  may  be  quite  persistent  and  vomiting 
may  occur. 

In  both  children  and  adults  the  attacks  may  last  for  from  one  to  four  days. 

Diagnosis. — When  the  physician  is  called  to  see  a  child  who  is  suffering  from 
moderate  fever,  a  somewhat  coated  tongue  and  epigastric  distress,  he  must  not 
be  hasty  in  stating  that  the  case  is  one  of  acute  gastric  catarrh,  because  many  of 
the  acute  infectious  diseases  begin  by  moderate  gastric  disorder  and  a  coating  of 
the  tongue.  Whenever  the  gastric  symptoms  persist  for  more  than  four  or  five 
days,  enteric  fever  should  be  suspected  as  being  the  cause  of  the  illness,  but  care 
must  be  taken  that  the  common  error  of  calling  mild  typhoid  fever  "  gastric  fever" 
is  not  made.  Uncomplicated  acute  gastric  catarrh  is  so  rare  in  adults,  who  have 
not  abused  alcohol,  that  great  care  should  be  taken  before  the  physician  is  satisfied 
with  this  diagnosis. 

Treatment. — The  treatment  consists  in  unloading  the  portal  and  hepatic  circula- 
tion, which  is  nearly  always  disordered,  by  the  use  of  small  doses  of  calomel,  giving 
I  of  a  grain  every  half-hour  for  eight  doses,  and  following  this  in  five  hours  by  a 
Seidlitz  powder  or  some  other  mild  and  cooling  saline  purge.  If  the  stomach  is 
very  irritable  the  Seidlitz  powders  should  be  divided  into  fourths  and  taken  at 
fifteen-minute  intervals.  After  this  treatment  has  acted  the  patient  should  receive 
small  doses  of  bismuth  subnitrate  and  oxalate  of  cerium.  For  a  child  2  grains  of 
the  former  and  1  of  the  latter  may  be  given  every  hour  for  five  or  six  doses.  x\dults 
may  take  .5  grains  of  the  bismuth  at  a  dose. 

The  rest  of  the  treatment  consists  in  the  use  of  small  quantities  of  litpiid  food, 
such  as  whey  or  barley-water,  or  scalded  toast.  Small  quantities  of  milk  and 
lime-water  may  be  used.  In  some  instances  total  abstinence  from  food  for  twelve 
or  twenty-four  hours  gives  the  best  results.  Rest  in  bed  is  also  very  advantageous 
for  both  children  and  adults. 

PHLEGMONOUS  GASTRITIS. 

Definition. — The  term  "plilcgnnnions  gastritis"  is  applied  to  a  condition  in 
which  the  inflammation  is  of  such  a  character  that  it  proceeds  to  suppuration,  the 
chief  part  of  the  suppurative  process  developing  in  the  submucous  tissues,  and 
sometimes  extending  to  the  muscular  coat  of  the  stomach  and  even  to  the  peri- 
toneum. 

Etiology. — ^The  disease  is  exceedingly  rare,  and  has  appeared  with  about  equal 
frequency  at  all  ages  from  ten  to  eighty  years.     In  some  instances  it  is  primary, 


DIPIITIIEIUTIC  GASTRiriS  527 

the  seat  of  the  infection  beginning  in  an  ulcer  or  growth,  or  more  rarely  from  some 
direct  traumatism.  The  secondary  cases  are  those  in  which  the  process  develops 
during  the  course  of  one  of  the  acute  infections,  such  as  typhoid  fe\'er,  puerperal 
fever,  pyemia,  and  variola.  Fifty  cases  have  been  gathered  by  Jacoby  and  85 
by  Leith,  but  these  figures  of  course  include  many  of  the  same  instances  of  the 
disease.  Phlegmonous  gastritis  is  of  two  kinds:  a  diffuse  form  with  a  rapid  course, 
profound  systemic  disturbances,  and  speedy  death,  and  a  circumscribed  form  in 
which  the  symptoms  are  much  less  severe;  the  patient  living,  it  may  be,  for  weeks, 
but  usually  dying  as  the  result  of  the  disease. 

The  pyloric  portion  of  the  stomach  is  chiefly  affected.  Its  walls  are  greatly 
thickened,  and  the  submucous  tissues  are  riddled  with  pus,  having  undergone 
almost  complete  necrosis.  Not  infrequently  many  perforations  of  the  mucous 
membrane  occur,  so  that  the  internal  surface  of  the  stomach  has  a  sieve-like 
appearance. 

Several  cases  of  suppurative  gastritis  have  been  reported  in  the  United  States, 
and  they  are  remarkable  enough  to  demand  notice.  In  Kinnicutt's  case  the  disease 
followed  an  alcoholic  debauch.  In  Hemmeter's  case  the  patient  had  vomited 
blood,  was  treated  for  gastric  ulcer,  and  did  not  die  until  tw'o  months  after  the 
onset  of  severe  symptoms.  The  infection  had  here  occurred  through  a  healed 
ulcer.  In  Smith's  case  violent  epigastric  pain  with  collapse  and  death  in  two  and 
a  half  days  took  place,  the  entire  submucosa  being  infiltrated  with  pus.  In  Loomis' 
case  abdominal  pain,  bilious  vomiting,  and  a  feeble  pulse  with  delirium  preceded 
death,  which  occurred  at  the  end  of  four  days.  In  Hun's  case  the  gastric  walls 
were  fully  one-half  inch  in  thickness  and  the  tissues  between  the  peritoneiun  and 
the  mucous  membrane  were  purulent. 

In  the  circumscribed  form  of  phlegmonous  gastritis  the  abscess  may  be  single, 
or  multiple  abscesses  may  be  present. 

Symptoms. — ^The  symptoms  in  the  diffuse  form  consist  in  the  sudden  development 
of  violent  epigastric  pain,  followed  hyfaintness  and  collapse,  with  incessant  vomiting. 
After  the  vomiting  has  continued  for  some  time,  the  vomited  matter  may  be  stained 
with  bile. 

When  the  disease  is  secondary  to  malignant  growth,  it  is  stated  that  vomiting 
does  not  often  develop.  Notwithstanding  the  severity  of  the  process,  pus  is 
never  found  in  the  vomit  in  the  acute  cases.  The  temperature  varies  from  103° 
to  105°.  The  pulse  is  rapid  and  feeble,  and  becomes  more  and  more  so  until  death 
occurs  in  collapse,  preceded  by  a  stage  of  apathy. 

Diagnosis. — There  is  practically  no  array  of  diagnostic  symptoms  in  cases  of 
this  disease  save  the  onset  of  violent  epigastric  pain. 

The  pus  may  escape  into  the  peritoneal  cavity,  the  patient  dying  with  symptoms 
of  perforation  and  collapse.  The  most  extraordinary  case  of  this  character  so 
far  recorded  is  the  one  reported  by  Callow^  in  which  the  patient  vomited  a  pint 
of  pus,  pus  appeared  in  the  stools,  and  there  were  seven  pints  of  it  in  the  peritoneal 
cavity.  All  this  pus  was  traced  to  a  large  abscess  cavity  in  the  wall  of  the  stomach 
which  had,  however,  not  been  accompanied  by  pain  during  its  formation. 

Treatment. — When  it  is  possible  to  make  a  diagnosis  prompt  operative  interference 
is  strongly  indicated.  So  far,  this  has  not  been  attempted  early  enough  in  any  case 
to  give  satisfactory  results.  The  parts  should  be  drained  and  a  gastro-enterostomy 
performed.  (For  an  excellent  paper  on  this  subject  see  Moynihan  in  the  Medical 
Chronicle  for  November,  1903.) 

DIPHTHERITIC  GASTRITIS. 

Inflammation  of  the  stomach  with  the  formation  of  a  false  membrane  due  to 
the  Klebs-Loeffier  bacillus  is  very  rarely  encountered.     It  nearly  always  follows 


528  DISEASES  OF  THE  STOMAdl 

diphtheria  in  the  upper  air-passages.  Still  more  rarely  in  cases  of  septicemia, 
scarlet  fever,  and  smallpox  a  false  membrane  may  develop  in  the  stomach.  The 
condition  is  of  interest  solely  from  a  pathological  stand-])oiiit. 

MYCOTIC  GASTRITIS. 

InHammation  of  the  stomach  due  to  tlic  growth  of  specific  micro-organisms 
upon  its  nuicous  membrane  is  very  rare.  The  thrush  fungus,  Oidkim  albicans, 
has  been  found  in  certain  cases.  Anthrax  of  the  stomach  has  also  followed  anthrax 
of  the  mouth.  The  yeast  fungus  is  not  infrequently  present,  but  rarely  produces 
severe  inflammation  of  the  stomach.  Cases  which  are  in  the  nature  of  medical 
curiosities  have  been  reported  in  which  acute  inflammation  of  the  stomach  was 
due  to  the  action  of  maggots  deposited  about  the  mouth  by  the  common  fly,  or 
swallowed  with  various  articles  of  food.  In  all  such  instances  the  functions  of  the 
stomach  have  been  profoundly  depressed,  as  otherwise  the  ability  of  this  organ  to 
destroy  invading  micro-organisms  and  parasites  prevents  it  from  becoming  infected. 

CHRONIC  GASTRITIS. 

Definition. — By  chronic  gastritis  is  meant  a  state  in  which  the  gastric  mucous 
membrane  suft'ers  from  prolonged  and  persistent  inflammation  of  a  low  grade, 
or  repeated  acute  or  subacute  attacks,  which  result  in  more  or  less  well-marked 
pathological  changes.  The  term  "chronic  gastric  catarrh"  is  often  used  as  a 
synonym  to  describe  this  condition. 

Etiology. — The  causes  of  chronic  gastritis  are  very  numerous.  In  the  majority 
of  cases  they  consist  in  the  frequent  entrance  into  the  stomach  of  irritating  foods 
or  drinks,  as  in  alcoholics,  or  in  persons  given  to  the  excessive  use  of  highly  seasoned 
foods.  In  these  cases  a  very  large  part  of  the  disorder  in  the  gastric  mucosa  is 
also  dependent  upon  the  engorged  portal  circulation  and  the  hepatic  torpor  which 
such  dietary  indiscretions  induce.  Cardiac  diseases  which  lead  to  hepatic  conges- 
tion very  frequently  induce  gastric  catarrh.  Alcohol,  bad  food,  or  badly  chewed 
food,  hepatic  cirrhosis,  and  congestion  of  the  liver  are,  therefore,  the  chief  causes 
of  this  condition. 

Pathology  and  Morbid  Anatomy. — The  changes  in  the  stomach  in  chronic  gastritis 
may  be  tlivided  into  two  classes:  In  the  first  there  is  a  proliferation  of  the  con- 
nective-tissue cells  and  formation  of  new  tissue,  which,  like  similar  forms  of  over- 
growth elsewhere,  results  in  atrophy  or  degenerative  changes  in  the  gastric  glands. 
In  other  words,  the  lesions  are  not  limited  to  the  superficial  portion  of  the  mucous 
membrane,  but  extend  well  down  into  the  deeper  layers.  As  the  contraction  of 
the  overgrown  connective  tissue  proceeds,  it  may  cause  the  projection  on  the 
surface  of  the  inner  wall  of  the  stomach  of  wart-like  masses,  so  that  broad,  raised 
I)atches  of  mucous  membrane  are  discernible,  or  even  polypoid  formations 
appear  (gastritis  polj^josa).  The  entire  gastric  mucosa  may  be  contracted  or 
jjlicated. 

In  other  cases  the  lesions  appear  to  be  more  of  a  degenerative  type;  the  sclerosis 
or  fibrosis  is  inconspicuous,  and  the  epithelial  or  granular  atrophy  is  most  marked. 
In  other  cases  cystic  alteration,  with  little  fibrous  hyperplasia,  may  be  the  dominant 
alteration.  In  the  pyloric  end  of  the  stomach  the  contraction  which  follows  the 
overgrowth  of  connective  tissue  may  produce  stenosis,  a  condition  which  is  empha- 
sized in  some  cases  by  the  inflammatory  process  extending  to  the  muscular  layer 
of  the  stomach,  by  which  means  still  greater  thickening  takes  place.  The  closure 
of  the  pyloric  orifice  is,  therefore,  due  to  a  true  hyperplasia.  The  cause  of  the 
nipple-like  projections  foimd  in  the  gastric  mucous  membrane  in  some  of  these 
cases  is  unknown.     It  may  be  due  to  the  constricting  influence  of  connective  tissue 


CHRONIC  nASTRiriS  529 

formed  between  the  tubules,  or  it  niiiy  arise  from  oxcrgrowtii  of  tlie  submucf)us 
coat  of  the  stomach. 

The  second  type  of  chronic  gastritis  is  that  characterized,  not  by  overgrowth 
of  connective  tissue,  as  has  just  been  descril)e(i,  but  by  wasting  or  atrophy  of  the 
glands.  In  some  cases,  however,  there  is  at  first  some  hyperplasia  of  connective 
tissue,  and  this  is  followed  by  atrophic  changes.  The  mucous  membrane  becomes 
thin  and  smooth  and  is  often  pigmented,  while  the  epithelial  cells  lining  the  gastric 
tubules  suffer  from  atrophic,  fatty  or  necrotic  changes.  The  deeper  tissues  in 
some  cases  escape,  but  in  others  they  also  undergo  wasting,  so  that  even  the  sub- 
mucous coat  and  the  muscular  coat  atrophy.  To  this  condition  has  been  given 
the  unfortunate,  but  etymologically  correct,  name  of  yhthisis  ventriculi.  In  such 
a  case  it  is  quite  possible  for  gastric  dilatation  to  develop. 

Atrophic  gastritis  is  mucli  more  rare  than  the  hyperplastic  type,  and  is  often, 
if  not  always,  associated  with  another  grave  condition,  pernicious  anemia.  Finally, 
in  very  rare  instances,  cases  of  atrophic  gastritis  may  develop  into  ulceration  of  the 
gastric  mucosa,  the  ulcers  being  small,  round  or  irregular  in  shape,  and  rarely 
penetrating  very  deeply  (erosive  gastritis).  They  are  found  chiefly  near  the  pylorus 
and  may  bleed  very  freely. 

Symptoms. — The  symptoms  of  chronic  gastritis  consist  in  loss  of  appetiie,  impair- 
ment of  the  sense  of  taste,  and  nausea,  which  is  particularly  prone  to  be  present 
in  the  morning  and  may  often  amount  to  actual  vomiting — the  "morning  vomiting 
of  the  drunkard."  The  vomited  matters  are  but  partly  digested  and  are  often 
mixed  with  much  mucus.  Most  cases  frequently  hclch  up  gas,  and  with  it  a  mouth- 
ful of  acid  fluid  majr  be  brought  up  which  scalds  the  pharynx.  Hydrochloric  acid 
may  be  lacking  in  the  gastric  contents,  but  in  its  place  an  excess  of  butyric  and 
acetic  acids  is  often  present,  particularly  if  the  stomach  is  feeble  and  is  unable 
to  expel  its  contents  into  the  bowel  with  sufficient  promptness.  Lactic  acid  is 
also  present  in  some  cases.  It  is  the  presence  of  these  acids  that  causes  lieartburn, 
or  pyrosis.  In  some  cases,  however,  an  excess,  or  at  least  a  normal  amount,  of 
hydrochloric  acid  is  secreted. 

The  tongue  is  moderately  coated,  the  bowels  are  prone  to  con-stipatioyi,  and  the 
general  nutrition  is  slightly  impaired,  partly  because  of  poor  digestion,  but  chiefly 
because  of  the  fact  that  tlie  patient  has  cut  off  from  his  diet  list  one  article  after 
another,  with  tlie  thought  that  it  "disagrees"  with  him.  There  is  not,  however, 
an  impairment  of  nutrition  sufficient  to  cause  great  loss  of  weight  in  many  cases, 
because  the  digestive  function  of  the  duodenum  is  not  always  impaired.  If  the 
liver  is  diseased,  a  very  considerable  loss  of  weight  is  usually  present.  Digestion 
is,  of  course,  as  is  clear  from  a  consideration  of  the  state  of  the  gastric  mucous 
membrane,  greatly  delayed  and  very  imperfect,  and  as  a  result  the  patient  becomes 
inert,  low-spirited,  and  vitally  depressed,  so  that  he  presents  the  clinical  picture 
of  what  is  commonly  called  bj^  the  laity  "a  confirmed  dyspeptic." 

If  the  cause  of  the  gastric  disorder  is  alcoholic  cirrhosis  of  the  liver,  the  symptoms 
of  cirrhosis  are  associated  with  those  of  gastric  catarrh. 

A  constant,  unproductive  cough  is  often  present  without  any  lesions  being 
found  in  the  lungs. 

When  the  atrophic  form  of  chronic  gastritis  is  present,  a  very  profound  degree 
of  anemia  is  often  developed,  as  already  stated. 

Diagnosis. — The  separation  of  chronic  gastritis  from  gastric  cancer  is  by  no 
means  easy  in  many  instances,  for  in  many  cases  of  cancer  gastritis  is  also  present. 
The  presence  of  a  mass,  of  considerable  pain,  of  coffee-ground  vomit,  and  an  absence 
of  HCl  in  the  gastric  fluids  would  point  to  the  diagnosis  of  cancer;  but  as  pain  is 
not  always  present  in  cancer,  as  ulcers  of  the  stomach  may  be  present  in  chronic 
catarrh,  giving  rise  to  bloody  vomit,  and  as  HCl  is  often  diminished  or  absent  in 
this  state,  these  signs  are  not  entirely  reliable.  Lactic  acid  is  not  commonly  present 
34 


530  DISEAfiHS  OF  THK  STOMACH 

ill  large  amount  in  chronic  gastritis,  but  it  is  usually  prcsc-nt  in  excess  in  cancer. 
Since  we  have  had  adequate  information  about  cholecystitis,  duodenal  ulcer,  and 
appendicitis  the  diagnosis  of  chronic  gastric  catarrh  is  less  frequently  made. 

Prognosis. — The  prognosis  in  a  case  of  chronic  gastritis  must  be  given  guardedly, 
for  while  one  patient  may  speedily  recover  under  proper  treatment,  other  patients 
remain  ill  for  long  periods,  even  with  the  most  skilful  treatment.  ]\Iuch  depends, 
too,  upon  the  course  of  the  disease  and  upon  the  general  health  of  the  patient. 
While,  on  the  one  hand,  the  malady  does  not  cause  death,  on  the  f)ther,  complete 
recovery  may  seem  impossible. 

Treatment. — Theoretically,  chronic  gastritis  may  be  prevented  by  a\'oiding  the 
use  of  irritating  and  indigestible  foods  and  alcoholic  drinks,  but,  practically,  patients 
are  not  seen  until  after  the  condition  has  been  developed  by  the  various  causes 
which  have  been  enumerated.  After  the  condition  has  developed  the  treatment 
must  be  devoted  to  the  removal  of  the  habits  which  act  as  causes,  to  the  relief  of 
the  conditions  which  exist  in  other  portions  of  the  body,  and  to  the  cure  of  the 
symptoms  already  present  in  the  stomach.  In  cases  in  which  errors  in  diet  exist 
these  must  be  rectified,  and  if  alcohol  is  used  it  nuist  be  stopped.  If  an  examination 
of  the  heart  shows  that  it  is  feeble,  and  that  the  gastric  condition  is  due  to  an 
impaired  circulation,  rest  and  the  use  of  moderate  doses  of  digitalis  must  be  resorted 
to,  but  it  must  not  be  forgotten  that  digitalis  in  full  doses  is  capable  of  causing 
gastric  distress.  Usually  it  is  necessary,  in  order  to  get  the  best  results,  to  admin- 
ister, every  few  days,  small  doses  of  blue  mass,  which  not  only  unloads  the  liver, 
but  seems  to  increase  the  efficiency  of  the  digitalis. 

The  local  treatment  of  the  stomach  consists  in  the  employment  of  lavage,  by 
means  of  which  the  excessive  quantities  of  mucus  and  undigested  food  are  removed. 
Emetics  should  not  be  employed,  as  they  are  too  violent  and  apt  to  increase  the 
inflammatory  process.  Not  infrequently  the  mucus  which  is  secreted  is  so  thick 
and  tenacious  that  there  is  some  difficulty  in  removing  it  from  the  stomach.  Under 
these  circumstances,  various  medicinal  substances  may  be  added  to  the  water 
which  is  employed  for  the  la\-age.  A  salt  solution  may  be  used,  composed  of  \ 
ounce  of  sodium  chloride  and  1  ounce  of  sodium  bicarbonate,  placed  in  a  quart 
of  warm  water.  After  the  stomach  has  been  thoroughly  cleansed,  it  may  be  washed 
a  second  time  with  boric  acid,  1:100;  salicylic  acid,  1:1000;  chloroform-water, 
1:200;  hydrochloric  acid,  1:200.  When  chloroform-water  is  used,  great  care 
should  be  taken  that  the  chloroform  is  thoroughly  mixed  with  water  and  that  the 
mixture  is  then  allowed  to  stand  for  a  sufficient  time  to  permit  of  the  separation 
of  any  excess  of  chloroform. 

Lavage  shoidd  be  carried  out,  as  a  ride,  not  oftener  than  twice  in  twenty-four 
hours;  in  many  cases  once  every  alternate  day  is  often  enough.  The  best  time 
to  perform  lavage  is  usually  in  the  e\'ening  at  about  9  o'clock,  so  that  the  stomach 
may  nave  complete  rest  for  the  next  ten  hours.  In  those  cases,  however,  in  which 
the  taking  of  food  in  the  morning  produces  great  distress,  it  is  often  jidvantageous 
to  use  lavage  on  first  arising,  in  order  that  mucus  may  be  removed. 

In  regard  to  drugs,  it  may  be  said  that  the  one  which  has  the  greatest  reputation 
is  the  nitrate  of  silver  given  in  pills  containing  \  grain,  or  in  solution  in  the  dose  of 
from  J  to  1  grain  to  2  drachms  of  one  of  the  aromatic  waters,  as  cinnamon-water  or 
peppermint-water.  Another  drug  which  has  a  high  reputation  is  the  subnitrate 
of  bismuth,  which  should  be  given  in  large  doses,  about  1  drachm  twice  or  tlu-ice 
a  day.  Both  of  these  forms  of  treatment  possess  the  disadvantage  that  they  are 
constipating,  and  therefore  the  patient  usually  has  to  take  a  small  dose  of  one  of 
the  mild  laxative  saline  waters  on  first  arising  in  the  morning. 

For  the  relief  of  loss  of  appetite  and  for  absence  of  hydrochloric  acid,  the  various 
simple  bitters,  such  as  cinchona,  quassia,  and  cardamom,  may  be  given.  Of  the 
pompound  tincture  of  cardamom,  1  or  2  draclims  may  be  given  once  or  twice  a 


GASTRIC  DILATATION  531 

day  with  meals.  If,  in  addition,  it  is  believed  that  the  stomach  lacks  motive 
power,  strychnine  may  also  be  used,  and  the  fiiiidextract  of  condurango  may  be 
given  in  the  dose  of  a  draclira  three  times  a  da>'.  If  digestion  is  delayed  because 
of  a  lack  of  hj'drochloric  acid,  15  drops  of  this  dilute  acid  may  be  given  with  each 
meal,  combined  with  a  good  essence  of  pepsin.  The  administration  of  nitrate  of 
silver  one  hour  before  meals  usually  diminishes  pyrosis,  or  heartburn,  but,  if  it 
does  not,  magnesium  carbonate  or  bicarbonate  of  sodium  may  be  used  for  this 
purpose.     These  alkalies  frequently  diminish  pain  by  decreasing  acidity. 

The  diet  should  consist  of  easily  digested  foods,  and  it  is  to  be  remembered  that 
small  meals  given  five  of  six  times  a  day  are  better  than  large  meals  given  three 
times  a  day.  Chicken,  beef,  and  mutton  broths,  free  from  fat  and  fortified  by  the 
addition  of  barley  or  rice,  are  exceedingly  useful.  If  solids  are  taken,  the  patient 
must  be  instructed  to  chew  both  the  meats  and  starches  thoroughly.  Often  it  is 
advisable  to  have  the  meat  made  tender  by  pounding  it,  or  by  cooking  it  in  such 
a  way  that  its  fibres  are  readily  dissolved  by  the  gastric  juice. 

The  digestion  of  starches,  like  baked  potatoes,  toasted  bread,  zweiback,  and 
pulled  bread,  should  be  aided  by  the  use  of  taka-diastase  or  pancreatin.  Often  a 
konseal  containing  both  of  these  digestive  ferments  will  be  ach^antageous  in  its  effect. 

Milk  may  be  gi^^en  to  those  with  whom  it  agrees.  In  some  instances,  when  it 
cannot  be  taken  pure,  it  can  be  digested  readily  if  diluted  with  some  sparkling 
water,  particularly  Vichy-water.  In  other  instances  the  addition  of  a  small  quantity 
of  salt  aids  in  its  digestion,  and  in  still  others  lime-water  may  be  given  with  it. 

The  question  as  to  the  use  of  the  light  wines  by  a  patient  suffering  from  chronic 
gastritis  is  debatable.  If  any  fermentation  is  present,  they  must  not  be  used. 
If  patients  are  accustomed  to  drinking  wine  with  each  meal,  it  may  be  advisable 
to  permit  small  quantities,  particularly  with  luncheon  and  dinner.  Champagnes 
are  usually  distinctly  harmful. 

GASTRIC  DILATATION. 

Definition. — By  dilatation  of  the  stomach  is  meant  a  condition  in  which  this 
viscus  loses  its  propulsive  power  to  a  greater  or  less  degree  and  also  undergoes  a 
certain  amount  of  dilatation,  so  that  its  capacity  is  increased.  It  is  sometimes 
called  "gastric  ectasy,"  or  "gastrectasis." 

Etiology. — While  it  is  true  that  dilatation  is  the  state  which  impresses  itseH 
most  forcibly  upon  the  clinician  when  a  patient  is  examined  who  is  suffering  from 
this  malady,  it  is  also  a  fact  that  the  dilatation  is  always  the  result  of  some  primary 
difficulty  in  expelling  the  contents  of  the  stomach  into  the  duodenimi.  In  some 
instances  this  is  due  to  stenosis  of  the  pylorus  produced  by  a  thickening,  as  in 
chronic  gastric  catarrh;  in  others  it  may  be  due  to  what  is  called  h^'pertrophic 
stenosis  of  the  pylorus,  and  in  still  others  the  obstruction  may  be  offered  by  a 
tumor  at  this  point  or  by  a  cicatrix  or  other  form  of  stricture.  Rarely  the  pylorus 
becomes  so  glued  to  nearby  tissues  that  it  is  held  abnormally  high,  and  is  so  fixed 
that  it  is  almost  impossible  for  the  stomach  to  force  its  contents  past  the  orifice. 

A  second  cause  of  difficulty  in  emptying  the  stomach  exists  in  a  weakness,  con- 
genital or  acquired,  which  so  impairs  the  motor  power  of  the  viscus  that  it  is  too 
feeble  to  empty  itself.  Neither  obstruction  nor  inherent  weakness  of  the  muscle 
fibres  in  the  gastric  wall  are  necessarily  associated  with  dilatation,  but  it  can  be 
readily  understood  that  these  causes  may  so  residt.  It  is  conceivable  that  in  the. 
obstructive  cases  the  stomach  may  undergo  some  hypertrophy,  and  this  takes 
place  in  a  considerable  number  of  cases  as  a  primary  result  of  the  obstruction. 
The  constant  endeavor  of  the  stomach  to  empty  itself,  however,  ultimately  causes 
fibroid  changes  in  the  muscle  fibres  from  fatigue,  and  this  condition  is  emphasized 
by  impaired  nutrition  of  the  stomach,  and  perhaps  by  impaired  nerve  supply  as 


532  DISEASES  OF  THE  STOMACH 

well.  Finally,  it  is  undoubtedly  true  that,  in  some  persons  at  least,  the  repeated 
distention  of  the  stomach  by  large  amounts  of  food  and  drink  may  cause  permanent 
dilatation,  particularly  if  these  materials  be  of  such  a  character  that  tliey  produce 
chronic  gastritis,  and  so  impair  the  tone  of  the  gastric  walls.  Workmen  in  breweries 
who  partake  of  large  amounts  of  beer,  and  diabetics  who  eat  and  drink  to  excess 
because  of  their  disease,  often  sufi'er  from  gastrectasis. 

Dilatation  of  the  stomach  is  usually  a  disease  of  middle  age  or  of  adult  life, 
but  cases  are  not  uncommon  in  children.  The  youngest  case  I  ever  saw  was  in  a 
child  of  eighteen  months.  The  dilatation  due  to  obstruction  is  the  type  in  which 
tlie  greatest  enlargement  of  the  stomach  develops. 

Pathology  and  Morbid  Anatomy. — The  size  of  the  stomach  may  be  greatly  in- 
creased, so  that  the  average  capacity  of  a  cjuart  (1000  c.c.)  increased  to  even  four 
quarts.  Under  these  circumstances,  the  lower  border  of  the  stomach  extends  far 
below  the  normal  level.  Its  walls  are  decreased  in  thickness,  there  is  atrophy  of 
the  lining  mucous  membrane,  and  the  muscular  fibres  are  even  more  wasted,  so 
that  many  of  them  disappear  and  are  replaced  by  connecti^•e  tissue.  AVhen  primary 
atrophy  of  the  muscularis  has  been  present,  it  not  rarely  happens  that  an  excess 
of  muscle  fibres  are  found  in  the  pyloric  region,  although  advanced  secondary 
wasting  has  occurred  elsewhere.  In  some  cases  of  dilatation  the  gastric  walls 
do  not  become  thin,  but  may  appear  thicker  than  normal,  because  of  an  overgrowth 
of  connective  tissue  which  supplants  the  muscular  layer  of  the  organ. 

Gastric  dilatation  does  not  always  result  in  an  equally  well-developed  increase 
in  size.  In  some  instances  the  cardiac  orifice  and  the  pylorus  are  near  one  another, 
so  that  the  great  curvature  hangs  like  a  plumber's  trap;  in  other  cases  cicatrices 
distort  it  and  even  cause  an  hour-glass  form,  with  a  dilatation  on  either  side. 

Symptoms. — The  symptoms  of  gastric  dilatation  are  usually  considered  by  the 
patient  to  be  those  of  "chronic  dyspepsia."  There  is  usually  loss  of  appetite,  a 
sense  of  gastric  discovifort  and  weight,  or  a  feeling  of  dragging  dmrn  in  the  abdomen 
and  a  good  deal  of  helching  of  gas,  which  is  often  accompanied  by  some  particles 
of  food  mixed  with  fluid.  The  sense  of  distention  and  distress  gradually  increases 
until  it  is  almost  insupportable,  and  then  the  viscus  finding  the  burden  too  great, 
unloads  itself  by  an  attack  of  vomiting,  in  which  the  patient  is  surprised  to  find 
articles  of  food  ingested,  perhaps,  several  days  before.  Both  the  physician  and  tlje 
patient  are,  not  rarely,  amazed  at  the  quantity  expelled,  for  the  volume  shows  that 
it  represents  the  ingested  fluids  and  solids  of  several  days.  Such  an  attack  of 
vomiting,  in  which  the  quantity  expelled  is  far  in  excess  of  the  amount  recently 
swallowed,  is  a  very  important  diagnostic  point.  These  attacks  of  vomiting  usually 
occur  at  night.  When  the  dilatation  is  severe,  so  that  the  stomach  cannot  com- 
pletely empty  itself,  the  relief  given  by  vomiting  is  only  partial,  and  perhaps  no 
relief  follows. 

The  boicels  are  constipated,  and  the  stools  when  passed  are  scanti/,  because  so 
much  of  the  food  ingested  is  not  passed  on  into  the  duodenum.  The  vrine  is  also 
scanty.     Not  rarely  it  is  decreased  to  one-third  the  nonnal  quantity. 

IMany  of  the  symptoms  are  due  to  stasis  of  the  food  in  the  stomach,  fermentation, 
and  the  absorption  of  toxic  materials  from  bacterial  growth. 

In  cases  in  which  bile  appears  in  the  urine,  the  cause  of  the  dilatation  jjrobably 
does  not  depend  upon  gastric  dilatation  alone,  but  upon  some  obstruction  in  the 
duodenum,  which  dams  back  the  food  in  the  pyloric  orifice  and  so  forces  the  stomach 
to  vuidcrgo  distention. 

The  physical  signs  of  gastric  dilatation  are  as  follows:  On  inspection  in  some  of 
these  cases,  it  may  be  possible  to  outline  the  stomach  if  it  is  distended  with  food 
and  gas.  This  determination  of  its  area  and  limitation  is,  however,  much  better 
accomplished  by  percussion  after  the  stomach  has  been  emptied  by  the  use  of  the 
stomach-tube  and  then  has  been  distended  by  gas.     This  distention  may  be  pro- 


GASTRIC  DILATATION  533 

duced  either  by  giving  the  halves  of  a  Seidlitz  powder  separately  (or  by  the  use 
of  30  grains  of  tartaric  acid  in  a  half-glass  of  water  and  2  drachms  of  sodium 
bicarbonate  in  another  half-glass  of  water),  or  by  introducing  a  stomach-tube, 
attaching  a  Davidson  syringe  to  it  and  then  {)iunping  air  into  the  stomach  until 
it  is  distended.  This  latter  plan  is  probably  the  safer  of  the  two  if  idcer  is  supposed 
to  be  present,  but  if  the  patient  is  not  accustomed  to  the  use  of  the  tube  its  presence 
causes  so  much  retching  and  gastric  unrest  that  it  is  usually  impossible  to  make  a 
satisfactory  examination  of  the  true  area  of  gastric  tympany. 

The  tympanitic  note  produced  by  the  ixrcussion  of  a  stomach  so  distended 
very  clearly  outlines  it  in  many  cases.  If  there  is  doubt  as  to  the  presence  of 
gas  in  the  colon,  which  may  cause  tympany,  the  large  intestine  should  be  filled 
with  fluid,  by  the  injection  of  a  large  clyster,  when  the  areas  of  gastric  tympany 
and  intestinal  flatness  on  percussion  can  be  readily  defined.  In  other  cases  the 
stomach  may  be  filled  with  fluid,  and,  if  need  be,  the  bowel  filled  with  air  to  develop 
the  same  outlines. 

It  has  been  held  by  some  clinicians  that  the  use  of  carbonic  acid  for  the  purpose 
of  dilating  the  stomach  for  diagnostic  purposes  is  dangerous,  but  when  we  consider 
the  hundreds  of  instances  in  which  it  has  been  used  in  e\'ery  part  of  the  world 
without  evil  effect,  we  must  conclude  that  it  rarely  does  harm.  Belirend  has 
reported  3  cases,  however,  in  which  death  followed  its  use,  the  patient  in  one  instance 
suffering  from  a  profuse  hemorrhage,  another  patient  bringing  up  froth  and  blood, 
and  the  third,  who  did  not  die  for  five  days,  suffering  from  great  distress  and 
prostration.  Wharton  and  Rlusser  have  reported  a  perforation  of  the  stomach 
after  drinking  a  glass  of  carbonated  water.  All  of  these  cases  were  complicated 
by  gastric  ulcer. 

Auscultation  of  the  epigastrium  may  reveal  splashing,  or  succussion,  in  many 
cases  of  gastric  dilatation,  but  this  sign  should  never  be  regarded  of  very  great 
import,  for  not  rarely  the  same  sound  is  produced  by  fluid  in  the  bowel. 

Another  means  of  diagnosis  is  the  use  of  the  .r-rays  after  the  patient  has  received 
a  large  dose  of  bismuth  subnitrate  (|  to  1  ounce).  By  this  means  the  area  of  the 
stomach  can  be  determined. 

The  use  of  drugs,  which  are  dissolved  only  in  the  intestine,  to  test  the  motor 
power  of  the  stomach  is  of  some  diagnostic  value.  Salol,  for  example,  is  given 
in  the  dose  of  15  or  20  grains,  and  the  urine  tested  after  five  hours  for  salicyluric 
acid  by  means  of  the  perchloride  of  iron  test,  which  consists  in  adding  tincture 
of  iron  chloride  to  the  urine,  when,  if  this  acid  is  present,  a  purple  color  is  obtained. 
When  dilatation  is  present  there  may  be  no  response  for  twenty-four  hours. 

Finally,  as  a  means  of  determining  that  the  digestive  power  of  the  stomach  is 
greatly  impaired,  a  test  meal  should  be  used  after  the  stomach  has  been  cleaned 
by  lavage.  If  dilatation  is  present,  the  digestive  process  will  always  be  very  slow 
and  imperfect. 

Cases  of  gastric  dilatation  sometimes  develop  a  state  called  gastric  tetany,  in 
which  tetanic  spasms  develop  in  the  extremities.  This  is  preceded  by  a  sensation 
of  formication,  or  numbness,  associated  with  drowsiness.  It  has  ensued,  as  a  rule, 
upon  the  employment  of  lavage.  Following  the  sensory  symptoms  the  patient 
is  seized  with  violent  vomiting,  and  after  or  during  this  attack  of  emesis  the  muscles 
of  the  thumb  and  fingers  contract,  so  that  the  thumb  is  drawn  into  the  palm  of 
the  hand  and  the  fingers  are  flexed.  The  wrist  is  also  strongly  flexed,  but  it  may  be 
extended.  The  forearm  is  flexed  on  the  arm,  and  the  biceps  is  hard  and  tense. 
These  positions  may  not  be  maintained,  but  be  changed  into  extension.  Both 
sides  are  involved,  but  one  side  usually  suffers  more  than  the  other.  When  the 
legs  are  affected  the  toes  are  flexed  and  the  knees  bent.  The  facial  muscles  may 
be  in  spasm  and  the  patient  may  have  explosive  speech,  as  if  in  a  shouting  delirium. 
If  the  affected  arm  be  pressed  upon  over  the  course  of  its  vessels  or  nerves,  the 


534  DISEASES  OF  THE  STOMACJI 

attacks  may  be  reproduced  (Trousseau's  sign);  if  the  point  of  exit  of  the  facial 
nerve  be  tapped,  facial  spasm  develops  (Chvostek's  sign);  if  electricity  is  used  it  is 
found  that  the  muscles  are  excessively  irritable  (Erb's  sign).  The  cramp-like 
contractions  arc  painful.  In  severe  cases  death  may  occur  from  exhaustion.  Out 
of  101  cases  reported  by  European  clinicians,  no  less  than  7.")  died. 

Although  the  employment  of  the  stomach-tube  has  induced  attacks  of  gastric 
tetany  in  some  cases,  attacks  not  tlue  to  this  cause  are  to  be  ])re^'ented  by  frequent 
and  thorough  lavage,  and  are  to  be  combated,  when  present,  by  nerve  sedatives 
such  as  morphine  or  hyoscine  liypodermically.  Their  occurrence  in  a  mild  form 
urges  upon  the  physician  the  need  of  operation  for  the  gastric  state. 

Gastric  tetany  occurs  in  cases  of  dilatation  more  frequently  than  in  cases  of  ulcer. 

Diagnosis. — As  a  rule,  the  diagnosis  of  gastric  dilatation,  in  its  well-developed 
stage,  is  not  difficult.  Care  must  always  be  exercised,  however,  that  dilatation 
and  gastroptosis  are  not  confused,  for  in  both  affections  the  lower  border  of  the 
stomach  may  be  found  far  below  the  normal  level,  particularly  if  it  is  distended 
with  liquid  or  gas.  The  use  of  any  of  the  methods  of  percussion  and  palpation, 
or  the  other  means  of  diagnosis  just  described,  will  speedily  separate  the  one  state 
from  the  other,  and  the  relatively  limited  capacity  of  the  stomach  in  ptosis  and 
its  large  capacity  in  dilatation  will  be  another  factor  in  deciding  upon  the  real 
state  which  is  present. 

Treatment. — The  treatment  of  gastric  dilatation  is  not  promising  unless  the 
patient  is  seen  and  his  condition  recognized  in  the  early  stages  of  the  disease.  At 
this  time,  and  later  on  as  well,  his  diet  should  be  most  carefully  regulated.  He 
should  be  instructed  to  avoid  all  fatty  articles  of  food  which  may  give  rise  to  lactic 
and  butyric  acid  fermentation,  and  should  also  avoid  the  use  of  sweet  materials, 
which  may  also  luidergo  fermentative  changes.  The  food  which  he  takes  should 
be  thoroughly  masticated  and  insalivated,  it  being  remembered  that  the  saliva 
is  an  important  digestive  juice,  and  that  much  may  be  done  in  aiding  the  digestion 
by  thoroughly  moistening  the  food  with  this  secretion.  The  patient  must  also 
be  warned  not  to  eat  a  large  amount  of  food  at  any  one  time,  but  rather  to  subsist 
on  four  or  five  small  meals  a  day.  He  should  also  be  instructed  not  to  take  large 
quantities  of  liquids  with  his  meals. 

As  to  the  articles  of  diet,  he  may  have  beef,  mutton,  chicken,  or  other  simple 
varieties  of  meats,  broiled  or  roasted,  but  not  fried.  Potatoes  should  only  be  taken 
when  baked,  and  then  in  moderation.  Zweiback,  or  soda  biscuits  which  have 
been  once  more  cooked  by  pouring  scalding  water  over  them,  may  be  taken  in 
moderation.  The  digestion  of  the  starches  should  always  be  aided  by  the  simul- 
taneous ingestion  of  a  konseal  containing  2  grains  of  taka-diastase  and  2  grains  of 
pancreatin.  If  the  diet  is  largely  a  meat  diet,  digestion  should  be  aided  by  the 
use  of  hydrochloric  acid  and  pepsin,  5  to  20  drops  of  the  dilute  acid  and  2  teaspoon- 
fuls  of  a  good  essence  of  pepsin  being  used.  Often  it  is  wise  to  add  to  this  mixture  20 
drops  of  the  tincture  of  nux  vomica,  or  ^V  of  a  grain  of  strychnine,  for  its  eft'ect  as  a 
bitter  tonic  and  for  the  purpose  of  improving,  if  possible,  the  acti^'ity  of  the  stomach. 

In  no  case  should  the  patient  be  allowed  to  accumulate  fluid  and  food  in  the 
stomach  for  more  than  twenty-four  horn's.  In  other  words,  we  should  not  wait 
until  nature  relieves  the  stomach  by  an  attack  of  vomiting. 

As  in  clironic  gastric  catarrh,  lavage  should  be  performed  once  in  every  twenty- 
four  hours,  preferably  at  night  before  going  to  bed.  In  all  cases  it  should  be 
remembered  that  the  stomach  is  loaded  with  fermenting  matter  and  is  thereff)re 
incapable  of  dealing  with  new  food,  which  if  taken  simply  adds  to  the  decomposing 
mass  already  present. 

In  many  of  these  cases  it  is  advisable,  after  emptying  the  stomach  of  its  contents, 
to  wash  it  out  with  one  of  the  solutions  named  in  the  article  on  the  Treatment  of 
Chronic  Gastric  Catarrh. 


GASTRIC  DILATATION  535 

Emptying  the  stomach  by  means  of  the  stomach-tube  and  forbidding  the  use 
of  excessive  quantities  of  food  are  not  only  advantageous  in  that  they  permit 
digestion,  poor  as  it  may  be,  to  proceed,  but  also  do  good  in  that  they  prevent  the 
stomach  from  being  overloaded  and  distended,  and  so  further  dilated,  by  its  con- 
tents. It  seems  hardly  necessary  to  add  that  beer,  sweet  wines,  and  champagnes 
should  be  absolutely  forbidden  for  such  patients. 

Some  physicians  of  experience  resort  to  the  use  of  faradic  electricity  in  these 
cases,  introducing  a  stomach-tube  containing  the  positive  electrode  and  applying 
the  negative  electrode  to  some  point  on  the  surface  of  the  body. 

In  cases  in  which  the  dilatation  is  so  severe  and  the  symptoms  so  distressing 
that  none  of  the  measures  so  far  suggested  give  adequate  relief,  the  question  of 
operative  interference  must  be  considered.  Under  these  circumstances,  the 
question  as  to  the  cause  of  the  dilatation  becomes  an  important  factor.  If  it  is 
dependent  upon  pyloric  stenosis,  a  gastro-enterostomy  or  pylorectomy  is  indicated. 
But  if,  on  the  other  hand,  it  does  not  depend  upon  this  cause,  but  upon  inherent 
atony  and  failure  of  the  gastric  walls,  pylorectomy  is,  of  course,  of  little  value, 
and  a  gastro-enterostomy  is  indicated.  Before  proceeding  to  operation,  however, 
it  must  be  remembered  that  there  is  some  difference  between  an  operati^■e  recovery 
and  benefit  to  the  patient.  Not  infrequently  in  these  cases  the  patient  siu'\-ives 
the  operation  and  makes  a  surgical  recovery,  but  abdominal  discomfort  persists, 
either  because  of  the  presence  of  adhesions,  irritation  of  nerve  fibres,  or  other 
causes  which  it  is  difficult  to  determine,  and  which  may  be  dependent  upon  the 
altered  course  of  food  from  the  stomach  to  the  bowel. 

Acute  Gastrectasis. — Under  the  names  acute  gastric  dilatation,  gastro-intestinal 
paralysis,  atonic  gastrectasis,  toxic  gastrectasis,  and  paralytic  dilatation  of  the 
stomach,  there  occurs  an  acute,  often  rapidly  fatal,  dilatation  of  the  stomach 
alone  or  of  the  stomach  and  intestines. 

Etiology. — Some  cases  are  apparently  causeless,  and  even  at  autopsy  no  cause 
may  be  demonstrable.  Others  occur  in  the  course  of  acute  infectious  processes, 
some  of  which  are  systemic,  such  as  scarlet  fever  and  typhoid  fever;  in  others  the 
lesion  is  some  distance  from  the  affected  viscus,  as  in  pneumonia  and  meningitis, 
while  still  others  depend  for  their  development  upon  infectious  processes  in  the 
neighborhood  of  the  stomach  or  intestine,  conspicuous  among  which  may  be  men- 
tioned peritonitis.  The  condition  occasionally  follows  surgical  anesthesia,  and 
it  has  been  suggested  that  swallowing  of  mucus  saturated  with  the  anesthetic  may 
be  the  cause  in  some  cases.  It  has  been  attributed  to  acute  pyloric  obstruction, 
as  by  foreign  bodies  or  spasm,  but  that  this  is  not  always  the  cause  is  shown  by 
the  reported  instances  in  which  dilatation  extended  through  the  pylorus  and  first 
and  second  parts  of  the  duodenum  or  even  into  the  ileum.  It  has  been  thought 
to  depend  upon  obstruction  of  the  duodenum  by  the  superior  mesenteric  vessels. 
It  sometimes  follows  operation  involving  the  peritoneum,  and  may  commence  after 
labor.  Eeynier  strongly  urges  the  influence  of  the  nervous  system  in  the  production 
of  acute  gastro-intestinal  paralysis. 

Morbid  Anatomy. — At  autopsy  the  stomach  is  large,  thin,  and  flaccid;  it  may 
extend  almost  to  the  pubes.  It  contains  gas  and  fluid;  the  latter  may  be  thick 
and  viscid,  but  it  is  usually  thin,  watery,  greenish  or  occasionally  brownish  in 
color,  and  frequently  contains  flocculi.  The  gastric  mucosa  may  weep  blood  and 
the  vessels  be  widely  distended. 

Symptoms. — These  usually  come  on  rapidly.  In  operative  cases  they  may  be 
delayed  twenty-four  to  forty-eight  hours.  There  is  viarked  abdominal  distention 
amounting  to  actual  ballooning;  the  dilated  organ  occupies  the  middle  and  upper 
left  areas  of  the  abdomen,  and  may  be  outlined  through  the  abdominal  wall.  Peri- 
staltic waves  are  rarely  recognizable.  Vomiting  is  nearly  always  present.  In 
the  few  reported  cases  in  which  vomiting  has  been  absent,  it  has  been  suggested 


536  DISEASES  OF  THE  STOMACH 

that  the  associated  rehixation  in  the  abdominal  wall  has  rendered  eniesis  impossible. 
The  vomited  fluid  is  thin,  watery,  greenish  or  brownish.  Profound  depression 
or  symptoms  bordering  on  collajjse  quickly  appear.  The  jnike  is  small,  raj^id, 
and  weak;  the  respirations  shallow  and  frequent;  the  temperature,  in  the  absence 
of  complications,  is  usually  Ioav  and  may  be  subnormal.  Thirst  is  intense,  and, 
on  account  of  suppressed  absorption  and  prompt  vomiting,  is  unrelieved  by  drinks. 
The  urine  is  scanty  or  even  siqjpressed. 

Diagnosis. — The  acuteness  of  the  symptoms  and  rapidly  progressing  collapse 
differentiate  the  condition  from  clxronic  dilatation.  The  vomiting  is  more  incessant 
and  the  pain  less  tlian  in  \ohulus  of  the  stomach,  wliicJi  in  some  respects  it  closely 
resembles.  Tlie  gastrorrhea  that  accompanies  it  and  the  character  of  the  vomit 
is  unlike  acute  indigestion,  and,  ordinarily  there  is  no  expulsion  of  fragments  of 
the  mucosa  as  in  true  toxic  gastritis.  The  relaxed  abdominal  wall  is  quite  unlike 
the  rigid  wall  of  peritonitis. 

Prognosis. — The  mortality  is  high;  in  Herff's  series  of  .34  cases,  29  died.  In 
the  so-called  reflex  group — those  unassociated  with  any  intra-al)dominal  lesion — 
prompt  treatment  promises  some  relief. 

Treatment. — Its  prevention  after  operation  may  be  accomplished  by  lavage 
immediately  at  the  end  of  anesthesia,  and  if  vomiting  appear  and  persist,  lavage 
should  be  repeated.  As  it  is  probable  that  the  condition  is  of  toxic  origin,  free 
lavage  should  repeatedly  be  practised,  and  the  stomach  kept  empty  by  the  frequent 
use  of  the  stomach-tube.  Water  and  food  had  best  be  given  by  enema.  Strychnine 
and  pituitrin  have  been  used.  As  early  as  possible  saline  purgatives  should  be 
administered  in  small,  but  often  repeated,  doses.  As  relapses  are  possible  as  late 
as  the  third  day,  feeding,  and  even  the  administration  of  fluids,  must  be  begun  most 
cautiously  in  cases  fortunate  enough  to  survive. 

GASTRIC  ULCER. 

Definition. — Ulcer  of  the  stomach,  often  called  peptic  ulcer,  or  idcns  ventriculi, 
is  due  to  necrosis  of  a  part  of  the  mucous  membrane  of  this  organ,  so  that  an  exposure 
of  the  submucous  tissue  is  present. 

Etiology. — Almost  ever  since  the  processes  of  gastric  digestion  have  been  known, 
animated  discussions  have  arisen  as  to  why  the  stomach  is  not  digested  by  its 
own  juices  and  a  large  number  of  explanations  have  been  ofl'ered,  many  of  which 
have  been  anything  but  satisfactory.  At  present  the  conditions  which  result 
in  gastric  ulcer  are  known  to  be  closely  connected  with  the  inability  of  the  gastric 
mucosa  to  resist  the  action  of  the  gastric  juice.  If,  by  any  cause,  the  vital  resistance 
of  the  mucous  membrane  is  impaired,  at  the  point  of  greatest  impairment  an  ulcer 
may  be  developed.  In  very  rare  instances  an  injury  to  the  surface  of  the  abdomen 
may  extend,  or  be  transmitted,  deeply  enough  to  cause  a  lesion  in  the  ga.stric  wall; 
but  it  is  more  common  for  injuries  to  occur  by  internal  agents,  as  by  the  use  of 
certain  articles  of  food  which  may  interfere  with  the  circulation  in  the  wall  of  the 
stomach,  as,  for  example,  boiled  tea,  taken  very  hot,  which  contains  an  excess 
of  tannic  acid.  So,  too,  an  embolus  or  thrombus  in  a  branch  of  a  gastric  artery 
may  deprive  an  area  of  its  blood  supply,  and  subserjuent  digestion  remove  the  dead 
tissue  and  so  form  an  ulcer.  Another  predisposing  cause  of  ulcer  is  the  secretion 
of  superacid  juice  or  of  an  excess  of  ordinary  juice,  and  finally,  in  some  cases,  a 
local  necrosis  of  the  tissues  is  produced  by  the  entrance  of  infecting  micro-organisms, 
which,  however,  cannot  enter  the  mucosa  if  normal  vital  resistance  is  maintained. 

Frequency. — The  frecjuency  of  gastric  ulcer  in  some  parts  of  the  world  is  far 
greater  than  in  others.  Even  between  England  and  the  United  States  the  difference 
is  extraordinary.  Out  of  .59,7(52  medical  cases  in  the  London  hospitals,  there  were 
IGiO  cases  of  gastric  ulcere  while  out  of  75,612  medical  cases  in  hospitals  in  different 


GASTRIC   ULCER  537 

cities  in  the  United  States,  there  were  only  44G  cases.  According  to  these  figures 
the  morbidity  of  gastric  ulcer  is  more  than  four  times  as  great  in  England  as  it 
is  in  the  United  States.  Since  these  figures  were  compiled  Howard  has  confirmed 
them  by  others. 

In  regard  to  the  relationship  of  age  and  ulcer  statistics  vary  slightly,  but  those 
of  Welch  are  still  to  be  considered  the  most  competent.  He  found  that  the  largest 
number  of  cases  of  ulcer  occurred  between  twenty  and  thirty  years  of  age,  and  Lebert 
also  found  that  seven-tenths  of  252  cases  were  between  twenty  and  forty  j'ears 
of  age.  A  case  of  ulcer  in  an  infant  only  thirty  hours  old  had,  however,  been 
recorded  by  Goodhart.  Cutler,  in  an  exhaustive  search  in  literature,  found  only 
24  cases  under  ten  years  of  age  with  autopsy  and  2  without  autopsy,  and  has 
added  3  more  which  occurred  in  the  Massachusetts  General  Hospital ;  29  in  all. 

Women  suffer  from  ulcer  far  more  frequently  than  men.  This  is  shown  by  all 
statistics  and  is  illustrated  by  the  following  figures:  Of  1548  cases  of  gastric  ulcer 
collected  from  the  official  reports  of  hospitals  in  the  United  States  and  England, 
1273  occurred  in  women  and  275  in  men.  Of  1699  cases  examined  postmortem 
and  studied  by  Welch,  1020  were  in  women  and  679  in  men.  Cantlie  states  that 
out  of  20,586  cases  in  Montreal  there  were  85  cases  of  gastric  ulcer,  and  of  these 
82  were  women.  The  average  age  was  twenty-seven  and  a  half  years.  W.  J. 
Mayo  thinks  that  the  percentage  in  the  two  sexes  is  nearly  equal.  This  may 
be  so  in  the  severe  cases  but  it  is  untrue  of  the  average  case. 

Other  etiological  factors  of  interest  are  occupation  and  associated  disease.  Thus, 
seamstresses  and  servant  girls  are  singularly  prone  to  ulcer,  as  are  also  tailors 
and  shoemakers.  Such  persons  are  usually  chlorotic  or  anemic.  So,  too,  ulcer 
is  sometimes  a  complication  of  tuberculosis,  and  it  maj^  be  in  itself  tuberculous. 

Moynihan  believes  that  in  the  majority  of  cases  gastric  ulcer  is  not  primarily 
or  chiefly  a  lesion  in  the  stomach,  but  is  the  outcome  of  a  chronic  infection,  as  a 
rule  in  some  abdominal  organ.  This  view  he  supports  by  the  fact  that  in  cases 
of  chronic  gastric  and  duodenal  ulcer  there  is  frequently  found  a  focus  of  infection 
in  the  abdomen,  most  commonly  in  the  appendix. 

Gastric  ulcer  may  be  divided  into  four  classes:  In  t]\e  first  the  lesion  is  very  mild, 
the  mucous  membrane  being  eroded  in  such  a  manner  that  its  superficial  epithelium 
is  destroyed.  All  authors  do  not  agree,  however,  that  these  erosions  are  a  form 
of  peptic  ulcer.  The  second  type  is  characterized  by  an  ulcerative  process  which 
penetrates  more  deeply,  so  that  the  submucous  tissues  are  aft'ected.  The  third 
invades  the  submucous,  muscular,  and  even  the  peritoneal  coat,  and  may  cause 
perforation.  The  fourth  type  is  that  in  which  as  a  result  of  cicatrization  and  con- 
traction scars  and  deformities  develop,  which  produce  serious  consequences. 

Pathology  and  Morbid  Anatomy. — Gastric  ulcer  is  usually  single,  but  cases  are 
not  very  rare  in  which  the  ulcers  are  numerous.  When  acute  it  forms  rapidly 
and  presents  a  peculiar  punched-out  appearance.  In  the  usual  chronic  form  the 
edges  are  more  shelving,  indurated,  and  not  so  sharply  defined.  The  size  of  the 
ulcer  varies  from  a  small  spot  scarcely  larger  than  a  pinhead  to  an  enormous  excava- 
tion covering  nearly  two-thirds  of  the  gastric  surface.  These  large  ulcers  are, 
however,  very  rarely  met  with. 

The  depth  to  which  the  ulcerative  process  extends  is  also  variable.  The  mucous 
membrane  nearly  always  suffers  most,  but  the  tissues  beneath  it  are  affected  as 
well,  and  the  destructive  process  may,  as  just  stated,  extend  as  far  as  the  peritoneal 
coat.  Undermined  ulcers  are  extremely  rare.  Around  the  edge  of  the  ulcer  there 
is  usually  marked  hyperemia,  and  the  surrounding  tissues,  especially  in  chronic 
ulcers,  are  often  infiltrated  by  formative  cells  or  by  the  development  of  connective 
tissue.  Usually  the  rest  of  the  stomach  exhibits  more  or  less  marked  chronic 
gastritis. 

Ulcer  of  the  stomach  is  usually  found  on  the  posterior  wall  of  the  viscus  near  the 


538  DISEASES  OF  THE  STOMACH 

pylorus  and  on  the  lesser  curvature  (75  per  cent.),  i)robahly  hecause  this  is  the  part 
of  the  stomach  wliich  carries  out  the  grinding  process  and  urges  the  food  into  the 
duodenum,  and  therefore  is  exposed  to  injury  and  abrasion.  Armstrong  has 
however,  analyzed  440  cases  of  gastric  ulcer  and  found  the  anterior  wall  att'ected  in 
125  cases,  the  posterior  wall  in  only  32. 

If  the  healing  process  is  not  rapid  enough  to  arrest  the  ulcerative  process,  the 
wall  of  the  stomach  may  be  perforated  and  so  produce  severe  abdominal  symptoms. 
More  commonly,  however,  as  tiie  inflammatory  process  approaches  the  surface 
of  the  stomach  it  causes  this  viscus  to  become  glued  to  a  neighboring  organ,  and 
so  it  happens  that  the  floor  of  the  ulcer  may  be  formed  by  an  adjacent  viscus. 
In  this  way  neighboring  organs  may  be  involved  in  the  inflammatory  and  septic 
process,  and  not  rarely  subphrenic  abscess  is  due  to  this  cause.  Sometimes  a  per- 
foration takes  place  into  the  colon  or  duodenum,  and  cases  have  been  recorded 
in  which  the  pericardium  and  pleura  have  been  involved  in  this  manner.  The 
liver  is  also  sometimes  infected.  Fenwick,  in  an  analysis  of  127  cases,  found  the 
stomach  adherent  to  the  pancreas  in  49,  to  the  liver  in  .'5.3,  and  to  the  li^•er  and 
pancreas  in  10. 


Diagram  showing  the  situation  of  ulcers  of  the  stomach  on  the  lesser  curvature  and  near 
the  pylorus.     (Modifieci  from  English.) 

Ulcers  on  the  anterior  surface  of  the  stomach  are  less  common,  but  more  prone 
to  perforation  into  the  peritoneum  than  those  situated  posteriorly.  It  is  held 
that  the  anterior  wall  is  more  movable  than  the  posterior,  and  hence  time  for 
adhesion  to  opposed  tissue  is  less. 

In  many  cases,  a  tendency  to  healing  asserts  itself  and  gradually,  the  exposed 
tissues  are  healed  by  the  formation  of  a  cicatrix  which  may  cause  considerable 
puckering  as  it  develops. 

If  the  ulcer  has  been  near  the  pylorus  this  may  cause  pyloric  stenosis,  or  if  it 
be  near  the  middle  of  the  stomach  and  the  ulcer  has  been  extensive  an  hour-glass 
contraction  may  result.     (See  Hour-glass  Stomach.) 

Symptoms. — Ulcer  of  the  stomach,  at  least  in  its  milder  forms,  may  exist  for 
years  without  its  presence  being  suspected,  the  patient  sufi'ering  from  a  train  of 
moderate  gastric  symptoms,  generally  described  as  dyspeptic.  In  most  cases, 
however,  it  makes  its  presence  known  by  symptoms  which  sooner  or  later  send 
the  patient  to  her  physician  for  relief.  The  symptoms  now  complained  of  are 
discomfort  and  pain,  with  a  constant  gnawing  between  meals  when  the  stomach 
is  empty.  Not  infrequently  this  gastric  distress  is  relieved  by  taking  some  food, 
and  then  increases  as  an  excess  of  gastric  juice  is  poured  out  to  digest  the  food. 
The  pain,  when  characteristic,  is  peculiar  in  its  distribution,  for  it  radiates  from 
the  ei)igastrium  back  to  the  shoulder-blade,  or  to  a  spot  between  the  shoulder-blade 


GASTRIC  ULCER  539 

and  the  spine.  Head  has  also  shown  that  in  gastric  ulcer  there  is  an  area  of  cuta- 
neous hyperesthesia  in  a  small  triangular  spot  in  the  left  epigastrium.  This  is 
demonstrable  by  a  light  touch,  and  not  on  deep  palpation.  At  times  the  pain 
is  exceedingly  severe,  and  it  may  require  active  medication  because  of  its  intensity. 
Oftentimes  the  patient  attemi)ts  to  find  relief  by  lying  on  the  stomach  or  placing 
a  pillow  against  it,  but  as  a  rule  the  epigastrium  is  .so  tender  that  any  pressure 
on  the  part  of  the  physician  makes  the  patient  wince.  Careful  palpation  may, 
however,  reveal  an  area  of  thickening  or  induration,  if  the  ulcer  is  a  chronic  one. 
Associated  with  these  symptoms  there  is  often  vomiting  of  very  acid  fluid,  and  an 
examination  of  the  gastric  contents  will  show  an  excess  of  hydrochloric  acid  both 
as  to  percentage  and  actual  quantity.     Constipation  is  usually  viarked. 

It  is  important  to  remember  that  ulcer  of  the  stomach  does  not  by  any  means 
always  cause  the  same  train  of  symptoms.  Attention  has  already  been  called 
to  the  fact  that  the  symptoms  may  be  latent.  In  other  cases  there  may  develop, 
with  great  suddenness,  a  profuse  hematemesi^  or  symptoms  of  collapse  from  perfora- 
tion, and  one  of  these  accidents  may  be  the  first  symptom  of  any  importance.  In 
other  instances  there  is  a  general  failure  of  health,  marked  emaciation,  and  a  develop- 
ment of  profound  anemia.  In  still  others  violent  neuralgic  pains  (gastralgia)  are 
the  chief  manifestations.  In  some  instances  the  disease  lasts  but  a  few  weeks;  in 
others  it  is  prolonged  for  years. 

The  symptoms  so  far  described  are  chiefly  those  of  acute  or  subacute  ulcer. 
Chronic  ulcer,  on  the  other  hand,  may  produce  none  of  these  sjTnptoms  when  the 
patient  presents  herself  for  treatment.  Beyond  a  history  of  gastric  distress,  which 
may  have  existed  for  many  years,  there  may  be  no  pain  on  pressure  and  no  soreness, 
in  the  sense  of  tenderness.  Indeed,  the  symptoms  may  be  those  of  gastric  dilata- 
tion, or  of  pyloric  stenosis.  The  patient  is  emaciated  by  reason  of  voluntary 
starvation,  to  decrease  discomfort,  and  by  the  loss  of  food  by  ^•omiting.  So,  too, 
a  cicatrix  near  the  middle  of  the  stomach  may  produce  an  hour-glass  stomach. 
This  may  become  evident  on  distending  the  stomach  with  gas  or  fluid,  but  it  is 
to  be  recalled  that  there  is  danger  that  rupture  may  ensue  from  this  practice. 
(See  Pyloric  Stenosis  and  Dilatation  of  the  Stomach.) 

In  no  other  disease,  save  pernicious  anemia,  is  there  such  a  notable  diminution 
of  red  blood  cells  as  takes  place  in  many  cases  of  chronic  gastric  ulcer.  This  is 
due  to  the  more  or  less  constant  loss  of  blood  which  escapes  by  the  bowel,  the  loss 
of  which  is  usually  not  recognized.  When  hemorrhage  does  not  occur  great  anemia 
is  rare,  although  the  patient  may  appear  pallid. 

When  hemorrhage  from  the  stomach  takes  place  the  blood  may  be  vomited  or  be 
passed  by  the  bowel.  The  hemorrhage  may  follow  many  weeks  of  suffering  or  it 
may  be  the  first  sign  that  the  gastric  mucous  membrane  is  diseased.  The  quantity 
of  blood  lost  may  be  very  small  or  so  large  as  to  almost  exsanguinate  the  patient, 
the  variation  depending  upon  the  size  of  the  bloodvessel  which  is  eroded.  If  a 
large  vessel  is  perforated  by  a  small  ulcer  it  is  not  difficult  to  understand  why  it  is 
that  hemorrhage  may  be  the  first  symptom.  In  other  words,  the  hemorrhage 
may  be  the  first  symptom  of  ulcer.  On  the  other  hand,  not  infrequently  gastric 
hemorrhage,  particularly  if  it  be  from  a  chronic  ulcer,  may  be  so  scanty  as  never 
to  cause  bloody  vomiting,  the  small  amount  of  blood  escaping  with  the  food  into 
the  bowel.  Moynihan  believes  that  all  ulcers  bleed  at  some  time  in  their  existence. 
(See  Diagnosis.) 

In  studying  the  question  of  perforation  of  gastric  ulcer  it  is  well  to  recall  that 
this  accident  may  or  may  not  be  preceded  by  symptoms  which  will  serve  as  a 
warning  to  the  physician  if  not  to  the  patient.  There  is,  in  some  cases,  a  pro- 
gressive increase  in  discomfort  and  pain,  a  greater  degree  of  tenderness  or  pain 
over  the  epigastrium,  and  more  frequent  vomiting.  When  such  signs  are  present 
the  patient  must  be  placed  at  absolute  rest,  and  if  the  symptoms  do  not- speedily 


540  DISEASES  OF  THE  STOMACH 

become  modified  operation  must  be  considered.  On  tlie  other  hand,  the  literature 
on  this  subject  contains  cases  in  wliicli  tiie  liistory  of  j^astric  disorder  was  entirely 
absent,  and  the  patient  was  suddenly  seized  by  symptoms  of  perforation. 

When  perforation  does  develop,  it  is  usually  in  the  anterior  gastric  wall,  and 
from  what  has  been  said  of  the  various  ways  in  which  perforation  of  the  stomach 
occurs,  it  must  be  evident  that  the  symptoms  may  vary  over  a  wide  range  of 
severity.  When  no  inflammatory  adhesions  have  been  formed  and  the  gastric 
contents  escape  suddenl\-  into  the  general  peritoneal  cavity,  the  onset  is,  of  course, 
startling  in  its  acuteness  and  the  iMin  is  exceedingly  severe,  but  the  locality  of  the 
pain  is  frequently  far  removed  from  the  area  of  the  accident.  ]'oiiiiiin(i  and  collaitse 
may  soon  develop,  and  (/eneral  peritonitis  begins  if  operative  relief  is  not  i)romi)tly 
given. 

If  the  perforation  is  more  gradual  the  symptoms  are  less  violent  and  the  opening 
may  at  first  be  so  small  that  only  a  little  of  the  gastric  contents  escapes  into  the 
peritoneal  cavity.  In  those  cases  in  which  adhesions  have  formed  before  perfora- 
tion takes  place  subphrenic  abscess  may  result.  In  such  instances  the  perforation 
is  usually  on  the  posterior  wall  of  the  stomach. 

Sometimes  perforation  of  the  stomach  may  take  place  without  tlie  sharji  and 
decisive  symptoms  just  described. 

While  the  pulse  usually  is  rapid  it  may  not  be  materially  increased  in  rate. 

Again,  it  is  important  to  remember  that  after  perforation  of  the  stomach  there 
may  be  a  "period  of  repose,"  or  "fallacious  calm,"  during  which  time  the  patient 
feels  less  pain  and  distress,  and  the  pulse  approximates  its  normal  speed. 

At  one  time,  it  will  be  recalled,  a  decrease  in  the  area  of  liver  dulness  was  sup- 
posed to  be  indicative  of  gastric  or  intestinal  perforation,  but  we  now  know  that 
the  absence  of  this  sign  does  not  negati\-e  perforation.  Thus,  Pearson  found  a 
decrease  in  the  area  of  liver  dulness  in  33  per  cent,  of  140  cases  of  gastric  ulcer  at 
some  period  during  their  stay  in  the  hospital,  yet  ])erforation  took  place  in  none 
of  them. 

Diagnosis. — Gastric  ulcer  in  some  instanc'cs  is  so  manifestly  present  that  there  is 
little  difficulty  in  determining  the  cause  of  the  illness.  In  other  cases  a  correct 
diagnosis  is  almost  impossible;  it  is  more  a  supposition  than  a  diagnosis. 

The  irritation  produced  by  gallstones  may  produce  symptoms  resembling  gastric 
ulcer,  but  in  these  cases  the  history  of  gallstone  colic  may  be  given  and  the  taking 
of  food  has  no  immediate  influence  upon  the  pain.  Then,  too.  the  pain  in  the 
back  due  to  ulcer  is  to  the  left  of  the  middle  line  near  the  twelfth  dorsal  vertebra 
whereas  that  due  to  gallstone  is  on  the  right  of  the  median  line  and  a  little  lower 
down.  So,  too,  palpation  of  the  neighborhood  of  the  gallbladder  may  reveal  an 
enlargement  of  this  viscus,  and  jaundice  points  to  cholelithiasis  rather  than  to 
ulcer.     (See  Cholelithiasis). 

Cases  of  chronic  ulcer  of  the  stomach  with  nuich  cicatricial  tissue  amund  the 
ulcer,  or  at  the  seat  of  an  ulcer  which  has  healed,  may  present  symptoms  almost 
identical  with  those  of  gastric  cancer.  Pain  and  obstruction  to  the  passage  of 
food  through  the  pylorus,  gastric  dilatation  due  to  this  latter  cause,  and  emaciation 
from  all  these  causes  may  combine  to  present  a  clinical  picture  of  gastric  cancer, 
particularly  if  the  physician  finds,  on  palpation,  that  he  can  feel  a  mass  or  masses 
in  the  gastric  wall.  The  comparative  youth  of  the  patient  in  cases  of  ulcer,  the 
absence  of  cachexia  even  if  anemia  is  marked,  and  a  remembrance  that  ulcer  of  the 
stomach  is  more  common  in  the  female  sex  helps  to  make  the  diagnosis  possible. 
Again,  in  ulcer  the  gastric  contents  show  an  excess  of  hydrochloric  acid  after  a 
test  meal,  whereas  in  cancer  this  acid  is  usually  absent  or  less  than  normal.  (For 
the  tests  of  the  stomach  contents  see  article  on  Gastric  Cancer.) 

There  can  be  no  doubt  that  the  use  of  the  .r-rays  aft'ords  a  valuable  means  of 
investigating  these  cases,  particularly  when  a  bismuth  meal  is  given  and  the  fluoro- 


GASTRIC   ULCER  541 

scope  is  used.  Sometimes  the  ulcer  causes  spasmodic  hour-glass  contractions  which 
if  shown  in  an  .T-ray  photograph  may  give  rise  to  the  belief  that  this  deformity  is 
permanent.  The  contraction  chiefly  affects  the  greater  cur\-ature  but  it  is  impor- 
tant to  exclude  neuroses,  tabes,  renal  colic  and  even  hepatic  cirrhosis  since  spas- 
modic hour-glass  stomach  has  been  met  with  in  such  patients.  Again,  the  retention 
of  the  bismuth  in  the  stomach  for  more  than  six  hours  is  significant,  but  not  diag- 
nostic of  ulcer,  the  retention  being  due  to  pyloric  spasm  or  cicatricial  tissue.  Some- 
times the  bismuth  adheres  to  the  ulcer  and  gives  a  shadow.  When  an  ulcer  is 
old  enough  to  have  induced  scar  formation  there  is  often  delayed  emptying,  a 
shadow  at  the  cicatrix,  sometimes  reversed  gastric  waves  of  marked  intensity  or 
the  stomach  may  be  fixed  by  an  adhesion. 

Care  must  be  taken  that  the  pain  of  appendicitis,  gallstone  colic,  renal  colic,  and 
intense.menstrual  colic  is  not  taken  for  that  due  to  perforation.  ■Nloynilian  speaks 
of  3  cases  operated  upon  for  gastric  perforation  in  which  menstruation  was  the  cause 
of  the  pain.  Severe  pain  in  the  stomach  due  to  locomotor  ataxia  (gastric  crises) 
can  usually  be  excluded  by  the  presence  of  Argyll-Robertson  pupils,  absence  of 
knee-jerks,  and  swaying  when  the  patient  stands  with  the  eyes  shut.  Epigastric 
and  umbilical  hernia  must  be  excluded.  Aortic  aneurysm  may  mislead  as  may 
also  lead  colic. 

Finally  it  must  be  recalled  that  duodenal  ulcer  may  cause  symptoms  so  closely 
resembling  gastric  ulcer  that  a  differentiation  may  be  impossible.  If  blood  is 
passed  in  the  stools  in  considerable  quantity  without  hematemesis  the  lesion  is 
probably  duodenal.     (See  Duodenal  Ulcer.) 

The  demonstration  of  minute  quantities  of  blood  in  the  feces  is  of  great  value 
in  the  diagnosis  of  both  gastric  and  duodenal  ulcer,  but  does  not  separate  them. 
It  has  been  proven  experimentally  that  the  ingestion  of  so  small  a  quantity  as 
3  c.c.  of  blood  gives  a  positive  reaction  for  blood  in  the  feces,  and  this  fact  shows 
that  even  minute  hemorrhages  may  giA^e  rise  to  similar  positive  reactions.  Hemor- 
rhage in  ulcer  is  often  absent  and  when  it  occurs  is  apt  to  be  inconstant.  In  cancer, 
if  ulceration  is  present,  it  is  constant. 

Before  performing  the  test  for  blood  all  other  sources  of  hemorrhage,  such  as  the 
swallowing  of  blood  from  wounds  in  the  mouth  or  from  lesions  in  the  respiratory 
tract  must  be  guarded  against,  and  the  absence  of  hematuria,  and  in  women 
metrorrhagia  and  menstrual  blood,  must  also  be  assured.  No  red  meat,  fish,  or 
sausages  are  allowed  for  two  days  before  the  test  is  made. 

Boas  prefers  the  aloin  test  as  recently  recommended  by  Klunge  and  Schaer  to 
the  older  guaiacum  test.  It  is  performed  as  follows:  5  to  10  grams  of  feces,  which, 
if  hard,  are  to  be  softened  by  the  addition  of  a  small  quantity  of  water,  are  mixed 
with  20  c.c.  of  ether,  3  to  5  c.c.  of  glacial  acetic  acid,  and  the  mixture  is  well  shaken 
in  a  reagent  glass.  Then  more  ether  is  added,  and  also  20  or  30  drops  of  an  old 
oil  of  turpentine.  'If  to  this  mixture  there  now  be  added  10  or  15  drops  of  a  solution 
made  by  dissolving  in  3  to  5  c.c.  of  70  per  cent,  alcohol  as  much  aloin  as  can  be 
taken  up  on  the  tip  of  a  small  spatula,  a  light  red  color  is  soon  produced  if  blood 
is  present.  This  light  red  gradually  assumes  a  cherry-red  hue  if  the  mixture  is 
allowed  to  stand.  If  no  blood  is  present  the  mixture  remains  of  a  yellow  color 
for  from  one  to  two  hours,  when  it  changes  to  rose-red. 

The  possibility  of  parenchymatous  gastric  hemorrhage,  and  of  hemorrhage 
from  varicose  or  atheromatous  bloodvessels  in  the  esophagus  or  stomach,  must  of 
course  be  taken  into  consideration  before  a  diagnosis  in  doubtful  cases  is  reached. 

Prognosis. — The  prognosis  of  cases  of  gastric  ulcer  must,  of  com-se,  vary  greatly 
with  the  severity  of  the  lesion,  and  the  time  during  which  it  has  lasted.  In  those 
cases  in  which  superficial  erosions  are  present,  the  patient  probably  reco^'ers  in 
the  great  majority  of  instances.  When  actual  ulceration  is  present,  the  proposition 
is,  of  course,  a  different  one.     The  most  divergent  views  exist  as  to  the  prognosis. 


542  DISEASES  OF  THE  STOMACH 

Whiite\x'r  may  be  the  percentage  as  to  recoverj',  it  cannot  be  doubted  that  in 
many  instances  it  is  once  an  nicer  always  an  ulcer,  in  the  sense  that  relapses  take 
place  soon  after  the  ulcer  seems  well.  In  a  collection  of  500  cases  at  the  London 
Hospital,  made  by  Bulstrade,  211  had  had  ulcer  before,  18  per  cent,  died,  and  42 
per  cent,  were  not  cured  on  discharge.  The  surgeon  who  sees  an  old  ulcer  which  has 
produced  such  severe  symptoms  that  the  patient  is  forced  to  submit  to  the  knife, 
readily  comes  to  believe  that  recovery  never  occurs  except  by  operation  and  even 
goes  so  far  as  to  state  that  the  ulcers  that  have  been  cured  by  the  medical  man 
were  only  supposititious.  That  complete  reco\'ery  of  a  well-de\'cloped  ulcer  takes 
place  is  still  a  subject  for  debate;  probably  it  does  not.  Often  after  a  period  of 
good  health  a  relapse  occurs  or  worse  still  an  old  quiescent  ulcer  undergoes  malignant 
change.  The  surgeon  says  "operate  to  avoid  these  evils;"  the  physician  says 
"sometimes  the  patient  dies  of  the  operation."  The  direct  mortality  from  ulcer 
in  hospital  practice  is  about  12  per  cent.;  in  private  practice  al)Out  3  per  cent. 
The  question  is  one  of  a  comfortable  life  rather  than  one  of  life  or  death.  (See 
Treatment.) 

Ulcers  near  the  pylorus  heal  more  slowly  than  those  which  occur  elsewhere. 

The  mortality  in  cases  which  suffer  from  hemorrhage  is  not  high.  The  direct 
mortality  from  this  cause  is  only  2.1  per  cent.,  according  to  Russell.  So  far  as 
recovery  from  the  ulcer  is  concerned,  when  it  is  severe  enough  to  cause  hemorrhage 
the  outlook  is  not  good  44.7  per  cent,  continued  in  ill  health  and  42.6  per  cent. 
recovered  (Russell). 

Treatment. — The  treatment  of  gastric  ulcer  may  be  medical  or  surgical  depending 
on  the  lesion  and  the  character  of  the  sjinptoms.  The  percentage  of  "cures" 
under  medical  treatment  naturally  varies  greatly  with  the  class  of  patients,  in  what 
the  patient  and  physician  considers  as  a  "cure,"  and  in  the  time  which  elapses 
before  a  case  is  recorded  as  "cured."  Leube,  in  Germany,  reports  90  per  cent, 
of  cases  as  clinically  cured  within  a  few  weeks.  These  statistics  are  of  little  value 
because  the  longer  such  cases  are  followed  the  greater  is  the  number  that  relapse. 
Greenough  and  Joslin  some  years  ago  found  82  per  cent,  "cured"  but  only  40  per 
cent,  remained  so,  and  Joslin  has  just  published  results  in  another  series  which 
are  practically  identical.  Statistics  collected  by  others  give  similar  results.  Lock- 
wood  in  cases  followed  for  three  years  found  50  per  cent,  cured.  On  the  other  hand, 
surgical  treatment  gives  by  no  means  perfect  results.  Deaver  after  operations 
found  that  42  per  cent,  still  had  symptoms  and  14  per  cent,  died  from  some 
surgical  complication.  In  Bettmann  and  White's  statistics  10  per  cent,  died  from 
the  results  of  the  operation  and  31  per  cent,  were  improved.     (See  Prognosis.) 

When  the  ulcer  is  chronic — that  is,  has  lasted  a  long  time — its  edges  may  be  so 
indurated  and  the  bloodvessels  in  its  cavity  so  eroded  that  little  hope  of  cure  by 
natural  processes  can  be  entertained,  an  operation  is  essential;  first,  because  this 
is  the  only  way  to  give  real  relief;  second,  because  the  cicatrization  process  partly 
or  completely  interferes  with  gastric  motility,  and  by  no  means  least  important 
because  some  of  these  ulcers  undergo  malignant  change  and  such  a  disaster  should 
be  avoided. 

Much  depends  upon  the  skill  of  the  surgeon.  The  best  have  a  direct  mortality 
of  about  2  per  cent.,  the  average  surgeon  8  to  10  per  cent,  and  the  general  surgeon, 
to  use  Lockwood's  term,  10  to  15  per  cent.  In  other  words,  the  advice  of  the 
medical  man  as  to  operation  must  be  based  on  the  state  of  the  patient  and  very 
considerably  upon  his  opinion  of  the  capacity  of  his  surgical  colleague.  It  is  also 
to  be  borne  in  mind  that  although  a  gastro-enterostomy  may  result  in  the  healing 
of  the  ulcer  it  does  not  always  mean  the  recovery  of  perfect  health.  As  Graham 
says,  basing  his  conclusions  on  several  hundred  cases  in  the  Rochester  clinic  "The 
patient  may  be,  and  often  is,  freed  from  disease  and  life  prolonged;  yet  he  may 
not  be  freed  from  symptoms  quite  distressing.     This  is  not  always  the  fault  of 


GASTRIC   ULCER  543 

treatment,  but  an  inevitable  result  of  the  pathologic  condition,  occurring  before 
treatment  was  undertaken." 

In  deciding  whether  an  operation  is  needful  in  a  case  whicli  has  liad  an  attack 
of  gastric  hemorrhage,  consideration  must  be  given  to  the  character  of  the  ulcer. 
Even  those  surgeons  who  are  most  radical  in  advising  operative  measures  in  these 
cases  state  that  in  cases  of  hemorrhage  from  acute  ulcer  medicinal  measures  will 
usually  control  that  particular  bleeding,  and,  as  an  immediate  second  hemorrhage 
is  rare,  operation  at  once  is  not  demanded.  (See  Prognosis.)  When  the  hemorrhage 
does  recur  and  particularly  if  it  be  profuse  on  recurrence,  operation  is  to  be  consid- 
ered carefully,  whether  the  ulcer  be  acute  or  chronic  provided  the  patient's  hemo- 
globin is  above  60  per  cent.  The  operation  of  election  is  gastro-enterostomy,  for 
it  has  been  found  impossible  to  find  the  bleeding  spot  in  most  cases  because  the 
bleeding  often  comes  ffom  several  spots,  and  indeed  may  ooze  from  a  multitude 
of  eroded  spots.  Needless  to  say  that  the  gastro-enterostomy  is  not  designed  to 
stop  a  bleeding  already  in  active  progress,  but  is  to  be  performed  as  soon  as 
possible  to  prevent  further  bleedings. 

The  medical  treatment  of  gastric  ulcer  consists  in  restricting  the  diet,  in  the 
administration  of  medicines  qualified  to  impro\'e  the  state  of  the  gastric  mucous 
membrane,  and  in  the  institution  of  rest  for  the  general  system  as  well  as  for  the 
stomach.  Foods  which  are  verj^  hot,  or  very  cold,  particularly  those  which  are 
very  hot,  should  be  carefully  avoided,  and  hyperacidity  is  to  be  counteracted  by 
the  use  of  calcined  magnesia  or  bicarbonate  of  soda: 

IJ — Sodii  bicarbonatis, 
MagnesiEe  ponderosse, 

Calcii  carbonat aa     oj- 

01.  menth.  piperitse Tllx. 

Sig. — ^A  heaping  teaspoonful  in  half  a  glass  of  water  when  needed. 

In  most  instances  it  is  wise  to  insist  that  the  patient  remain  in  bed  for  a  period 
of  three  or  four  weeks,  during  which  time  the  rest  cure  may  be  instituted  in  a 
modified  form,  since  with  the  improvement  in  general  health,  and  the  cure  of  anemia, 
healing  of  the  ulcer  progresses  more  rapidly. 

There  are  two  plans  of  treatment  from  the  stand-point  of  dietetics  which  are 
diametrically  opposed  to  one  another.  The  first  consists  in  almost  starving  the 
patient  in  the  endeavor  to  give  the  stomach  rest  and  to  decrease  to  the  lowest 
point  the  secretion  of  HCl. 

The  diet  should  consist  of  milk  which  is  predigested  by  a  peptonizing  powder 
either  before  or  immediately  after  it  is  taken  into  the  stomach.  Under  certain 
circumstances  it  may  be  permissible  to  give  the  patient  very  soft  milk-toast  in 
small  quantities,  or  to  give  scalded  soda  biscuits  digested  by  means  of  taka-diastase 
or  pancreatin.  When  the  ingestion  of  food  increases  gastric  pain  and  distress 
it  may  be  necessary  to  give  the  patient  nothing  by  the  stomach  for  a  period  varj-ing 
from  one  or  two  days  to  two  weeks,  and  to  nourish  him  as  far  as  possible  during 
this  period  by  nutritive  enemata,  which  should  consist  of  four  ounces  of  peptonized 
milk  and  one  egg,  injected  three  times  in  the  twenty-four  hours,  the  bowels  being 
carefully  washed  out  with  normal  saline  solution  before  each  injection  in  order 
that  the  residue  from  the  previous  injection  may  be  removed. 

For  the  purpose  of  relieving  thirst,  it  is  often  advantageous,  when  the  stomach 
is  irritable,  to  give,  daily,  normal  saline  solution  by  hypodermoclysis.  In  other 
instances  a  pint  to  a  quart  of  normal  saline  solution  may  be  given  high  up  into  the 
colon. 

A  number  of  years  ago  the  late  J.  M.  DaCosta  strongly  recommended  ice-cream 
as  a  diet  for  these  cases.  Care  should  be  taken  that  the  ice-cream  does  not  contain 
too  much  sugar,  as  this  will  cause  fermentation  and  distress.  Frozen  milk  flavored 
with  vanilla  is  better. 


544  DISEASES  OF  THE  SrOMACH 

The  other  plan  instituted  by  Lenhartz,  consists  in  free  feedinj;  on  the  ground 
that  it  is  essentia!  for  the  healing  of  the  ulcer  that  the  vital  resistance  of  the 
patient  shall  be  raised,  that  the  anemia  which  is  almost  constantly  present  be 
overcome  and  the  general  nutrition  improved.  Further,  he  claims  that  the  dis- 
tention of  the  stomach  by  large  amounts  of  milk  taken  in  twenty-four  hours  is 
deleterious  and  that  the  gastric  activity  incident  to  the  ingestion  of  semisolid  or 
solifl  food  is  not  deleterious,  or  if  so  is  the  lesser  of  two  evils.  Lciiliartz's  method 
undoubtedly  suits  some  cases  but  in  those  instances  in  which  pain  is  produced  by 
the  ingestion  of  food  has  to  be  used  sparingly,  if  at  all.  The  method  is  as  follows: 
Every  hour  from  7  a.m.  to  7  p.m.  the  patient  is  fed  very  slowly  2  drachms  of  egg;  4 
drachms  of  milk,  which  quantities  are  gradually  increased  day  by  day  until  by 
the  sixth  day  she  receives  7  drachms  of  egg  and  14  drachms  of  milk  every  hour. 
After  the  the  third  day  1  to  2  ounces  of  sugar  are  given  also  every  hour.  After 
the  seventh  day  one  ounce  of  scraped  beef  is  also  given  divided  into  three  doses. 
During  the  first  week  the  bowels  are  given  absolute  rest.  After  this  they  are 
moved  by  a  glycerin  or  hot-water  enema.  Lenhartz  asserts  that  the  incidence  of 
hemorrhage  in  his  experience  before  using  this  diet  was  20  in  100  cases,  and  in  the 
next  135  cases  only  8  had  hemorrhages,  and  that  recovery  of  health  is  very  rapid. 

The  patient  suffering  from  gastric  ulcer  sh.orld  receive,  in  the  way  of  medicine, 
J  of  a  grain  of  nitrate  of  silver  with  5  of  a  grain  of  extract  of  hyoscyamus  in  pill 
three  or  four  times  a  day  and  take  them  an  hour  before  taking  food,  in  order  that 
these  drugs  may  act  upon  the  stomach,  exercising  a  healing  influence,  and  preventing 
an  excessive  secretion  of  gastric  juice.  If  pain  is  severe,  opium  may  be  substituted 
for  hyoscyamus,  but  there  is  some  evidence  that  opium  does  not  decrease,  and  may 
sometimes  increase,  the  flow  of  gastric  juice.  In  other  instances  chloretone  in  the 
dose  of  from  3  to  5  grains  may  be  given  three  or  four  times  a  day,  and  it  is  par- 
ticularly useful  if  pain  is  present.  In  other  cases  hyperacidity  and  pain  are  best 
controlled  by  10  to  20  grain  doses  of  bromide  of  strontium  or  of  sodium. 

The  administration  of  massive  doses  of  bismuth  subnitrate  has  been  strongly 
recommended,  chiefly  by  Fleiner.  He  gives  150  to  300  grains,  stirred  in  5  or  6 
ounces  of  warm  water,  after  the  stomach  has  been  carefully  cleansed  by  lavage. 
Of  course  a  heavy  precipitation  of  liismuth  occurs  upon  the  gastric  mucous  mem- 
brane.    This  plan  is  more  suitable  for  chronic  cases  than  for  acute  ones. 

In  all  cases  of  gastric  ulcer  it  is  important  that  the  bowels  shoidd  be  moved 
every  day  or  two  by  means  of  one  of  the  alkaline  purgative  waters,  of  which  probably 
Carlsbad  water  has  the  greatest  reputation.  The  Carlsbad  and  Hathorn  spring- 
waters  of  Saratoga  do  almost,  if  not  quite  as  well,  as  the  imported  water.  The 
advantage  of  employing  these  waters  is  that  they  not  only  unload  the  bowels, 
but  tend  to  correct  acidity  and  relieve  chronic  gastric  catarrh  by  their  favorable 
influence  upon  the  gastro-intestinal  mucous  membrane. 

Should  hemorrhage  from  the  stomach  occur,  the  patient  shoidd  be  put  to  bed, 
and  if  not  too  depressed  by  the  bleeiling,  a  small  ice-bag  may  be  placed  over  the 
epigastrium,  and  2  teaspoonfuls  of  adrenalin  chloride  (1: 1000),  mixed  with  2  or  3 
ounces  of  water  may  be  given  by  the  mouth,  with  the  hope  that  the  ailrenalin 
chloride  will  contract  the  bloodvessels  and  arrest  the  hemorrhage.  Where  adrenalin 
chloride  cannot  be  obtained,  from  5  to  30  drops  of  iMonsel's  solution  may  be  given 
in  2  ounces  of  water.  The  use  of  ergot  hypodermically,  or  by  the  mouth,  in  this 
condition  can  scarcely  be  of  benefit,  as  it  will  raise  arterial  pressure  in  other  parts 
of  the  body  and  may  increase  the  hemorrhage.  The  general  treatment  in  these 
cases  is,  of  course,  identical  with  that  of  profuse  hemorrhage  occurring  from  other 
parts  of  the  body,  and  consists  in  the  use  of  j  of  a  grain  of  morphine  hypodermically 
to  allay  mental  distress,  and  hypodermoclysis  of  normal  salt  solution.  Should  the 
hemorrhage  be  sliarj)  and  \cry  profuse,  the  question  of  operative  interference 
arises. 


CANCER  OF   THE  STOMACH  545 

The  surgical  treatment  of  gastric  ulcer  with  perforation  is  no\v  a  well-recognized 
procedure  in  modern  medicine.  When  perforation  occurs  operation  should  be 
resorted  to  at  once,  unless  the  patient  is  profoundly  shocked,  when  some  delay 
is  advisable  in  order  that  she  may  rally. 

The  best  results  are  obtained  in  the  cases  which  are  operated  on  during  the 
first  twelve  hours  after  the  occurrence  of  perforation.  An  analysis  of  these  statistics 
shows  that  the  mortality  under  operation  has  been  progressively  reduced: 

In  July,  1899,  Tinker  added  57  cases  to  Keen's  list  of  156,  and  in  1900  he  collected 
19  others,  which  made  the  total  number  of  232,  with  a  mortality  of  48.81  per  cent. 
Later,  in  the  year  1900  Finney  made  an  addition  of  36  cases  to  Tinker's  last  list, 
thus  bringing  the  number  up  to  268,  of  which  the  mortality  was  48  per  cent.  Of 
163  cases  collected  since  the  publication  of  Finney's  paper  in  1900,  102  recovered 
and  61  died — a  mortality  percentage  of  37.04.  Lund  states  that  SO  per  cent,  of 
these  cases  recover  if  operated  upon  within  twelve  hours.  English  puts  the 
recoveries  at  a  little  better  than  50  per  cent,  and  Moynihan  says  35  to  40  per  cent. 


CANCER  OF  THE  STOMACH. 

Gastric  carcinoma  is  one  of  the  most  common  forms  of  malignant  growth.  Many 
years  ago  AVelch  showed  that  in  31,482  cases  of  cancer  the  disease  affected  the 
stomach  in  21.4  per  cent.  Startling  statistics  as  to  the  increasing  frequency  of 
cancer  have  been  published  by  several  writers,  of  which  one  of  the  leaders  has  been 
Roswell  Park,  of  Buffalo.  In  the  L'nited  States  census  for  1890,  the  deaths  from 
gastric  cancer  were  placed  at  2014  as  against  304  from  cancer  of  the  rectum,  and  876 
from  cancer  of  the  liver;  whereas,  in  the  census  for  1900,  there  were  4220  deaths 
from  cancer  of  the  stomach,  574  from  cancer  of  the  rectum,  and  1784  from  cancer 
of  the  liver.  As  a  large  proportion  of  cases  of  cancer  of  the  liver  are  secondary 
to  growths  elsewhere,  particularly  in  the  stomach,  these  facts  are  of  great  interest. 
In  the  city  of  Washington  the  deaths  from  cancer  of  the  stomach  in  the  decade 
from  ISSfto  1890  were  191,  and  in  the  decade  from  1891  to  1900,  339,  which  shows 
an  increase  greater  in  proportion  than  the  gro-^-th  of  the  city  population.  So, 
too,  Templeton,  of  Dundee,  found  that  from  1877  to  1902  the  death  rate  from 
gastric  and  esophageal  cancer  increased  12.66  per  10,000. 

Etiology. — Gastric  cancer  is  far  more  common  in  males  than  in  females.  Welch 
states  the  proportion  to  be  5  to  4,  but  in  Osier's  cases  the  proportion  was  5  to  1. 
Gastric  ulcer  is  the  site  for  the  development  of  gastric  cancer  in  about  50  per  cent, 
of  cases.  But  while  some  patients  state  that  they  have  been  subject  to  gastric 
disorders  for  years  before  the  final  illness  develops,  it  has  been  my  experience 
that  a  very  large  proportion  state  that  hitherto  they  have  had  perfect  digestion, 
and  have  never  know'n  what  it  w^as  to  have  gastric  distress  in  previous  years.  In 
other  words,  given  a  man  who  complains  of  grave  gastric  symptoms  and  loss  of 
weight,  who  has  not  cirrhosis  of  the  liver,  or  dilatation  of  the  stomach,  who  has 
not  used  alcohol  to  excess,  and  who  boasts  of  his  good  stomach  during  the  first 
forty  years  of  life,  that  man  will  often  be  found  to  have  gastric  cancer.  We  have 
no  knowledge  of  the  etiology  of  gastric  cancer  beyond  the  facts  already  named. 
Langwill  states  that  gastric  cancer  is  not  so  much  a  disease  of  middle  age  as  is 
commonly  believed,  a  marked  percentage  of  cases  occurring  under  forty  years. 

Morbid  Anatomy. — Gastric  cancer  is  usually  primary,  but  it  may  be  secondary. 
The  most  common  form  is  the  medullary  carcinoma,  a  form  of  the  spheroidal-cell 
cancer;  the  adenocarcinoma,  the  malignant  adenoma  of  German  writers,  or  cylin- 
drical-cell cancer,  is  second  in  point  of  frequency.  The  scirrhus  type  is  the  third 
in  frequency.  Gelatiniform  degeneration  occurs  in  the  first  and  second,  and  when 
present  such  tumors  are  called  colloid  cancers. 
35 


.")iii  i)isi':.\si':s  OF  nil':  stomach 

Tlic  niediillary,  or  splRToiilal-ccll  tyi)e,  is  the  niiwt  rapid  in  its  growth,  usually 
tends  to  ulcerate  early,  and  is  followed  by  metastasis  and  direct  extension  to 
contiguous  organs  sooner  than  the  other  types. 

The  scirrhus  is  a  denser  growtli,  infiltrating  and  indurating  the  submucosa 
often  to  some  distance,  or  even  all  of  the  organ,  diffuse  carcinoma  under  such 
circumstances;  the  thick,  dense,  gastric  wall  has  led  to  the  condition  being  called 
"India-rubber  bottle  stomach,"  or  "leathery  stomach." 

The  colloid  growths  form  tumors  of  greater  size,  often  extending  by  contiguity 
and  matting  adjacent  organs  into  a  sohd  mass.  On  section  the  clear  or  gra>ish 
gelatinifomi  trembling  matrix  is  found  to  be  enclosed  in  alveoli,  often  of  macro- 
scopic dimensions. 

The  pylorus  is  the  part  of  the  stomach  usually  affected;  next  to  it  in  frequency 
is  the  lesser  curvature,  but  out  of  Welch's  1300  cases  the  pylorus  was  affected  791 
times,  and  the  lesser  curvature  but  148. 

Moynihan,  of  Leeds,  has  investigated  the  subject  of  how  malignant  growths 
spread  in  the  gastric  wall,  and  has  concluded: 

1.  That  malignant  disease  of  the  stomach  begins  in  the  majority  of  instances 
near  the  pylorus,  just  below  the  lesser  curvature. 

2.  That  from  this  point  it  spreads  most  rapidly  and  most  widely  in  the  submucosa. 

3.  That  the  rate  of  growth  toward  the  cardiac  orifice  is  rapid,  toward  the  duo- 
denal side  extremely  slow.  The  duodenal  extremity  of  the  viscus  is  rarely  affected 
extensively. 

4.  That  the  tendency  of  the  growth  is  to  drift  toward  the  curvatures. 


The  lymphatic  vessels  and  glands  of  the  stomach:  a  is  the  most  frequently  affected  area,  b  is  next, 
and  c  is  the  "isolated  area."     (Moynihan.) 


He  found  that  the  lymphatic  system  of  the  stomach  was  comparatively  sinii)le. 
There  are  three  chief  lymphatic  areas  of  the  stomach  (Fig.  97). 

1.  An  area  along  the  lesser  curvature  (a)  from  which  the  lymphatic  vessels  pass 
upward  and  to  the  left  into  the  coronary  glands.  The  coronary  glands  lie  along 
the  artery  of  the  same  name.  At  the  celiac  axis  they  become  continuous  with 
the  glands  along  the  upper  border  of  the  pancreas. 

2.  An  area  (b)  along  the  greater  curvature  frt)ni  which  the  lymphatic  vessels 
pass  downward  and  to  the  right  into  the  glands  lying  along  the  greater  curvature. 
These  glands  are  more  numerous  near  the  pylorus,  and  from  here  ])ass  to  the  head 
of  the  pancreas  and  become  continuous  with  the  hepatic  grouj)  of  glands  which 
lie  along  the  hepatic  artery,  and  in  part  along  the  pyloric  artery. 


CANCm  OF  THE  STOMACH  547 

3.  In  addition  to  tliese  two  areas  is  a  third  (c),  for  which  Moynihan  suggested 
tiie  name  "isolated  area."  This  area  comprises  the  greater  tuberosity  of  the 
stomach,  the  lower  end  of  the  esophagus,  and  an  area  along  the  greater  curvature 
as  far,  approximately,  as  the  limit  of  supply  of  the  left  gastro-epipioic  artery.  Its 
lymphatic  vessels  pass  downward  to  the  hilum  of  the  spleen.  The  term  "isolated 
area"  seems  singularly  appropriate  for  this  region,  for  it  is  very  rarely  affected  by 
growth  spreading  upward  from  the  pylorus. 

If  a  cancer  of  the  stomach  arising  independently  of  ulcer  is  examined  in  its  early 
stages  it  will  usually  be  found  covered  with  mucous  membrane,  wliich  later  ulcer- 
ates. The  entire  wall  of  the  viscus  may  soon  be  involved,  but  in  the  colloid  form 
the  mucous  membrane  may  not  be  destroyed. 


Stomach.  Large,  ulcerating,  fungoid,  cylindrical-cell  carcinoma,  stiuated  on  the  posterior  wall  near 
the  pylorus,  which  was  slightly  obstructed  by  the  projecting  growth.  A  glass  rod  is  passed  through  a 
perforation  near  the  centre  of  the  floor  of  the  ulcer.  The  cardiac  end  of  the  organ  is  moderately  dilated. 
There  was  secondary  enlargement  of  the  lymph  nodes  behind  the  stomach,  and  metastatic  nodules  in 
the  liver. 

The  effects  of  cancer  of  the  stomach  upon  the  shape  of  this  viscus  depend  largely 
upon  the  character  of  the  growth,  and  chiefly  upon  its  situation.  The  general 
tendency  is  for  the  stomach  to  be  decreased  in  size,  but  if  the  growth  obstructs 
the  pylorus  the  stomach  may  be  greatly  dilated.  When  the  tumor  is  widely  diffused 
the  gastric  Avails  are  much  thickened,  and  if  it  be  of  large  size  it  may  displace  the 
pylorus  very  greatly  by  its  weight. 

Perforation  of  the  stomach  through  the  cancerous  mass  may  occur,  but  this  is 
not  a  frequent  complication. 

Symptoms. — The  symptoms  of  gastric  cancer  may  not  manifest  themselves 
for  a  long  period  after  the  growth  has  begun,  and  even  when  the  general  nutrition 
is  impaired  the  patient  may  not  complain  of  gastric  disorder.  It  is  a  mistake 
to  suppose  that  gastric  cancer  is  usually  very  painful. 


548  DISEASES  OF  THE  STOMAdl 

When  symptoms  are  present  they  may  he  divided  into  the  objective  and  the 
subjective.  The  objective  symptoms  are  pallor,  which  becomes  well  marked;  a 
loss  of  weight,  which  is  often  extraordinary,  amounting  to  a  loss  of  from  fifty  to 
seventy  pounds  in  a  few  months,  and  with  this  there  is  usually  a  rajjid  loss  of 
strciu/th.  The  anemia  is  chiefly  the  result  of  a  marked  decrease  of  hemoglobin, 
although  marked  reduction  and  morphological  alteration  in  the  erythrocytes  may 
yield  a  blood  picture  resembling  pernicious  anemia.  Sooner  or  later  Icukoci/tosis 
occurs  (see  below). 

The  symptoms  presented  by  the  patient,  in  the  sense  that  tliey  arc  complained 
of  by  him,  are  loss  of  strength,  gastric  distress  and  "dyspepsia,"  loss  of  appetite, 
nausea,  and  not  rarely  vomiting.  Vomiting  is  a  far  more  constant  symj^tom  when 
the  pylorus  is  obstructed  than  when  it  is  free,  and  the  matters  vomited  may  indi- 
cate a  feeble  digestive  power  and  be  colored  like  coft'ee  grounds  due  to  exuded  and 
altered  blood  arising  from  the  ulcerated  growth.  Sometimes  a  free  heinatcmesis 
develops.  Care  should  be  taken  that  the  presence  of  altered  bile  in  the  vomit  is 
not  taken  for  altered  blood. 

Not  rarely  the  patient  complains  of  constant  gnawing  pain  in  the  stomacli,  which 
may  or  may  not  be  increased  by  the  taking  of  food.  The  pain  is  usually  more 
severe  when  the  disease  is  in  the  region  of  the  pylorus.  If  the  skin  over  the  epigas- 
trium is  lightly  touched,  it  may  be  very  sensitive.  There  may  be  moderate  fever, 
constipation,  and  edema  of  the  ankles. 

Robson  states  that  pain  is  present  in  86  per  cent,  of  cases,  vomiting  in  85.3 
per  cent.,  and  a  tumor  is  palpable  in  76.6  per  cent.  These  figures  refer  to  the  entire 
history  of  the  cases  recorded,  and,  as  pointed  out  elsewhere,  none  of  these  symptoms 
may  be  present  during  the  early  stage  of  the  disease,  when  it  is  most  amenable 
to  surgical  treatment.  Such  percentages  are,  therefore,  of  greater  value  from  a 
statistical  than  from  a  diagnostic  stand-point. 

Diagnosis. — The  pallid,  cachectic  hue  of  the  patient,  combined  with  a  history 
of  loss  of  weight,  and  with  the  fact  that  the  patient  is  usually  beyond  the  fortieth 
year,  should  make  the  physician  at  least  suspect  the  presence  of  a  malignant  gro^\'th, 
and  this  suspicion  becomes  stronger  as  he  is  able  to  exclude  other  causes  of  anemia 
and  emaciation,  such  as,  for  example,  diabetes,  Bright's  disease,  and  pernicious 
anemia.  The  presence  of  cough  will  usually  be  a  guide  to  the  examination  of  the 
lungs  for  pulmonary  tuberculosis.  It  must  not  be  forgotten  that  abdominal 
tuberculosis  produces,  as  a  rule,  a  dry,  harsh  skin,  instead  of  the  peculiar  waxy 
or  greasy  skin  of  malignant  growth  and  pernicious  anemia. 

In  the  diagnosis  of  malignant  growth  the  blood  may  give  considerable  information 
and  aid  us  in  separating  this  condition  from  pernicious  anemia,  which  resembles 
it  very  closely  in  some  of  its  objective  symptoms.  Malignant  growth  is  character- 
ized by  a  marked  decrease  in  the  amount  of  hemoglobin  and  in  the  hemoglobin 
index,  a  condition  the  reverse  of  that  in  pernicious  anemia.  When  the  case  is  far 
advanced  there  is  usually  a  diminution  in  the  number  of  red  cells,  but  this  diminu- 
tion is  only  moderate  in  early  cases.  Leukocytosis  is  usually  present  in  moderate 
degree,  averaging,  perhaps,  20,000  to  25,000,  and  it  is  much  more  marked  if  metasta- 
sis, hemorrhage,  ulceration,  or  septic  infection  occur.  The  increase  in  white 
cells  is  chiefly  in  the  polymorphonuclear  neutrophilcs.  It  is  a  noteworthy  ])oint 
that  these  cells  may  be  relatively  increased  without  a  distinct  leukocytosis  l)eing 
present.  Normoblasts  and  myelocytes  are  sometimes  found  in  limited  nvnnbers 
when  the  disease  is  far  advanced. 

While  it  is  true  that  in  a  few  cases  of  pernicious  anemia  there  is  a  marked  diminu- 
tion in  the  quantity  of  hydr()chk)ric  acid,  it  is  rarely  if  ever  so  persistently  al)scnt 
as  it  is  in  gastric  carcinoma. 

.\nother  condition  which  may  give  rise  to  nmch  difliculty  in  diagnosis  is  ulcer 
of  the  stomach,  with  thickening  and  induration  around  it.     This  condition  is 


CANCER  OF  THE  STOMACH  549 

particularly  prone  to  appear  in  the  neighborhood  of  the  pylorus,  and  it  may  be 
impossible  by  palpation  to  differentiate  ulcer  and  induration  from  scirrhous  cancer. 
In  other  words,  every  case  in  which  a  mass  can  be  felt  in  the  stomach  is  not  one 
of  cancer.  (See  Treatment.)  In  such  a  case  the  excess  of  hydrochloric  acid  in 
ulcer  and  its  absence  in  cancer  are  valuable  factors  in  diagnosis.  Then,  too,  ulcer 
is  much  more  frequently  present  in  persons  under  forty,  but  cancer  is  more  common 
in  persons  over  forty. 

Inspection  of  the  epigastrium  very  often  gives  most  valuable  information,  because 
it  may  reveal  a  bulging  and  undue  pulsation  due  to  impulse  from  the  aorta  trans- 
mitted by  the  growth,  or  the  presence  of  a  nodule.  A  deep  breath  taken  during 
inspection  may  reveal  distinct  movements  of  the  mass.  If  a  Seidlitz  powder  is 
taken  in  two  parts,  so  that  the  contents  of  one  paper  follow  the  other,  the  tumor 
can  sometimes  be  seen  to  be  projected  against  the  abdominal  wall  by  the  distended 
viscus.  Palpation  may  reveal  a  mass  which  usually  presents  an  uneven  surface, 
and  this  may  be  distinctly  nodular. 

The  position  of  the  mass  may  be  varied  by  the  pressure  of  food  in  the  stomach. 
If  a  mass  cannot  be  felt,  immersing  the  patient  in  a  hot  bath  may  relax  the  tense 
belly  wall  so  that  the  tumor  may  be  demonstrable.  Percussion,  if  it  is  carefully 
and  gently  performed,  over  the  mass  may  give  an  impaired  note. 

Additional  signs  on  palpation  consist  of  a  hardening  of  the  gastric  walls  due  to 
contraction  of  their  muscular  fibres,  and  if  the  patient  is  thin  the  mass  may  be  so 
movable  that  it  may  be  pushed  high  up  under  the  ribs  or  far  down  toward  the 
pelvis.  The  mobility  is  of  some  diagnostic  value,  for  if  the  mass  be  due  to  indura- 
tion about  an  ulcer  the  gastric  wall  may  be  glued  to  adjacent  tissues,  and, 
therefore,  be  made  fast.  As  a  rule,  tumor  at  the  pylorus  is  more  readily  pal- 
pated than  one  at  the  middle  of  the  stomach,  and  a  gro^\i:h  at  the  cardia  is 
rarely  felt. 

Auscultation  may  reveal  constant,  direct,  or  reversed  peristalsis  if  the  growth 
obstructs  the  pylorus.  All  the  symptoms  of  gastric  dilatation  may  be  present 
if  the  growth  be  so  situated  (see  Gastric  Dilatation),  and  as  75  per  cent  of  gastric 
cancer  is  at  the  pylorus  obstruction  is  common.  A  bismuth  meal  and  the  .r-rays 
should  be  resorted  to  in  all  doubtful  cases  to  discover  obstruction,  tumor  or 
deformity. 

A  very  useful  and  reliable  method  for  the  purpose  of  determining  the  presence 
of  gastric  cancer  is  the  determination  of  the  character  of  the  stomach  contents. 

If  obstruction  at  the  pylorus  is  present,  food  remnants  are  found  in  the  gastric 
contents  hours  after  eating,  and  if  vomiting  occurs,  the  patient  may  be  surprised 
at  seeing  traces  of  food  taken  many  hours  or  even  days  before. 

If  the  stomach  contents  are  examined  after  a  test  meal  there  will  be  an  almost 
complete  or  total  absence  of  hydrochloric  acid  and  an  abnormal  amount  of  lactic 
acid  present.  To  determine  these  facts,  we  resort  to  the  use  of  a  test  meal  and 
certain  chemical  tests,  as  follows: 

Boas'  test  meal  consists  in  the  use  of  an  ordinary  breakfast  roll  weighing  about 
1  ounce,  with  10  ounces  of  water,  or  of  weak  tea,  which  should  contain  no  milk 
or  sugar.  This  is  allowed  to  remain  in  the  stomach  for  one  hour,  and  then  is 
removed  by  the  stomach-tube.  The  quantity  of  fluid  obtained  should  equal 
from  three-quarters  of  an  ounce  to  an  ounce  and  a  half.  It  is  best  to  examine  this 
fluid  microscopically,  and  then,  after  filtering  it,  to  apply  the  tests  for  hydrochloric 
acid  and  the  organic  acids.  The  two  common  tests  for  free  hydrochloric  acid  are 
Giinzburg's  phloroglucin-vanillin  and  Boas'  resorcin  tests.  Giinzburg's  reagent 
is  composed  of: 

Phloroglucin gr.  xxx  (2  gi'ams) 

Vanillin gr.  xv  (1  gram) 

Alcohol  (absolute) §i  (30  c.c.) 


550 


DISEASES  OF  THE  STOMACH 


This  solution  should  be  carefully  protected  from  the  light  by  being  kept  in  a 
dark  bottle  and  should  be  frequently  prepared,  as  stale  solutions  are  uncertain. 
One  or  two  drops  of  this  reagent  are  placed  in  a  porcelain  dish  or  capsule,  with  an 
equal  quantity  of  the  filtrate  obtained  from  the  gastric  contents.  The  dish  is 
then  gently  heated  over  an  alcohol  lamj)  or  Bunsen  burner  to  such  a  degree  that 
slow  evaporation  takes  place.     If  free  hydrochloric  acid  is  present,  a  typical  rose- 


Great  gastroptosis  and  dilatation  due  to  cancer  occurring  in  site  of  an  old  ulcer  at  pylorus.  The 
greater  curvature  is  as  low  as  the  pubes.  .\bove  the  dark  shadow  due  to  bismuth  is  fluid  in  the 
stomach  and  above  this  is  gas  in  the  splenic  flexure  of  the  colon. 


red  hue  develops  at  the  edge  of  the  mixture  where  it  is- drying  on  the  dish,  or  it 
may  be  less  of  a  pink  and  more  of  a  bright  red.  This  test  is  exceedingly  delicate 
and  very  certain. 

Boas'  reagent  depends  upon  the  fact  that  resorcin  produces  a  somewhat  similar 
reaction  with  free  hydrochloric  acid.     This  reagent  is  composed  of: 

Resublimed  resorcin pr.  Ixxv  f.5  grams) 

Cane-sugar gr.  xlv  (3  grams) 

Alcohol  (94  per  cent.) oii'ss  (100  c.c.) 


CANCER  OF   THE  STOMACH  551 

A  few  drops  of  this  reagent  are  placed  in  a  porcelain  dish  and  an  equal  quantity 
of  the  stomach  filtrate  added  to  them.  Heat  is  applied  as  in  the  previous  test, 
and  if  the  acid  is  present  a  very  perceptible  red  color  appears  at  the  edge  of  the 
evaporating  mixture.  The  discovery  of  a  hypochlorhydria  or  absence  of  IICl  is 
not  as  pathognomonic  a  symptom  of  gastric  cancer  as  was  thought  at  one  time. 
Particularly  is  this  statement  true  when  only  one  test  is  made.  Chronic  gastric 
catarrh  and  disorder  of  the  innervation  of  the  stomach  or  even  the  psychic  state 
of  the  patient  may  greatly  influence  the  secretion  of  gastric  juice. 

The  finding  of  occult  blood  in  the  stools  is  very  indicative  of  cancer,  because  in 
gastric  and  duodenal  ulcer  the  hemorrhage  is  apt  to  be  inconstant.  (See  Gastric 
Ulcer.) 

Still  another  point  of  diagnostic  importance  is  the  examination  of  the  stomach 
contents  by  the  microscope,  which  may  reveal  blood  cells  and  portions  of  malignant 
growth.  While  it  is  true  that  the  presence  of  blood  may  be  due  to  ulcer,  the  asso- 
ciated pieces  of  growth  are,  of  course,  diagnostic. 

Rommelaere  asserts  that  if  a  patient  over  forty  years  of  age  with  chronic  gastric 
disease  eliminates  less  than  ISO  grains  of  urea  a  day,  he  has  cancer.  This  is 
probably  too  dogmatic.  A  better  way  of  putting  it  is  to  say  that  when  a  patient 
with  these  symptoms  eliminates  450  grains  a  day  he  has  not  gastric  cancer. 

It  is  important  to  note  that  a  bacillus  called  the  Oppler-Boas  bacillus  is  present 
in  the  stomach  contents  of  cases  of  gastric  cancer  with  great  constancy.  Indeed, 
it  is  present  ninety-nine  times  in  a  hundred.  This  bacillus  is  a  very  long,  non- 
motile  organism,  which  has  the  power  of  converting  sugar  into  lactic  acid,  and 
lactic  acid  is  present  in  large  amount  in  this  disease. 

Prognosis. — The  prognosis  is  only  hopeful  in  inverse  ratio  with  the  size  of  the 
growth,  the  ability  of  the  surgeon  to  remove  it,  and  the  general  state  of  the  patient. 
Even  surgery  can  offer  only  temporary  relief,  for  in  the  majority  of  cases  recidivity 
takes  place.  Fenwick  asserts  that  if  the  potassium  sulphocyanide  disappears 
from  the  saliva,  the  patient  dies  within  a  month. 

Duration. — This  varies  greatly.  In  some  instances  death  comes  in  a  few  weeks 
after  the  disease  is  recognized.  In  others  it  is  deferred  for  months,  particularly 
if  the  growth  be  scirrhous  and  involves  the  pylorus,  when  gastro-enterostomy,  by 
relieving  obstruction  and  permitting  nourishment,  may  prolong  life  for  a  long 
period.  My  colleague,  Dr.  Keen,  performed  gastro-enterostomy  in  a  case  under 
my  care  in  which  the  growth  was  so  great  that  excision  was  impossible.  The 
patient  was  greatly  emaciated  and  more  than  sixty  years  of  age,  yet  he  gained 
nearly  thirty  pounds  in  six  months,  and  lived  in  comfort  for  two  years  and  a  half 
after  the  operation. 

Treatment. — ^Many  patients  with  gastric  cancer  can  be  much  improved  and  their 
lives  prolonged  and  perhaps  saved  by  operation,  but  it  is  essential  that  the  growth 
shall  be  limited  to  the  stomach  and  that  it  does  not  involve  neighboring  parts. 
For  this  reason  it  is  of  vital  importance  that  the  diagnosis  of  the  disease  shall  be 
made  at  the  earliest  possible  moment.  (See  Gastric  Ulcer.)  Indeed,  it  may  be 
said  that  every  patient  who  develops  persistent  gastric  symptoms  after  the  age  of 
forty  should  be  regarded  as  a  possible  case  of  gastric  cancer.  In  the  opinion  of  the 
writer,  every  case  of  suspected  gastric  cancer  in  any  stage  should  at  least  be  sub- 
jected to  exploratory  operation,  since  by  this  means  it  may  be  discovered  that  the 
diseased  area  may  be  excised.  Even  if  nothing  more  is  found  than  the  scar  of  an 
old  ulcer  the  operation  is  rewarded  in  the  avoidance  of  cancer  later  on.  The  danger 
of  exploratory  operation,  as  compared  to  the  certainty  of  death  if  the  growth  is 
not  interfered  with,  is  not  to  be  considered. 

Kronlein  has  shown  that  the  average  duration  of  life  after  patients  come  under 
observation  is  about  nine  months.  If  they  submit  to  operation  it  is  more  than 
twelve  months.     These  figures  are  average  figures.     If  the  growth  is  treated  early 


552  njSKASKS  OF   Till':  STOMACH 

enough  perfect  recovery  may  occur  and  at  least  from  three  to  five  years  of  existence 
remains.  Tiie  duration  of  hfe  is  greater  in  those  treated  by  gastrectomy  than  in 
tliose  treated  by  gastro-enterostomy,  but  tlie  surgeon  must  decide  after  lie  opens 
the  belly  what  course  to  pursue. 

The  medicinal  treatment  of  gastric  cancer  consists  first  in  the  administration 
of  anodynes  if  there  is  much  pain.  These  anodynes  may  consist  of  small  doses  of 
morphine  or  codeine  or  cannabis  indica.  Much  of  the  distress  due  to  so-called 
dyspepsia  can  be  relieved  ])y  the  use  of  S  to  20  dro])s  of  dilute  hydrochloric  acid, 
with  1  or  2  drachms  of  the  huidextract  of  condurango,  given  immediately  after  or 
with  each  meal.     If  starchy  foods  are  taken,  takadiastase  may  be  used. 

The  use  of  a  stomach-tube  for  washing  out  the  stomach  is  usually  inadvisable, 
as  it  may  produce  a  perforation  if  the  growth  is  soft  or  the  ulceration  deep. 

Should  vomiting  occur  and  blood  be  in  the  vomit,  the  directions  for  the  treatment 
of  hematemesis  in  the  article  on  Gastric  Ulcer  should  be  followed. 

HYPERTROPHIC  STENOSIS  OF  THE  PYLORUS. 

Definition. — This  condition,  as  its  name  implies,  is  one  in  which  there  is  thickening 
and  overgrowth  of  the  muscular  fibres  in  the  pyloric  portion  of  the  stomach,  with 
spasm  and  consequent  obstruction  to  the  free  passage  of  its  contents  into  the  bowel. 

Overgrowth  of  the  tissues  about  the  pylorus  may  be  di\'ided  into  three  t\'pes. 
In  one  the  gastric  walls  become  thickened  by  an  overgrowth  of  connecti\e  tissue, 
which  not  only  results  in  an  increased  diameter  of  the  part,  but  also  in  a  diminution 
of  the  size  of  the  entire  stomach.  A  second  form  has  been  described  by  French 
authors,  which  is  associated  with  sclerotic  hypertrophic  changes  in  the  other 
abdominal  viscera,  such  as  the  liver,  pancreas,  and  kidneys.  The  third  form  is 
that  which  is  known  as  congenital  hypertrophic  stenosis,  which  has  no  etiological 
relationship  to  the  two  forms  just  described.  All  three  of  these  forms  are  quite 
rare,  the  last  being  most  frequent. 

Etiology. — We  have  little  knowledge  of  the  causes  of  hj-pertrophic  stenosis  of  the 
pylorus.  In  some  instances  it  has  been  thought  that  the  overgro\\-tli  is  the  result 
of  some  congenital  defect,  or,  in  other  words,  that  it  is  a  primary  condition,  but 
in  others  it  has  seemed  to  be  certainly  secondary.  It  is  probable  that  in  the  hyper- 
trophic stenosis  of  adults  the  underlying  cause  is  chronic  gastritis.  When  it 
occurs  in  adults  hypertrophic  stenosis  is  usually  a  disease  of  middle  life. 

Morbid  Anatomy. — In  that  form  of  this  disease  which  arises  in  middle  life  and 
which  develops  as  a  result  of  chronic  gastritis,  notwithstanding  the  non-existence 
of  the  obstruction  at  the  pyloric  opening,  dilatation  of  the  stomach  as  a  secondary 
condition  seems  to  be  rare,  but  this  depends  somewhat  upon  how  diffuse  the  over- 
growth of  connective  tissue  happens  to  be.  When  it  is  limited  strictly  to  the  pyloric 
region,  dilatation  ensues  because  of  the  obstruction.  When  it  is  more  dift'use, 
the  stomach  may  be  diminished  in  size.  Very  rarely  does  the  overgrowth  of  con- 
nective tissue  develop  to  such  an  extent  as  to  make  it  possible  to  discover  any 
mass  by  carefid  palpation. 

When  tiu'  condition  is  due  to  some  congenital  defect,  the  pathological  condition 
is  somewhat  different.  It  is  found  that  the  organ  is  larger  than  normal  and  that 
its  walls  are  thickened  by  overgrowth  of  its  muscular  fibres.  At  the  pylorus  these 
muscular  fibres  have  undergone  great  hypertrophy,  so  that  this  part  of  the  stomach 
feels  like  a  solid  mass  between  the  fingers,  and  on  section  it  is  found  to  be  dense 
and  firm,  the  mucous  membrane  lining  the  part  being  thrown  into  folds  which 
lie  in  the  direction  of  the  long  axis  of  the  organ.  Sometimes  one  of  these  folds 
is  so  much  larger  than  others  that  it  aids  in  producing  obstruction  and  seems  to 
from  a  large  part  of  the  overgrowth.  ]\Ioynihan  has  well  said  that  such  a  .stomach 
may  appear  and  feel  much  like  the  bladder  and  prostate  when  they  have  been 


HYPERTROPHIC  STENOSIS  OF  THE  PYLORUS  553 

removed  by  dissection.  If  the  duodenum  is  opened,  the  pyloric  orifice  may  resemble 
that  of  the  cervix  uteri  when  it  is  seen  through  the  vagina.  The  thickening  of  the 
muscular  fibre  is  not  always  limited  to  the  pyloric  area,  but  sometimes  extends 
into  the  duodenum.  The  longitudinal  muscular  layers  are  not  greatly  increased 
in  size,  and,  although  there  is  a  general  hypertrophy  of  the  muscular  element 
throughout  the  entire  organ,  it  is  often  so  slight  at  the  cardiac  end  of  the  stomach 
that  it  is  scarcely  noticeable. 

Symptoms. — The  symptoms  of  stenosis  of  the  pylorus  in  adults  consist  in  a 
sensation  of  fulness,  pressure,  and  pain  in  the  stomach.  There  are  also  evidences 
of  motor  insufhciencj',  and  when  the  obstruction  to  the  pylorus  becomes  marked, 
vomiting  may  come  on  to  relieve  the  stomach  of  materials  which  cannot  escape 
into  the  intestine.  So,  too,  the  patient  may  lose  flesh  as  the  result  of  interference 
with  the  digestion  and  with  the  retention  of  proper  quantities  of  food.  The  hydro- 
chloric acid  of  the  gastric  contents  is  usually  diminished,  probably  because  of  the 
chronic  gastritis  which  precedes  the  disease. 

Diagnosis. — Even  if  a  mass  be  felt  in  the  pylorus  the  only  certain  diagnostic 
measure  is  the  bismuth  meal  and  the  .c-rays,  which  should  always  be  resorted  to. 
It  may  be  exceedingly  difficult  to  differentiate  hypertrophic  stenosis  of  the  pylorus 
in  an  adult  from  gastric  cancer  occurring  in  this  portion  of  the  stomach.  In  the 
article  on  Gastric  Cancer  it  was  pointed  out  that  many  of  these  patients  give  a 
history  of  perfect  digestion  and  no  gastric  distress  until  the  cancer  develops;  but 
in  hypertrophic  stenosis  there  is  usually  a  history  of  many  years  of  discomfort, 
with  a  constant  endeavor  to  find  food  which  would  not  cause  indigestion.  The 
absence  of  cachexia,  although  the  patient  may  be  anemic,  also  points  toward  hyper- 
trophic stenosis.  On  the  other  hand,  if  the  liver  or  gallbladder  seems  to  be  affected, 
the  condition  is  almost  certainly  carcinomatous.  In  some  instances  it  is  impossible 
to  make  a  differential  diagnosis  without  operation,  and  even  then  it  may  require  a 
microscopic  examination  to  determine  that  the  thickening  is  not  malignant.  So 
far  as  probabilities  are  concerned,  it  may  be  stated  that  the  presence  of  obstruction 
at  the  pylorus  in  a  person  at  or  past  middle  life  is  very  much  more  likely  to  be 
carcinoma  than  hypertrophic  stenosis,  since  the  former  condition  is  quite  common 
and  the  latter  condition  is  very  rare. 

Difficulty  may  also  be  experienced  in  differentiating  hypertrophic  stenosis  from 
cicatricial  contraction  due  to  the  remains  of  an  old  gastric  ulcer.  The  physical 
signs  and  symptoms  present  at  the  moment  of  examination  may  give  us  no  informa- 
tion, but  the  past  history  of  the  case  may  aid  us  materially.  Thus,  when  gastric 
ulcer  has  been  present,  there  may  be  a  history  of  hemorrhage  and  severe  pain, 
which  is  absent  in  cases  of  stenosis. 

Congenital  Pyloric  Stenosis. — As  already  stated,  the  condition  of  pyloric 
stenosis,  when  not  due  to  ulcer  or  cancer,  is  met  with  in  the  majority  of  cases  in 
very  young  children,  and  in  such  is  undoubtedly  congenital.  In  such  instances 
the  child  is  born  apparently  healthy,  and  after  two  or  three  days,  or  several  weeks, 
of  life  is  seized  with  sudden  and  persistent  mmiting,  for  which  no  errors  in  diet  can 
be  held  responsible.  The  vomiting  is  often  forcible  and  often  projectile  and  gives 
the  child  relief  for  the  time  being  until  more  food  is  taken,  when  it  recurs.  The 
time  during  which  the  food  is  retained  varies  from  a  few  minutes  to  several  hours, 
and  in  some  instances  the  mere  act  of  swallowing  seems  to  reflexly  produce  the 
motions  of  vomiting.  In  some  instances  the  vomiting  is  sufficiently  prolonged  to 
empty  the  stomach  thoroughly;  in  others  a  considerable  quantity  of  food  may  be 
retained.  It  is  a  noteworthy  fact  that  even  if  the  vomiting  is  severe,  hile  is  never 
present  in  the  ejected  material,  because  the  closed  pylorus  prevents  it  from  being 
drawn  from  the  duodenum.  The  result  of  the  ejection  of  the  food  almost  as  soon 
as  it  is  swallowed,  combined  with  the  deficient  digestive  function  of  the  stomach 
which  is  nearly  always  present,  is  rapid  emaciatum,  exhaustion,  and  death.     Some- 


554 


DISEASES  OF  THE  STOMACH 


times  a  period  of  semiconsciousness  ensues,  and  occiisionally  tlie  child  is  seized 
with  a  convulsive  attack. 

The  duration  of  life  varies  from  four  or  five  weeks  to  six  months. 

As  the  disease  progresses  and  emaciation  becomes  marked,  it  may  he  possible 
to  see  the  outline  of  the  stomach  in  its  forcible  contractions  if  the  abdomen  is 
carefully  examined  in  a  good  light.  If  deep  paljjation  can  be  ])racti.sed,  the  thick- 
ened pyloric  portion  of  the  stomach  can  be  felt  forming  a  distinct  contrast  to  the 
empty  and  collapsed  intestines,  which  are  prevented  from  containing  their  usual 
food  and  liquid  by  the  obstruction  at  the  pylorus.     (See  Fig.  100.) 


Showing  the  gastric  peristalsis.    Note  constriction  of  stomach  by  passing  wave.      (Ibraliim.) 


The  points  which  are  strongly  in  favor  of  hypertrophic  stenosis  of  the  pylorus 
in  infancy  are  the  causeless  and  persistent  vomiting,  the  absence  of  bile  from  the 
vomit,  the  constipation,  the  presence  of  a  tumor  in  the  pyloric  area,  the  collapsed 
intestines  and  distended  stomach,  and  the  fact  that  gastric  digestion  is  almost 
completely  arrested,  and,  finally,  that  these  symptoms  are  present  in  a  young 
child.    The  diagnosis  is  to  be  confirmed,  if  need  be,  by  bismuth  and  the  .r-rays. 

Prognosis. — The  prognosis  in  congenital  hypertrophic  stenosis  depends  upon 
the  degree  of  obstruction.     It  is  unfa\orable  as  to  recovery. 

Treatment. — The  treatment,  whether  the  state  be  congenital  in  infants  or  acquired 
in  adults,  consists  in  the  use  of  lavage  and  in  feeding  through  a  rubber  tube,  so 
that  the  movements  of  swallowing  are  not  necessary.  In  some  cases  it  may  be 
possible  to  ])revent  the  vomiting  by  gently  washing  out  the  stomach  before  each 
feeding,  but  this  is  only  of  service  in  those  instances  in  which  the  stenosis  is  not 
absolute.  When  this  measure  fails,  or  if  the  symptoms  are  exceedingly  severe, 
operative  procedure  must  be  resorted  to  before  the  patient  is  sufficiently  exhausted 
to  contra-indicate  the  operation.  The  operation  in  adults  should  either  be  pyloro- 
plasty or  gastro-enterostomy.  INIoynilian  states  that  anterior  gastro-enterostomy 
has  been  performed  9  times,  with  5  recoveries  and  4  deaths,  but  1  of  these  deaths 
was  due  to  acute  obstruction  caused  by  a  Murphy  button.  Loreta's  operation  of 
pylorodiosis  has  been  performed  9  times,  with  7  recoveries. 

It  has  been  generally  held  in  the  past  that  congenital  stenosis  of  the  pylorus 
could  be  relieved  only  l)y  operative  interference.  This  sweeping  conclusion  is 
erroneous,  since  much  depends  upon  the  degree  of  stenosis.  If  it  seems  to  be 
ab.solute  and  improvement  fails  to  take  place  after  the  use  of  lavage  and  gavage, 
operation  must  be  resorted  to  before  the  patient  is  too  exhausted  to  withstand 


HOUR-GLASS  STOMACH 


555 


the  shock.  There  are  so  many  cases  now  on  record  in  which  recovery  has  occurred 
without  operation  tliat  medical  means  should  always  be  given  a  fair  chance  to  do 
good.  The  claim  that  tlie  cases  which  have  recovered  without  oi^eration  have  not 
been  really  instances  of  organic  stenosis  but  spasm  is  proved  incorrect  by  the  fact 
that  subsequent  autopsy,  when  death  has  been  due  to  other  causes,  has  shown  an 
actual  hypertrophy  to  be  present.  The  mortality  imder  operation  is  about  50  per 
cent.,  or  higher  than  this  if  exhaustion  is  extreme. 

HOUR-GLASS  STOMACH. 

Definition. — Hour-glass  stomach,  sometimes  called  "bilocidar  stomach,"  or 
"  Sanduhrmagen,"  is  a  condition  in  which  the  stomach  is  divided  into  two  parts 
by  a  contraction  which  may  exist  anywhere  between  the  cardiac  and  pyloric  orifices. 
Very  rarely,  indeed,  a  trilocular  condition  may  be  present,  and,  still  more  rarely,  a 
quadrilocular  state  may  exist. 


Remarkable  hour-glass  stomach  with  perforation  of  ulcer.  The  upper  dark  mass  to  the  right  is  the 
remains  of  the  fundus.  To  the  left  is  the  barium  extravasated  into  the  tissues.  Below  is  the  hour- 
glass contraction,  and  below  it  is  the  distended  lower  half  of  the  stomach,  retentive  from  pyloric 
stenosis.     X-ray  diagnosis  confirmed  on  operating. 

Etiology. — Hour-glass  stomach  maj'  be  congenital  or  acquired.  There  is  some 
difference  of  opinion  as  to  the  relative  frequency  of  these  two  forms  of  the  condition. 
Some  authors  have  maintained  that  all  cases  are  acquired,  while  others  assert  that 
the  congenital  cases  are  more  common.  Fenwick  says  that  about  45  per  cent,  of 
the  cases  which  have  been  so  far  recorded  showed  no  sign  of  either  ulcer  or  scar 
in  the  stomach,  or  if  an  ulcer  or  scar  were  present  it  was  manifest  that  it  was  more 
recent  than  the  stricture  itself;  and  again  he  states  that  only  1  case  of  the  acquired 
type  has  been  found  in  the  London  Hospital  in  forty  years,  whereas  several  instances 
of  the  congenital  type  were  met  with  during  the  same  period  of  time.     To  those 


556  DISEASES  OF  THE  STOMACH 

who  believe  in  the  congenital  origin  of  these  cases,  Moynilian  is  strongly  opposed, 
and  he  is  undoubtedly  correct  as  modern  methods  of  investigation  prove. 

There  are  three  causes  of  hour-glass  contraction:  first,  perigastric  adiicsion; 
second,  chronic  ulcer;  and  third,  malignant  disease.  The  perigastric  adhesions 
are  most  commonly  due  to  ulcer  of  the  stomach  or  to  a  nearby  inflammatory  process 
set  up  by  the  presence  of  gallstone.  Chronic  ulcer  not  only  produces  perigastric 
adhesions,  but  it  may,  in  healing,  cause  much  contraction  and  thickening  of  the 
stomach,  so  that  its  wall  becomes  puckered  and  its  calibre  decreased.  Associated 
with  this  contraction,  due  to  the  formation  of  scar  tissue,  there  is  also  a  certain 
amount  of  muscular  spasm,  the  circular  muscular  fibres  contracting  in  such  a  way 
as  to  resemble  a  sphincter  muscle.  This  spasmodic  contraction  accounts  for  the 
paroxysms  of  tlisconifort  from  which  the  patient  occasionally  suffers. 

Pathology  and  Morbid  Anatomy. — On  examining  a  stomach  for  the  seat  ui  hour- 
glass contraction,  two  sets  of  thickened  muscular  fibres,  wliich  cross  one  another, 
may  sometimes  be  seen.  These  bundles  are  usually  one-half  inch  or  more  in 
width,  and  cross  one  another  at  the  point  of  contraction,  and  it  is  the  shortening 
of  these  muscular  fibres  which  produces  the  deformity.  That  this  is  not  the  cause 
in  most  instances,  however,  is  shown  by  the  fact  that  these  muscular  fibres  are 
frequently  absent,  or,  at  least,  are  not  abnormally  developed.  When  the  constric- 
tion is  due  to  the  formation  of  a  cicatrix  the  narrowed  band  forming  the  dividing 
septum  between  the  two  pouches  is  composed  of  fibrous  tissue;  this  may  be  puckered, 
indicating  that  it  has  followed  an  ulcer. 

Symptoms. — The  symptoms  of  hour-glass  contractions  of  the  stomach  are  by 
no  means  definite.  The  diagnosis  is  practically  always  made  l)y  the  use  of  a 
bismuth  meal  and  the  .r-rays. 

Treatment. — The  only  treatment  for  hour-glass  contraction  which  can  afford 
any  relief  is  operative.   Thus,  a  gastro-enterostomy  may  be  done  from  both  jjouches, 
or  gastroplasty  or  pyloroplasty  may  be  necessary.     For  these  operations  the  reader  . 
is  referred  to  books  on  surgery. 


GASTRIC  NEUROSES. 

At  the  present  time  several  states  of  the  stomach  are  known  to  exist  which  depend 
upon  an  altered  or  perverted  nerve  supply,  and  are  not  connected  with  any  patho- 
logical lesion  which  our  methods  of  examination  can  detect.  Gastric  neuroses 
are  not  commonlj'  met  with  as  conditions  independent  of  true  lesions,  and  the 
physician  must  not  rest  satisfied  with  a  diagnosis  of  gastric  neurosis  until  he  has 
exhuasted  every  possible  means  of  discovering  an  actual  morbid  change.  In 
some  instances  the  nervous  affection  of  the  stomach  is  a  manifestation  of  disease 
of  the  central  nervous  system;  in  others  it  is  a  sign  of  perverted  nervous  function 
due  to  neurasthenia  or  nervous  exhaustion,  and  in  still  other  cases  it  may  be  depend- 
ent upon  growths  which,  being  situated  in  adjacent  tissues,  press  upon  the  gastric 
nerves  and  so  cause  pain  or  spasm.  Finally,  it  is  to  be  remembered  that  even 
if  the  i)hysician  can  discover  no  sign  of  gastric  lesion,  this  does  not  justify  a  diagnosis 
of  gastric  neurosis,  because  it  not  rarely  happens  that  disease  elsewhere  causes  pain 
wiiich  is  incorrectly  referred  by  the  patient  to  the  region  of  the  stomach.  Thus,  a 
child  with  pericarditis  or  appendicitis  may  complain  bitterly  of  epigastric  pain. 

True  gastric  neuroses  may  be  divided  for  study  into  three  classes,  xh.,  di.inrdcrs 
of  mohiliUi,  (Imjrdcru  of  sensation,  and  disorders  of  secretion,  and  these  in  turn  are 
divisilile  into  states  of  excitation  and  depression. 

Cardiospasm,  or  cramp  of  the  muscular  fibres  in  the  cardiac  end  of  the  stomach, 
is  a  result,  as  a  rule,  of  irritation  of  the  gastric  mucous  membrane  by  superacid 
secretion.     Occasionally  it  may  develop  as  the  result  of  distention  of  the  stomach 


GASTRIC  NEUROSES  557 

by  gas,  and  in  some  instances  no  direct  cause  for  its  existence  can  be  discovered 
save  that  a  state  of  nervous  unrest  and  instability  is  present.  Cramp  of  tlie  cardia 
appears  in  an  acute  and  fieeting  form,  and  as  a  chronic  condition  which  causes  great 
distress  and  may  be  serious,  in  that  it  exhausts  the  patient.  In  the  former  cases 
pain  and  spasm  seize  the  patient  and  then  pass  away.  In  the  latter  it  often  happens 
that  the  patient  has  difficulty  in  swallowing  and  expresses  the  feeling  that  the  food 
cannot  enter  the  stomach,  but  remains  in  the  esophagus.  If  the  taking  of  food  is 
persisted  in,  it  speedily  accumulates  in  the  esophagus,  and  when  this  tube  is  dis- 
tended the  patient  regurgitates  the  food  undigested  and  devoid  of  gastric  juice,  for 
it  has  never  entered  the  stomach.  The  emaciation  which  follows  this  inal)ility  to 
take  food  may  lead  to  the  belief  that  a  gastric  carcinoma  is  present,  particularly 
if  the  patient  is  advanced  in  years.  When  chronic  cardiospasm  lasts  for  a  long  time, 
dilatation  of  the  esophagus  may  develop,  and  even  a  diverticulum  may  be  formed. 

Treatment. — The  treatment  consists  in  the  use  of  remedies  designed  to  prevent 
and  counteract  excessive  gastric  acidity,  the  avoidance  of  all  irritating  or  stimulating 
forms  of  food  and  drink,  the  use  of  lavage  if  there  is  any  evidence  of  chronic  gastric 
catarrh  or  of  fermentation  in  the  stomach,  and  in  feeding  through  a  stomach-tube 
if  there  is  any  difficulty  in  giving  the  patient  a  proper  amount  of  nourishment. 
Boas  states  that  in  some  cases  solids  are  taken  more  readily  than  liquids.  Seda- 
tives, such  as  chloretone,  the  bromides  and  chloral,  may  be  used.  Sometimes 
galvanic  electricity  gives  relief,  using  for  its  application  an  intragastric  electrode. 
In  some  instances  the  daily  passage  of  a  large-sized  gastric  or  esophageal  bougie 
produces  a  cure. 

Pylorospasm. — Pylorospasm  is  nearlj^  always  secondary  to  lesions,  although  a 
primary  spasm  may  occur.  In  pylorospasm  a  contraction  wave  may  be  seen,  in  a 
thin  patient,  endeavoring  to  urge  the  gastric  contents  tlirough  the  closed  pyloric 
orifice,  and  if  the  spasm  is  persistent  the  stomach  contents  will  not  only  be  retained, 
as  in  pyloric  stenosis,  but  they  may  undergo  fermentative  changes  as  well,  so 
that  symptoms  of  chronic  gastric  catarrh  or  dilatation  may  be  present.  In  other 
cases  a  reversed  peristalsis  is  set  up  and  vomiting  comes  on,  so  that  symptoms  like 
those  of  hypertrophic  pyloric  stenosis  ensue.  The  treatment  is  identical  with  that 
of  cardiospasm. 

Gastric  Hyperperistalsis,  called  by  Kussmaul  "peristaltic  unrest,"  is  a  con- 
dition in  which  the  stomach  almost  incessantly  continues  to  maintain  peristaltic 
movement.  As  a  rule,  it  is  most  active  after  meals,  but  it  may  be  present  when 
the  stomach  is  empty,  and  even  persist  at  night  during  absolute  rest.  Although 
marked  pain  is  usually  not  present,  the  incessant  movement  of  the  stomach  causes 
restlessness  and  gastric  discomfort.  Often  the  wave-like  movements  of  the  stomach 
can  be  felt  through  the  abdominal  wall,  and  their  progress  is  from  left  to  right. 
These  undulatory  movements  are  not  demonstrable,  as  a  rule,  unless  some  gastric 
dilatation  is  present  and  the  belly  wall  fairly  thin.  Three  causes  are  recognized, 
viz.,  excessive  acidity  producing  irritation,  great  reflex  excitability,  and,  most 
important  of  all,  stenosis  of  the  pylorus,  which  obstructs  the  flow  from  the 
stomach. 

Treatment. — The  treatment  consist  in  the  use  of  sedatives,  such  as  the  bromides, 
chloral,  codeine,  and  hyoscyamus,  and  in  the  use  of  counter-irritation  over  the 
epigastrium.  Not  rarely  an  absolute  rest  cure,  with  rectal  feeding  for  a  week, 
may  be  needful  to  cause  gastric  quiet.  Causes  which  produce  nervous  exliaustion 
and  indigestible  foods  are  to  be  forbidden  and  hydrotherapeutic  measures  should 
be  instituted. 

Merycismus. — Merycismus  is  a  neurotic  condition  in  which  the  patient  has 
the  ability  at  will  to  regurgitate  the  food  from  the  stomach  into  the  mouth  for  the 
purpose  of  rechewing  it,  as  is  done  by  ruminants.  It  is  usually  met  with  in  neurotic 
degenerates. 


558  DISEASES  OF  THE  STOMACH 

Nervous  Eructation. — Norvoiis  eructation  is  not  a  very  rare  affection.  The 
|);tticnt  is  usually  very  nervous  and  will  often  sit  for  hours  "rifting  up"  gas,  wliieli, 
in  many  ca.ses,  i.s  really  swallowed  air.  In  other  cases  the  movements  of  eructation 
are  performed  without  any  gas  being  brought  up.  This  condition  is  commonly 
seen  in  hysteria.  It  is  best  treated  by  the  rest-cure  and  the  administration  of 
tonics  or  nervous  sedatives,  such  as  the  bromides,  spirit  of  chloroform,  asafetida, 
or  chloretone. 

Closely  related  to  nervous  eructation  is  nervous  vomiting. 

Hyperesthesia. — Among  the  sensory  disorders  of  the  stomach  is  hypcrcstliesia, 
in  which  the  taking  of  food  causes  great  gastric  distress,  so  that  the  patient  refuses 
to  eat  enough  to  maintain  nutrition.  In  hysterical  cases  the  patient  may  be  able 
to  eat  what  she  wishes,  yet  has  pain  when  other  articles  of  food  are  given  to  her. 

This  condition  is  to  be  separated  from  the  hyperesthesia  due  to  gastric  ulcer 
since  it  sometimes  develops  when  this  lesion  is  not  present.  Sometimes  it  seems 
to  arise  from  the  abuse  of  alcohol,  coffee,  ice,  or  certain  drugs,  such  as  cjuinine  and 
the  salicylates,  or  tobacco.  In  other  instances  it  arises  from  nervous  exhaustion 
due  to  sexual  excess,  great  mental  strain,  prolonged  lactation,  or  menorrliagia. 
So,  too,  it  may  develop  in  the  course  of  chlorosis,  and  while  in  the  majority  of 
instances  this  condition  in  chlorosis  points  to  ulcer,  the  possibility  of  no  ulcer 
being  present  must  be  considered,  in  view  of  our  knowledge  of  the  existence  of 
tliis  state. 

Symptoms. — The  symptoms  consist  in  a  seiuse  of  fulness  and  distention  of  the 
stomach,  particularly  in  the  neighborhood  of  the  cardia,  with  some  aching  or 
burning,  which  extends  upward  imder  the  ribs.  Constipation  is  usually  present. 
As  the  condition  advances  the  disagreeable  sensations  in  the  stomach  become  so 
severe  as  to  amount  to  jxiin,  and  the  taking  of  food  usually  greatly  increases  the 
suffering.  When  fully  developed  the  patient  often  suffers  from  vomiting,  which 
may  occur  after  every  meal.  In  ulcer,  vomiting  usually  gives  temporary  relief, 
but  in  hyperesthesia  of  the  stomach  it  does  not.  If  the  disease  persists,  there  is 
emaciation  due  to  the  pain  and  constant  vomiting.  The  skin  over  the  epigastrium 
is  usually  hyperesthetic,  and  the  tenderness  on  deep  palpation  is  dift'use  and  not 
localized  as  in  ulcer.  An  examination  of  the  gastric  contents  usually  reveals  a 
normal  acidity,  but  in  some  cases  the  acidity  may  be  above  or  below  the  normal. 

Gastralgia. — Gastralgia,  gastrodynia,  or  gastric  neuralgia,  may  be  a  cause  of 
much  scN'ere  suffering,  for  the  patient  may  be  seized  by  a  paro.vi/sin  of  pain  which 
seems  as  violent  as  a  renal  or  hepatic  colic.  This  pain  is  felt  not  only  in  the  epigas- 
trium, but  along  the  edges  of  the  floating  ribs  to  the  spine,  and  it  often  recvirs  with 
a  peculiar  periodicity.  It  is  not  rare  in  hysteria  and  neurasthenia.  The  gastric 
crises  of  locomotor  ataxia,  the  pain  of  ulcer  of  the  stomach  and  duodenum,  gall- 
stones, and  that  caused  by  gas  must  be  carefully  excluded  before  a  diagnosis  of 
gastralgia  is  reached;  indeed,  a  diagnosis  of  simple  gastralgia  should  always  be 
looked  upon  with  suspicion,  because  gastric  pain  is  so  commonly  due  to  some  organic 
cause.     Unlike  the  pain  of  ulcer,  this  form  is  usually  relieved  l\v  taking  food. 

Bulimia. — A  neurosis  of  the  stomach  characterized  by  excessive  hunger  and 
the  ingestion  of  great  quantities  of  food  to  alleviate  the  discomfort  is  called  "Bu- 
limia." It  is  usually  met  with  in  cases  of  hysteria,  in  cases  of  exophthalmic  goitre, 
and  ill  ccrrbral  tumor  and  epilepsy. 

Anorexia  Nervosa  is  a  form  of  neurosis  with  persistent  lack  of  appetite. 

Nervous  Disorders  of  Secretion. — A  form  of  ner\ous  disorder  of  secretion  con- 
sists in  li\  persecrctlun  of  gastric  juice,  producing  the  ordinary  symptoms  due  to 
acid  stomach.  It  is  often  met  with  in  chlorotic  girls,  and  is  usually  associated 
with  constipation.  The  excessive  secretion  may  occur  in  paroxysms  or  be 
continuous. 

The  antithesis  of  this  state  is  that  in  which  there  is  an  absence  of  secretion, 


HEMORRHAGE  FROM   THE  STOMACH  559 

sometimes  called  achylia-riastrica  nervosa.  This  state  of  absence  of  IICl  is,  of 
course,  common  in  gastric  cancer,  and  it  arises  also  from  atrophy  of  the  gastric 
tubules,  but  there  are  instances  in  which,  apparently  because  of  disordered  nerve 
supply,  there  is  absence  of  secretion  for  weeks,  months,  or  even  j'ears,  yet  finally 
it  is  perfectly  re-established. 

Treatment. — The  treatment  of  these  disorders  of  sensation  consists  in  the  institu- 
tion of  a  rest  cure  for  the  rehabilitation  of  the  patient's  nervous  tone;  in  the  use 
of  hydrotherapeutic  measures  and  electricity  designed  to  bring  about  the  same 
result,  in  the  prescription  of  a  mode  of  life  which  will  avoid  nervous  worry 
and  strain,  provide  a  sufficient  number  of  hours  of  sleep  and  out-door  exercise,  and 
prevent  the  ingestion  of  articles  of  food  which  are  difficult  to  digest  or  irritating 
to  the  stomach.  For  the  prevention  or  relief  of  painful  or  flisagreeable  sensations, 
a  number  of  remedies  may  be  employed.  Not  infrequently  a  dose  of  a  drachm 
of  spirit  of  chloroform  and  a  drachm  of  compound  spirit  of  lavender  in  a  little 
water  will  dispel  gas  and  distention  and  act  as  a  sedative  to  the  stomach.  In 
other  instances  |  to  1  grain  of  menthol  may  be  gi^'en  in  capsule  or  pill.  In  still 
others  one  of  the  coal-tar  products,  as  antipyrin,  acetanilid,  or  phenacetin,  may  be 
used,  and  in  some  instances  much  relief  will  be  obtained  by  the  use  of  chloretone 
in  capsule,  or  tablet,  in  .3  to  5  grain  doses.  Where  there  is  a  distinct  hysterical 
element  and  it  is  considered  desirable  to  exercise  a  mental  influence,  the  stomach- 
tube  may  be  passed  once  or  twice  a  day.  If  an  excessive  secretion  of  hydrochloric 
acid  is  present,  associated  with  much  nervousness,  the  bromides  may  be  employed, 
or  nitrate  of  silver  and  hyoscyamus  may  be  used. 

HEMORRHAGE  FROM  THE  STOMACH. 

Hemorrhage  into  the  stomach  is  called  gastwrrhagia,  and  when  the  blood  is 
vomited  the  condition  is  one  of  hematemesis.  It  may  result  from  rupture  of  dilated 
gastric  and  esophageal  veins,  from  ulcer  of  the  stomach  and  duodenum,  from 
cancer  of  the  stomach,  and  from  dilatation  of  the  gastric  veins  in  chronic  gastric 
catarrh.  It  has  also  been  known  to  follow  severe  injuries  over  the  epigastrium. 
Occasionally  the  vomiting  of  blood  has  been  due  to  an  aneurysm  which  has  perfor- 
ated the  esophagus  and  then  drained  into  the  stomach.  The  physician  must  also 
remember  that  malingerers  sometimes  swallow  blood  for  the  purpose  of  deceiving 
their  attendants.  Sometimes  "  coffee-ground  cancer,  vomit,"  due  to  the  presence 
of  altered  blood,  is  met  with  in  cases  of  gastric  cancer,  in  certain  forms  of  purpura, 
in  hemophilia,  and  in  persons  suffering  from  such  poisons  as  phosphorus  and  car- 
bolic acid.  Occasionally,  too,  in  cases  of  exceedingly  severe  infectious  disease 
such  as  j'ellow  fever  and  smallpox,  vomiting  of  coffee-ground  material  occurs. 
By  far  the  most  frequent  causes  of  bloody  vomiting,  however,  are  cirrhosis  of  the 
liver,  ulcer  of  the  stomach  and  duodenum,  and  cancer  of  the  stomach.  When  due 
to  cirrhosis  it  is  usually  met  with  in  males,  and  when  due  to  ulcer  it  most  commonly 
occurs  in  females. 

Preble  has  made  a  most  complete  statistical  study  of  gastro-intestinal  hemorrhage 
in  hepatic  cirrhosis,  and  finds  that  the  great  majority  of  cases  occur  in  the  atrophic 
form,  although  occasionally  hemorrhage  takes  place  in  hypertrophic  cirrhosis. 
In  one-third  of  the  cases  the  first  hemorrhage  is  fatal ;  while  in  the  other  two-thirds 
the  hemorrhage  occurs  at  intervals  varj'ing  from  a  few  years  to  several  years,  the 
longest  duration  being  over  a  period  of  eleven  years. 

In  some  instances  it  is  possible  to  make  the  diagnosis  of  hepatic  cirrhosis,  but 
in  other  instances  the  change  in  the  size  of  the  liver  is  so  slow  that  not  for  months 
after  the  hemorrhage  occurs  is  this  organ  found  to  be  smaller  than  normal.  In 
80  per  cent,  of  the  cases,  according  to  Preble,  there  are  varices  in  the  esophagus, 
and  in  more  than  one-half  of  these  there  are  evidences  of  their  rupture.     It  has 


560  DISEASES  OF  THE  STOMACH 

also  been  found  that  fatal  hemorrhages  may  occur  in  cases  which  do  not  suffer 
from  esophageal  varices.  These  cases  are  probably  due  to  the  rupture  of  a  large 
number  of  capillaries  in  the  alimentary  mucous  membrane.  It  is  interesting  to 
note  that  in  only  G  per  cent,  of  the  cases  which  showed  esophageal  varices  was  the 
cirrhosis  typical  in  the  sense  tliat  the  ordinary  symptoms  of  this  condition  were 
present.  Very  profound  hemorrhages  may  come  from  a  very  small  opening  in  a 
bloodvessel,  so  that  at  autopsy  it  may  be  almost  impossil)le  to  discover  the  source 
of  the  bleeding. 

Aside  from  the  actual  vomiting  of  blood,  the  symptoms  of  gastric  hemorrhage 
are  those  of  ordinary  hemorrhage,  namely,  pallor,  faintncss,  or  actual  si/ncopc,  and 
sometimes  death.  The  vomited  blood,  if  it  has  been  poured  out  in  large  quantities, 
is  somewhat  venous  in  color  and  filled  with  clots,  and  if  it  remains  in  tiie  stomach 
any  length  of  time  it  may  become  brown  or  granular  in  appearance,  through  the 
action  upon  it  of  the  digestive  juices.  It  must  always  be  remembered  that  the 
tpiantity  of  blood  which  has  escaped  from  a  bloodvessel  is  not  shown  by  the 
amount  vomited,  as  a  very  large  amount  may  leak  into  the  stomach  before 
vomiting  occurs,  and  the  stomach  in  vomiting  may  not  completely  empty  itself. 
Care  must  be  taken  in  determining  that  the  blood  comes  from  the  stomach,  and 
that  the  red  color  is  really  due  to  blood.  Sometimes  a  bloody  color  of  the  vomit 
may  be  due  to  claret  or  the  juice  of  various  berries.  A  distinction  can  be  made 
by  a  microscopic  examination,  by  the  history  of  the  ingestion  of  certain  articles 
of  food,  and,  if  need  be,  by  the  use  of  the  spectroscope  and  the  various  tests 
which  are  employed  to  determine  the  presence  of  blood.  It  must  also  be  borne 
ill  mind  that  persons  who  suffer  from  nosebleed,  in  which  the  leaking  vessel  is  far 
back  in  the  nose,  may  swallow  considerable  quantities  of  blood  and  then  vomit  it. 

Hemorrhage  from  the  lungs,  or  hemoptysis,  is  to  be  separated  from  hematemesis 
by  the  fact  that  in  hemorrhage  from  the  lungs  the  blood  comes  up  with  coughing, 
and  in  hemorrhage  from  the  stomach  by  vomiting,  although  at  times  both  of  these 
symptoms  may  be  present  in  each  class  of  cases.  The  characteristic  appearance 
■of  a  patient  well  advanced  in  tuberculosis  will  be  of  great  diagnostic  aid  in  such 
cases,  and  an  examination  of  the  chest  in  the  case  of  hemoptysis  will  usually  reveal 
some  lesion;  whereas,  the  lungs  will  be  clear  in  hematemesis.  In  a  case  of  hema- 
temesis an  examination  of  the  abdomen  may  reveal  an  atrophied  liver  and  an 
enlarged  spleen,  or  some  other  abdominal  state,  such  as  the  caput  medusa',  which 
will  indicate  that  there  is  venous  stasis  in  the  abdomen.  (See  Hepatic  Cirrhosis.) 
In  hemoi)tysis  the  blood  is  jiink  and  frothy.  In  hemorrhage  from  the  stomach 
it  is  dark,  has  little  air  mixed  with  it,  and  is  often  acid  in  reaction;  whereas,  that 
in  hemoptysis  is  usually  alkaline.  In  hemoptysis  no  dark,  tarry  stools  are  present, 
but  they  are  frequently  seen  after  an  attack  of  hematemesis.  A  day  after  an 
attack  of  hemoptysis  the  patient  may  cough  up  some  thickened,  bloody  mucus, 
but  there  is  no  difficulty  in  separating  this  from  the  more  fluid,  dark  blood  from  the 
stomach.  An  additional  aid  in  the  diagnosis  of  hematemesis  is  Boas'  test  given 
in  the  article  on  Gastric  Ulcer. 

Notwithstanding  the  profound  mental  shock  and  vital  depression  which  often 
follow  a  profuse  hemorrhage  from  the  stomach,  it  is  worthy  of  note  that  death 
very  rarely  occurs  as  the  immediate  result  of  this  loss  of  blood,  unless  the  patient 
is  already  devitalized  by  advanced  disease  or  repeated  hemorrhages. 

For  the  treatment  of  bloody  vomiting  see  Treatment  of  Gastric  Ulcer. 

CYCUC  VOMITING. 

Under  the  name  of  cyclic,  periodical,  or  recurrent  vomiting,  a  condition  has 
been  rarely  met  with  in  which,  at  certain  periods,  a  child  is  seized  b\'  an  attack 
of  persistent  vomiting,  which  not  only  continues  while  the  stomach  is  being  emptied 


DUODENAL   ULCER  561 

of  its  normal  contents,  but  persists  for  many  hours  afterwarfi,  and  in  some  instances 
ends  fatally.  The  condition  in  all  probability  depends  upon  a  form  of  ciiito-inivxica- 
tion.  The  auto-intoxication  consists,  apparently,  in  a  condition  of  acidosis,  a 
condition  in  which  acetone,  diacetic  acid  and  even  /3-oxybutyric  acid  appear  in 
the  urine  as  the  result  of  faulty  metabolism  of  fats.  The  preventive  treat- 
ment consists  in  carefully  regulatuig  the  diet,  cuttmg  down  fats  and  proteids 
and  increasing  the  carbohydrates,  exercising  care  that  an  excess  of  starchy  food 
does  not  cause  intestinal  disorder.  The  active  treatment  consists  in  administering 
alkalies,  2  or  more  drachms  of  sodium  bicarbonate  by  mouth,  by  rectum,  or  even 
by  hypodermoclysis  and  the  rectal  injection  of  several  drachms  of  levulose. 


DISEASES  OF  THE  INTESTINES. 

DUODENAL  ULCER. 

Ulcer  of  the  duodenum  is  a  more  frequent  condition  than  is  generally 
supposed,  and  in  some  cases  is  associated  with  ulcer  of  the  stomach.  W.  J.  Mayo 
thinks  it  is  three  times  as  common  as  gastric  ulcer.  ■  Wilkie,  in  490  post- 
mortem examinations,  found  it  41  times,  and  in  only  6  of  these  was  a 
diagnosis  made  during  life.  The  proportion  given  by  Burwinkel  of  gastric 
and  duodenal  ulcer  is  12  to  1.  On  the  other  hand,  von  ^Yyl  found  onh' 
3  duodenal  ulcers  in  nearly  13,000  postmortem  examinations,  and  Kinnicutt,  in 
an  analysis  of  30,000  postmortems,  places  its  frequency  at  0.4  of  1  per  cent.  The 
condition  may  arise  at  any  period  of  life,  but  is  most  frequent  between  the  tenth 
and  fortieth  years.  Hahn  has  recorded  a  case  in  a  child  only  a  day  and  a  half 
old.  Such  an  ulcer  must  have  been  antenatal.  Holt  has  collected  95  cases  during 
the  first  year  of  life  and  as  all  but  21  have  been  reported  since  190S  it  would  appear 
that  the  lesion  is  far  more  common  in  children  than  it  has  been  thought.  Out 
of  65  cases  70  per  cent,  occurred  between  6  weeks  and  5  months  of  age. 

Unlike  gastric  ulcer,  the  great  majority  of  duodenal  ulcers  are  found  in  men. 
Murphy,  of  Chicago,  quotes  Laspeyres  as  stating  that  men  are  affected  two  or 
three  times  oftener  than  women.  Krauss,  in  64  cases,  found  the  ratio  to  be 
10  to  1;  Lebert,  in  39  cases,  4  to  1;  Trier,  in  54  cases,  5  to  1;  and  out  of  176  cases 
collected  by  Weir,  144  were  in  men. 

Wilkie  thinks  that  the  sex  incidence  of  duodenal  ulcer  is  explained  on  anatomical 
grounds.  The  relatively  high  pylorus  and  short  fixed  duodenum  of  the  male 
allows  of  its  vascular  supporting  ligament,  the  hepatoduodenal  ligament,  being 
exposed  to  strain,  which,  in  the  female  with  her  relatively  low  pylorus  and  lax 
duodenum,  is  borne  by  the  left  border  of  the  gastrohepatic  omentum  and  lesser 
curvature  of  the  stomach. 

Etiology. — Among  the  causes  of  duodenal  ulcer  may  be  mentioned  burns,  which 
in  some  unknown  way  produce  ulceration  in  this  portion  of  the  bowel.  Renal 
disease,  which  occasionally  results  in  the  ulceration  of  the  large  bowel,  may  also 
cause  this  lesion  in  the  duodenum.  Pulmonary  tuberculosis,  which  produces  its 
lesion  by  infection  of  a  solitary  follicle,  and  diseases  of  the  heart  and  liver,  which 
result  in  impairment  of  vitality  in  the  intestinal  wall,  so  that  localized  infections 
may  occur,  are  also  causes. 

As  with  gastric  ulcer,  so  with  duodenal  ulcer,  a  large  number  of  theories  have 

been  advanced  as  to  its  direct  causation.     Most  authorities  at  the  present  time 

believe  that  it  is  due  to  erosion  produced  by  the  gastric  juice,  the  vital  resistance 

of  the  part  having  been  diminished  by  inflammation  or  circulatory  changes.     That 

36 


5G2  DISEASES  OE  THE  ISTESTIXES 

ac-iflity  of  the  gastric  contents  may  so  result  seems  likely,  from  the  fact  that  ulcer 
most  frec[ueiitly  occurs  in  the  duoflcuum  near  the  pylorus,  at  a  point  where  the 
acidity  of  the  gastric  juice  may  he  hut  little  modified  hy  the  alkaline  secretion  which 
it  would  meet  a  few  inches  farther  on  in  the  Ijowel. 

It  would  seem  probahle,  howe\'er,  that  a  number  of  factors  may  produce  this 
form  of  ulcer,  acting  in  some  cases  together  and  in  other  cases  singly.  These 
factors  are  well  summed  up  by  Murphy  and  made  into  four  divisions:  hyperchlor- 
hydria,  local  infection,  embolism  or  thrombosis,  and  foreign  bodies.  To  these 
four  divisions  Murphy  would  add  a  fifth,  namely,  disorders  of  the  organs  of  elimina- 
tion, as  in  burns  of  the  skin  or  other  serious  lesions  in  this  part  of  the  bo<ly,  as 
pemphigus  and  erysipelas,  and  in  other  cases  renal  disease. 

Not  rarely  duodenal  ulcer  is  caused  by  or  associated  with  ulceration  or  disease 
of  the  colon  or  of  the  appendix.  Indeed  in  many  cases  of  appendicitis  injlammation 
of  the  duodenum  is  present,  which,  perhaps,  accounts  for  the  epigastric  discomfort 
in  many  cases  of  chronic  appendicitis. 

■  Pathology  and  Morbid  Anatomy. — Duodenal  ulcers  are  usually  single,  but  they 
may  be  multiple — 10  to  2(1  per  cent.  Sometimes  ulcers  are  opposed  to  one 
another — the  so-called  "kissing  ulcers"  of  Moynihan.  Out  of  233  cases  collected 
by  Collins,  195  were  single. 

Ulcer  usually  occurs  in  the  first  part  of  the  duodenum;  within  half  an  inch  of  the 
pylorus  in  85  per  cent,  of  cases.  The  reason  for  this  is  that  the  first  part 
of  the  duodenum  arises  from  the  foregut,  as  does  the  stomach,  and  thus  its  mucous 
membrane  is  free  from  folds  but  rich  in  lymph  follicles  in  which  ulcer  readily 
develops.  This  is  the  reason  that  obstruction  of  the  stomach  or  hematemesis 
so  often  takes  place.  Out  of  149  cases  collected  by  Perry  and  Shaw,  the 
first  portion  of  the  duodenum  was  involved  123  times,  the  second  portion  16 
times,  and  the  third  and  fourth  portions  twice.  These  statistics  agree  with  those 
which  have  been  collected  concerning  the  area  and  greatest  frecjuency  of  perfora- 
tion complicating  ulcer  of  the  duodenum.  In  the  great  majority  of  cases  it  is  on 
the  anterior  wall. 

When  perforation  occurs,  it  takes  place  nearly  twice  as  often  in  the  anterior 
as  in  the  posterior  wall,  still  more  rarely  in  the  superior  wall,  and  almost  never 
in  the  inferior  wall.  Perforation  occurs  much  more  frecjuently  in  ulcer  of  the 
duodenum  than  in  ulcer  of  the  stomach,  if  we  can  rely  upon  the  statistics  which 
have  so  far  been  collected.  Thus,  in  404  cases  mentioned  by  Chvostek,  Collins, 
and  Oppenheimer,  perforation  took  place  in  246.  On  the  other  hand,  it  must  be 
remembered  that  a  very  large  number  of  cases  of  duodenal  ulcer  are  not  recognized 
unless  perforation  does  occur,  and  it  is  highly  probable  that  this  accident  is  far 
less  frequent  in  duodenal  ulceration  than  these  statistics  would  indicate,  because 
it  is  a  well-known  fact  that  duodenal  ulcer  is  a  condition  most  difficult  to  recognize 
unless  it  is  found  in  the  course  of  an  abdominal  section,  further,  it  is  well  known 
that  these  ulcers  frequently  heal.  Thus,  Perry  and  Shaw  found  evidence  of  repair 
in  half  of  their  cases,  and  Krug,  in  1220  autopsies,  met  with  30  cases  of  healing 
of  duodenal  ulcer.  Unlike  ga.stric  ulcer,  duodenal  ulcer  rarely  undergoes  malignant 
change. 

As  in  perforations  of  the  stomach,  so  in  perforation  of  the  duodenum,  a  general 
peritonitis  ensues,  or  a  localized  peritonitis  may  develop,  the  extravasated  materials 
being  walled  off  from  the  rest  of  the  i)critoneal  cavity  by  an  inflammatory  exudate. 
As  with  gastric  ulcer,  so  again  with  duodenal  ulceration,  adhesions  may  take  place 
in  neighboring  organs,  and  perforation  may  take  place  into  them.  Thus,  it  has 
occurred  that  the  duodenum  has  lieen  perforated,  and  so  permitted  its  contents  to 
enter  the  gall-bladder,  the  abdominal  aorta,  the  vena  cava,  the  portal  vein,  the 
superior  mesenteric  vein,  and  the  hepatic  artery;  but  Murphy  asserts  that  a  gas- 
troduodenal  fistula  has  never  been  found  as  a  result  of  perforation  of  a  duodenal 


DUODENAL   ULCER  563 

ulcer.  In  some  instances  perforation  of  the  duodenum  has  resulted  in  suljphrenic 
abscess.  The  perforation  is  very  small  and  may  occur  just  outside  the  pyloric 
ring. 

Symptoms. — The  symptoms  of  duodenal  ulcer,  unless  the  ulceration  proceeds 
to  hemorrhage  or  perforation,  are  too  indefinite  to  make  a  positive  diagnosis  possible 
in  many  cases.  Indeed,  in  fully  half  the  cases  in  which  duodenal  ulcers  are  found 
at  autopsy,  there  have  been  no  symptoms  during  life  which  ha\'e  raised  suspicion 
of  its  existence  and  in  many  cases  the  patient  remains  well  nourished. 

When  the  symptoms  do  occur,  they  so  closely  resemble  those  of  gastric  ulcer  that 
a  differentiation  may  be  impossible.  There  is  pain  and  vomiting,  and  if  a  blood- 
vessel is  ulcerated  there  may  be  hematemesis  or  bloody  stools.  The  pain  is  usually 
much  less  severe  than  in  ulcer  of  the  stomach,  but  at  times  it  may  be  agonizing. 
There  seems  to  be  a  general  consensus  of  opinion  that  it  rarely  radiates  toward 
the  back,  as  does  the  pain  of  gastric  ulcer,  but  cases  have  been  reported  in  which 
pain  in  the  neighborhood  of  the  shoulder-blade  has  been  a  pronounced  symptom. 
It  differs  from  gastric  ulcer  in  that  the  taking  of  food  is  not  immediately  followed 
by  pain,  but  by  relief;  being  delayed  for  several  hours  after  a  meal,  then  developing 
when  the  food  enters  the  duodenum  from  the  stomach.  Occasionally  the  entrance 
of  food  into  the  duodenum  causes  pain.  IMoynihan  says  that  the  nearer  the  ulcer 
is  to  the  stomach,  the  sooner  is  the  pain  developed.  Not  infrequently  it  causes 
evidence  of  pyloric  obstruction.  It  has  been  said  that  if  the  .I'-rays  and  bismuth 
meal  cannot  be  used  the  patient  may  be  given  a  little  partly  cooked  rice  and  a 
few  raisins  at  bedtime;  and  their  presence  in  the  stomach  contents  in  the  morning 
indicates  obstruction  (Mayo),  but  this  is  a  sign  of  obstruction  not  necessarily  of 
ulcer  of  the  duodenum. 

The  hemorrhage,  when  it  takes  place,  may  be  sufficiently  profuse  to  cause  death, 
or  it  may  be  small  in  amount  and  be  frequently  repeated,  in  which  case  death  may 
ultimately  occur  from  exhaustion,  ^'omiting  rarely  occurs  except  when  the  stomach 
is  overloaded,  or  when  blood  enters  it  from  the  duodenimi. 

Perforation  of  a  duodenal  ulcer  may  be  the  first  manifestation  of  any  lesion 
in  this  portion  of  the  bowel.  According  to  Schwartz,  patients  suffering  from  per- 
foration of  the  duodenum  were  healthy  in  20  out  of  25  instances  prior  to  the  accident, 
and  in  Weir's  51  cases  they  were  without  gastric  or  duodenal  symptoms  in  25  out 
of  34.  So,  too,  in  Perry  and  Shaw's  151  cases,  91  per  cent,  presented  no  evidences 
of  disease  until  perforation  or  hemorrhage  developed. 

While  cases  of  ulcer  may  recover,  the  tendency  is  to  a  progression  of  the  disease. 
On  the  other  hand,  progress  does  not  necessarily  mean  early  death,  for  Chvostek 
has  reported  a  case  in  which  there  had  been  present  symptoms  of  duodenal  ulcer 
occasionally  for  thirty-nine  years. 

Symptoms  of  perforation  of  duodenal  ulcer  are  severe  epigastric  or  right  hypochon- 
driac pain,  followed  it  may  be  by  collapse;  the  symptoms  resemble,  perhaps,  acute 
hemorrhagic  pancreatitis,  and  death  occurs  sometimes  as  early  as  twenty-one 
hours  after  the  accident.  The  symptoms  of  general  peritonitis  soon  develop,  or, 
if  the  lesion  is  localized  by  adhesions,  localized  peritonitis  is  found,  as  already 
stated.     Leukocytosis  is  usually  marked. 

Diagnosis. — The  tests  for  minute  traces  of  blood  in  the  stools,  which  are  described 
in  the  article  on  Gastric  Ulcer,  may  be  used  in  these  cases. 

Duodenal  ulcer  must  be  separated  from  gastric  ulcer,  if  possible.  Where  there 
is  hematemesis  with  little  if  any  blood  in  the  stools  the  source  of  the  blood  is  prob- 
ably but  not  certainly  gastric,  whereas  a  large  bloody  stool  without  bloody  vomit 
is  probably  duodenal  in  origin.  In  the  majority  of  instances  the  character  of  the 
blood  in  the  stool  is  dark  and  tarry,  owing  to  its  alteration  by  the  intestinal  juices. 
If  it  is  bright  in  character,  it  probably  comes  from  ulceration  of  a  lower  portion 
of  the  bowel.     When  duodenal  ulcer  occurs  in  infancy  there  may  be  no  symptoms 


564  DISEASES  OF  THE  INTESTINES 

save  intestinal  in{lif!;estion  niitil  hemorrhage  or  purpura  develops.  While  von  Wyl 
admits  that  it  is  impossible  to  make  a  diii'erential  diagnosis  in  90  per  eent.  of  the 
cases,  he  gives  us  the  following  points  wliich  are  of  value  in  differentiation: 

Gastbtc  Ulcer.  Duoden.\l  Ulceh. 

1.  Usually   in   women    twenty    to    thirty-five         1.  Most  frcciuent  in  men. 

years  of  age. 

2.  Pain  comes  on  soon  after  eating.  2.  Pain    two    to    four    hours    after    eating, 

and    located    in   right    hypochondrium. 

3.  Pain  lessened  by  vomiting.  3.  Vomiting  docs  not  relieve  pain. 

4.  Vomitiis    contains    mucus,    food    remnants        4.  Vomiting  more  rare  than  in  gastric  ulcer, 

and  often  blood.  and  does  not  often  contain  blood. 

5.  Severe  dyspeptic  symptoms  usually  present.        5.  Dj'speptic  symptoms  slight. 

6.  Helena  rare.  6.  Melena  comparatively  frequent. 

Estimates  of  the  acidity  of  the  gastric  contents  are  not  of  much  value  iti  differ- 
ential diagnosis  since  hyperacidity  is  often  present  in  both  gastric  and  duodenal 
ulcer. 

Gallstone  colic  is  to  be  separated  from  duodenal  ulcer  by  the  fact  that  hemorrhage 
does  not  occur  in  gallstone  colic,  and  by  a  previous  history  of  gallstones;  but  it  is 
to  be  remembered  that  the  absence  of  a  history  of  jaundice  is  of  little  value,  for 
jaimdice  is  not  a  constant  symptom  in  cholelithiasis.  As  Murphy  well  points 
out,  jaundice  was  present  only  16  times  in  400  cases  of  cholelitliiasis  operated  on 
by  him. 

Acute  fat-necrosis  often  cannot  be  differentiated  from  duodenal  idcer  with 
perforation.  As  a  rule,  the  vomiting  in  fat-necrosis  is  more  persistent,  and  the 
depression  or  collapse  is  more  prompt  and  severe.  A  high-pitched  percussion 
note  is  found  in  the  right  hypochondrium  in  fat-necrosis,  but  this  area  is  usually 
flat  in  perforation  of  the  duodenum,  unless  peritonitis  has  already  progressed  to 
the  stage  of  general  tympanitic  distention.  In  fat-necrosis  there  is  an  absence  of 
leukocytosis;  in  perforation  there  is  a  marked  leukocytosis.  In  fat-necrosis  there 
is  usually  no  rise  in  temperature;  in  perforation  there  is  not  infrequently  a  primary 
rise. 

Intestinal  obstruction  may  closely  resemble  perforated  duodenal  ulcer.  The 
pain  in  ulcer  is  constant;  in  obstruction  colicky;  there  is  hyperperistalsis  in  ob- 
struction; there  is  an  absence  of  peristalsis  in  perforation;  there  is  absence  of  leuko- 
cytosis in  obstruction;  there  is  marked  leukocytosis  in  perforation.  In  both  there 
is  usually  a  history  of  constipation.  Perforation  of  a  duodenal  ulcer  has  been 
mistaken  for  appendicitis  of  the  fulminant  type  and  the  correct  diagnosis  not 
reached  even  after  the  abdomen  has  been  opened.  Codmau  says  e\"ery  sixteenth 
case  he  has  operated  upon  for  appendicitis  has  been  a  duodenal  perforation. 

The  .r-rays  give  us  little  assistance  in  duodenal  ulcer  except  that  they  may  slmw 
stricture  (rarely).  It  is  thought  tliat  hurried  emptying  of  the  stomach  is  significant 
of  this  lesion,  the  reverse  state  from  gastric  ulcer.  Much  depends  on  the  situation 
of  the  ulcer.  If  it  is  below  the  pylorus  it  hurries  the  food  out  of  the  stomach;  if 
in  the  pyloric  zone  it  may  cause  spasm  and  retain  food. 

As  ilhi,strati\e  of  how  difficult  it  is  to  make  a  correct  diagnosis,  e\en  wiicn  perfora- 
tion occurs,  IMoyniiian  tells  us  that  in  only  12  out  of  51  cases  of  duodenal  ulcer  was 
a  correct  diagnosis  made  liefore  operation,  and  that  in  4!)  cases  of  perforated  duo- 
denal ulcer  IS  were  operated  upon  for  appendicitis. 

Prognosis. — The  prognosis,  like  that  of  gastric  ulcer,  is  not  good  for  recovery. 
In  perforative  cases,  if  operation  is  not  performed,  the  outlook  depends  entirely 
upon  whether  the  infective  material  is  walled  off  by  adhesions.  If  this  is  the 
case,  and  a  subphrenic  abscess  is  formed,  much  depends  upon  tiie  point  at  which 
this  abscess  ruptures.  If  the  extravasated  material  is  not  confined  by  adhesions, 
death  occurs  from  general  peritonitis. 

When  the  perforation  is  recognized  and  operation  is  performed,  the  prognosis 


DIARRHEA  565 

is  much  more  favorable.  The  difficulty  is  that  in  many  cases  the  diagnosis  is  so 
obscure  that  operation  is  not  performed  until  so  many  hours  have  passed  that 
recovery  is  impossible.  Thus,  out  of  51  cases  operated  upon  in  INIoynihan's  collec- 
tion there  were  only  8  recoveries,  and  in  20  cases  collected  by  Darras  only  3  re- 
covered. In  79  cases  collected  by  Weir  and  Foote  the  mortality  after  operation 
was  71  per  cent. 

Treatment. — The  treatment  of  these  cases  consists  in  absolute  rest  in  bed  and 
in  dietetic  and  medicinal  measures  which  are  practicallj-  identical  witli  those  of 
gastric  ulcer  (which  see).  If  after  some  weeks  no  improvement  ensues  or  if  relapses 
occur  a  surgeon  should  perform  a  gastro-enterostomy.  If  a  severe  intestinal 
hemorrhage  develops  the  patient  should  be  operated  on  as  soon  as  he  has  recovered 
from  the  immediate  effects  of  the  loss  of  blood  lest  another  hemorrhage  prove 
fatal.  Whenever  a  surgeon  operates  for  appendicitis  and  finds  a  normal  appendix 
he  should  investigate  the  duodenum  and  gallbladder  and  whene\er  he  operates 
for  ulcer  and  finds  it  not  he  should  investigate  the  appendix  and  gallbladder. 
There  is  no  medicinal  treatment  that  will  check  hemorrhage  from  a  duodenal 
ulcer.  Hypodermoclysis  or  intravenous  saline  injections  may  be  used.  If  perfo- 
ration has  taken  place'  and  surgery  cannot  be  resorted  to,  then  there  is  nothing 
left  for  the  physician  but  to  relieve  pain  by  the  use  of  opium  and  to  hope  that 
the  inflammatory  process  may  be  localized. 

DIARRHEA. 

Diarrhea  is  not  a  disease,  but  a  symptom,  just  as  headache  and  dropsy  are 
symptoms.  It  occurs,  however,  from  so  many  different  causes  and  is  so  often 
present  without  the  presence  of  any  organic  change  in  the  intestinal  walls  that 
it  is  best  considered  as  a  functional  malady,  at  least  in  several  of  its  forms. 
Diarrhea  is  the  symptom  or  condition,  above  all  others,  in  some  cases,  but  in 
others  it  is  of  little  significance  as  compared  to  the  organic  lesion  which  produces  it. 

Serous  Diarrhea. — Serous  or  watery  diarrhea  may  arise  from  the  ingestion  of 
irritating  foodstuffs,  wliich  cause  the  intestinal  mucosa  to  become  hyperemic 
and  to  pour  into  the  bowel  the  serum  of  the  blood,  to  dilute  the  poison,  and  to 
wash  it  out  of  the  intestine.  In  many  instances  the  attack  is  very  brief,  and 
even  if  by  an  accident  an  autopsy  is  possible,  no  lesion  may  be  found. 

In  still  other  cases  the  same  result  may  follow  sudden  exposure  to  cold  and 
dampness,  in  Avhich  case,  if  the  visceral  congestion  is  severe,  a  secondary  catarrh 
of  the  intestinal  mucosa  may  develop  as  a  later  condition. 

In  some  instances  a  serious  diarrhea  seizes  persons  who  are,  or  who  are  about 
to  be,  subjected  to  a  severe  nervous  strain,  as  actors  at  their  first  appearance,  or 
medical  students  about  to  go  before  a  severe  examiner,  upon  whose  verdict  much 
depends.     Such  a  nervous  diarrhea  is  not  rarely  met  witli  in  hysterical  persons. 

Finally,  in  chronic  renal  disease,  patients  sometimes  are  seized  by  a  profuse 
watery  purging  designed,  apparently,  to  eliminate  from  the  body  certain  poisonous 
materials  that  the  diseased  kidneys  permit  to  accumulate. 

All  of  these  forms  of  serous  diarrhea  occur  without  being  accompanied  by  much 
pain  and  without  the  passage  of  much  flatus.     (See  Catarrhal  Enteritis.) 

Treatment. — The  treatment  depends  largely  upon  the  cause  of  the  disorder. 
If  it  is  due  to  the  ingestion  of  bad  food,  the  patient  should  receive  a  moderate 
dose  of  castor  oil  (|  to  1  ounce),  and  with  it  a  dessertspoonful  of  paregoric  to  pre- 
vent griping.  By  this  means  the  offending  matter  is  swept  out  and  a  secondary 
constipating  influence  follows,  or  can  be  produced  by  the  measures  about  to  be 
referred  to. 

Aside  from  this  all  cases  of  serous  diarrhea  are  to  be  treated  by  rest,  counter- 
irritation  in  the  form  of  a  capsicum  or  mustard  plaster  over  the  abdomen,  the 


566  DISEASES  OF  THE  IXTESTINES 

application  of  external  heat  if  the  temperature  falls,  and  the  internal  use  of  a 
grain  of  camphor  every  two  hours  for  several  doses,  or  of  a  mixture  of  aromatic 
sulphuric  acid  and  fiuidextract  of  hematoxylon  in  syrup  of  ginger  every  two  hours. 
All  foods  should  he  forhidden  until  the  diarrhea  is  to  some  extent  controlled,  when 
predigested  milk,  arrowroot,  and  broths  may  he  allowed. 

When  the  jjurging  is  an  effort  at  elimination  in  Hriglit's  di.sease,  care  must  he 
taken  not  to  clieck  tlic  diarrhea  suddenly,  lest  toxemia  dc'vcl(i]i. 

CATARRHAL  ENTERITIS. 

Acute  and  clironic  catarrii  of  the  small  intestine  are  of  frequent  occurrence 
and  the  symptoms  produced  in  the  acute  form  may  be  very  like  those  described 
under  Serous  Diarrhea,  save  that,  as  a  rule,  there  is  more  pain  and  (jripinr/  in  the 
bowels.  In  both  conditions  there  is  present  at  first  an  acute  hyperemia  of  the 
intestinal  mucosa,  followed  by  a  true  catarrhal  process,  in  which  the  glandular 
epithelium  becomes  swollen  and  the  submucous  tissues  infiltrated  with  exudate. 
A  careful  examination  of  the  mucous  membrane  reveals  slight,  if  any  distinct 
reddening,  except  at  the  edges  of  the  valvuhe  conniventes.  If  the  process  has 
been  subacute  or  chronic  the  intestinal  mucosa  is  boggy  and  swollen,  but  not 
reddened,  and  the  lymph  follicles,  as  well  as  the  mucous  glands,  are  enlarged.  After 
some  days,  rarely  earlier,  and  not  in  all  cases,  the  swollen  solitary  follicles  may  be 
the  seat  of  superficial  necroses,  shown  by  yellowish,  grayish,  or  grayish-yellow 
erosions  surmounting  each  follicular  eminence;  such  ulcers  are  rarely  of  any  size. 
When  the  process  has  lasted  many  davs  the  mucosa  may  be  thickened.  It  is  to  be 
remembered  that  in  all  of  these  cases  the  changes  are  not  confined  to  the  small 
bowel,  but  are  also  present  in  the  large  intestine  as  well. 

Symptoms. — Aside  from  the  diarrhea  and  griping  pain  already  referred  to,  the 
patient  suffers  from  rumbling  in  the  bowels  due  to  hyperperistalsis,  from  loss  of 
appetite,  and  weakness  due  to  the  abdominal  discomfort  and  the  serous  purging. 
The  stools  may  be  light  yellow  and  very  fluid,  and  in  the  water  which  is  discharged 
will  be  found  particles  of  undigested  food,  cast-oft'  epithelium,  flakes  of  bile-stained 
mucus,  and  myriads  of  micro-organisms.  The  pulse  is  usually  quick,  and  there 
may  be  fever  of  moderate  degree. 

Treatment. — The  treatment  is  rest  in  bed,  counter-irritation  to  the  alidonien, 
and  full  doses  of  bismuth  after  the  bowel  has  been  swept  out  by  castor  oiL 

ILEOCOLITIS  OF  CHILDHOOD. 

Definition. — The  ileocolitis  of  cliildhood  is  a  state  in  which  sym])tom  of  gastro- 
intestinal disorder  develops,  as  manifested  by  pnrging,  vomiting,  and  abdominal 
distress.  It  cannot  be  distinctly  separated  from  the  catarrhal  enteritis  of  adults, 
either  from  the  stand-point  of  pathology  or  symptomatology,  yet  clinicians  have 
universally  recognized  the  fact  that  such  a  division  at  the  bedside  is  advisable. 

Etiology. — The  ileocolitis  of  infancy  depends  chiefly  for  its  existence  upon  the 
action  of  micro-organisms  and  their  poisons  on  the  intestinal  mucosa.  This 
infection  may  be  produced  by  a  large  number  of  organisms,  some  of  which  are  not 
])athogenic  when  the  child  is  in  perfect  health,  and  whicin  only  i)econie  competent 
to  cause  disorder  or  disease  when,  by  some  additional  cause,  the  general  or  local 
vitality  of  the  patient  is  reduced.  Thus,  it  not  rarely  happens  that  the  stools 
contain  myriads  of  streptococci,  staphylococci,  the  Bacterium  lactis  acrocjcncs,  or 
the  Bacillus  pyocyaneus,  the  pathogenic  micro-organism  which  causes  green  stools, 
and  other  bacteria.  More  important  than  all,  the  bacillus  of  dysentery  of  Shiga 
and  that  of  Flexner  is  now  known  to  be  a  cause  in  a  large  proportion  of  cases.  (See 
Cholera  Infantum  and  Dysentery.)     Shiga's  bacillus  produces  an   extracellular 


ILEOCOLITIS  OF  Cf/ILDHOOD 


567 


toxin  and  that  of  Flexner  an  endotoxin.  Tlie  character  of  the  organism  which  is 
chiefly  responsible  for  the  illness  is  an  important  consideration  since  the  prognosis 
and  the  treatment  depend  to  some  extent  upon  a  knowledge  of  the  type  present. 
On  the  other  hand,  it  is  not  always  the  case  that  the  severity  of  the  illness  is  in 
direct  ratio  to  their  number  since  a  virulent  strain  in  comparatively  small  numbers 
may  cause  very  severe  symptoms  of  profound  toxemia. 

Although  we  cannot  separate  cases  due  to  difl'erent  micro-organisms  by  the  symp- 
toms, for  these  are  much  alike,  it  is  important  to  do  so  bacteriologically  from  the 
stand-point  of  treatment.  Thus,  if  Shiga's  dysentery  bacillus  is  present  a  low 
protein  diet  and  an  excess  of  carbohydrate  diet  is  useful.  On  the  other  hand,  if 
the  gas  bacillus  is  dominant  carbohydrates  are  harmful  and  lactic  acid  milk  is 
useful  because  its  acid  and  high  content  of  protein  is  unfavorable  to  its  growth. 


AVERAGE  MONTHLY  DEATHS  FROM  INFANTILE  DIARRHEAL  DISEASES 
DURING  10  YEARS,  MODIFIED  FROM  KOBER 


DEATHS 

(               I 

1 

103 

100 
05 
00 

a5 
so 

73 

70 
05 
60 

50 
-15 
iO 
33 
30 
23 
20 
15 
10 

0 

■ 

■ 

1 

■ 

-t 

1 

■ 

■ 

_ 

■ 

_t"             ' 

_         i 

I 

■ 

■ 

MAR. 

MAY    JJUNE     JU 

The  conditions  that  usually  cause  these  organisms  to  develop  are  exposure  to  cold 
or  excessive  heat,  so  that  the  bowel  is  congested  and  its  circulation  impaired,  and 
the  use  of  foods  which  are  unsuitable  in  kind  or  have  become  so  by  infection  or 
chemical  change.  Winds  carrying  dust,  flies  carrying  infection,  and  air  carrying 
gases  may  all  aid  in  impairing  the  quality  of  food.  At  times  the  condition  develops 
as  a  result  of  an  attack  of  an  infectious  disease,  such  as  measles.  Heat  and  humidity 
not  onlj'  reduce  the  resistance  of  the  child,  but  greatly  increase  the  number  of  micro- 
organisms in  raw  foods,  especially  milk,  in  which  they  sometimes  number  as  many 
as  100,000,000  per  cubic  centimetre.     (Park  and  Holt.i) 

Pathology  and  Morbid  Anatomy. — The  ileocolitis  of  childhood  affects  particularly 
the  lower  part  of  the  ileum  and  the  colon,  the  extent  depending  upon  the  vital 


'  Those  interested  in  the  effect  of  temperature,  season,  and  milk  supply  upon  infant  mortality  should 
read  a  statistical  paper  by  Park  and  Holt  in  the  Medical  News,  December  5,  1903. 


568  DISEASES  OF  THE  INTESTINES 

resistance  of  the  child  and  the  virnience  of  the  infection.  Even  in  those  cases  due 
to  the  bacilkis  of  Sliiga,  the  most  varied  lesions  are  found.  The  degree  of  patho- 
logical change  varies  within  wide  limits.  In  some  instances  there  is  only  a  super- 
ficial catarrh,  with  some  infiltration  of  the  mucous  meml)rane,  while  in  others  the 
submucous  tissues  are  affected,  and  in  still  others  areas  of  mucous  membrane  may 
slough.  In  these  severe  cases  the  mucous  membrane  of  the  entire  alinientar.y  canal 
may  show  more  or  less  catarrh. 

If  tlie  raucous  membrane  of  the  small  intestine  is  examined  at  autopsy,  its  \illi 
are  found  to  be  soft  and  swollen,  so  that  the  surface  of  the  bowel  presents  a  velvety 
aspect.  In  mild  cases  the  hyperemia  is  not  intense.  A  universal  congestion  is 
present  in  severe  cases,  and  even  punctate  extravasations  of  blood  may  be  seen. 
The  solitary  follicles  are  swollen  and  protrude  above  the  surface  in  both  the  small 
and  large  bowel  and  at  the  summits  of  follicles  beginning  ulceration,  which  rarely 
is  extensive,  is  noticeable.  Peyer's  patches  may  also  be  infiltrated,  but  they  are 
rarely  ulcerated.  In  severe  or  long-continued  cases  the  solitary  glands  may  ulcer- 
ate, but  the  agminated  glands  very  rarely.  An  appearance  which  at  first  glance 
may  be  thought  to  be  an  ulcerated  Peyer's  patch  will  he  found  to  be  due  to  the 
running  together  of  several  ulcers  of  solitary  follicles. 

In  severe  cases  a  condition  of  acute  membranous  enteritis  develops,  the  lower 
ileum  and  colon  being  covered  l)y  a  thin  false  membrane,  which  can  be  seen  in 
some  cases  only  with  difficulty.  This  membrane  may  be  of  a  yellowish-green  hue 
and  it  lies  over  a  part  of  the  bowel  which  is  greatly  thickened  by  an  inflammatory 
process  which  involves  its  deeper  coats.  Curiously  enough,  ulceration  of  the 
mucous  membrane  in  such  an  area  is  unusual. 

Symptoms. — The  symptoms  of  acute  ileocolitis  in  childhood  vary  greatly  in 
their  severity  and  duration.  In  the  mild  catarrhal  form  there  is  a  slight  ri.se  of 
temperature  of  from  1°  to  2°,  with  several  loose  movements  of  the  bowel  each  day. 
These  stools  have  a  little  mucus  in  each  of  them  and  perhaps  a  few  small  flecks 
of  undigested  food. 

If  the  condition  is  more  severe  there  is  pain  in  the  bowels,  with  vomiting,  high 
fever,  and  the  frequent  passage  of  yellow  or  greenish  stools  containing  mucus  and 
considerable  amounts  of  undigested  food,  and  if  the  condition  persists  the  mucus 
may  become  streaked  with  blood,  and  tenesmus  may  be  severe.  There  is  little 
flatus  and  little  oflor  to  the  passages.     The  tongue  is  coated  and  anorexia  is  marked. 

Because  of  the  fever,  vomiting,  and  diarrhea,  the  patient  is  rapidly  prostrated 
and  loses  flesh  with  remarkable  speed. 

If  the  course  of  the  colon  is  palpated  through  the  tumid  abdominal  wall,  some 
tenderness  is  usually  found.  As  recovery  begins  the  stools  become  less  frequent, 
have  a  more  normal  color,  the  quantity  of  mucus  decreases,  and  the  fever  falls. 
If,  on  the  other  hand,  at  the  end  of  a  week  or  two  there  is  no  change  for  the  better, 
the  more  severe  state,  in  which  ulceration  of  the  intestinal  lining  takes  place,  is 
probably  present,  and  death  may  ensue  from  exliaustion  and  depression,  with 
signs  of  toxemia. 

If  recovery  takes  place  it  is  very  slow,  a  tendency  to  looseness  of  the  bowels 
persisting  for  weeks,  mucus  being  seen  in  almost  every  stool,  and  a  relapse  being 
threatened  at  each  change  in  weather  or  in  the  food. 

In  the  well-developed  ulcerated  form  the  systemic  disturbance  is  profound  and 
often  sudden  in  onset,  and  its  very  severity  may  serve  to  prevent  a  sharp  febrile 
reaction.  The  stools  are  often  much  fewer  per  day  than  in  the  catarrhal  form, 
but  they  contain  more  mucus  and  less  blood.  Unlike  the  stools  in  the  milder 
type,  these  passages  smell  bad.  The  bell;/  i^  diUended  and  the  general  loss  of 
flesh  is  very  severe.     The  mouth  and  tongue  are  dry  and  foul. 

In  the  membranous  form  the  stools  contain  mucus  and  blood  and  particles  of 
false  membrane,  which  are  easilv  discerned  if  the  stools  are  first  mixed  with  water 


CHOLERA  INFANTUM  569 

and  then  strained  through  a  sieve.  The  degree  of  prostration  and  evidence  of 
toxemia  in  these  cases  is  very  severe,  and  upon  the  prolapsed  rectal  mucous  mem- 
brane the  false  membrane  may  be  sometimes  seen.  At  times  such  cases  present 
at  onset,  or  late  in  the  disease,  severe  cerebral  symptoms  which  may  mask  the 
intestinal  state. 

Diagnosis. — Ileocolitis  must  be  separated  from  the  typhoid  fever  of  infancy. 
In  most  cases  this  is  not  difficult,  because  in  the  typhoid  fever  of  children  constipa- 
tion is  often  present,  and  the  rose  spots  may  be  found.  The  chief  diagnostic 
points  which  separate  the  two  affections  are  that  enteric  fever  is  rare  and  ileocolitis 
common,  that  in  enteric  fever  the  onset  is  usually  gradual;  in  ileocolitis  it  is  acute. 
In  one  there  is  an  enlarged  spleen  and  the  Widal  reaction;  in  the  other  neither 
one  of  these  signs  is  present.  If  the  illness  is  due  to  the  Bacillus  dysenterice,  the 
agglutination  test  may  reveal  that  fact.     (See  Dysentery.) 

Prognosis. — The  prognosis  depends  upon  several  facts.  Young  children  fare 
worse  than  children  after  the  fourth  year.  City-bred  children  succumb  more 
rapidly  than  children  in  the  country,  particularly  if  the  weather  is  hot.  Children 
who  are  strong  and  hearty  at  the  onset  have  a  better  prospect  than  poorly  nourished 
weaklings.  High  fever,  many  stools,  much  vomiting,  much  mucus,  marked 
nervous  symptoms  and  signs  of  toxemia  are  of  evil  omen. 

Treatment. — The  treatment  of  ileocolitis  consists  in  the  application  of  mild, 
continuous,  counter-irritation  over  the  abdomen  by  means  of  a  spice  poidtice, 
which  consists  of  equal  parts  of  powdered  nutmeg,  allspice,  cloves,  and  cinnamon, 
moistened  with  warm  brandy  or  vinegar.  If  this  cannot  be  had  a  mustard  plaster, 
composed  of  one-quarter  to  one-half  mustard  flour  and  wheat  flour,  may  be  applied, 
the  idea  being  to  produce  continuous,  but  not  severe,  counter-irritation. 

The  child's  diet  should  be  carefully  regulated.  If  it  is  passing  undigested  food 
in  its  stools,  those  articles  which  are  not  being  properly  dealt  with  by  the  digestive 
apparatus  should  be  withheld.  If  undigested  curds  of  milk  are  present,  milk 
should  be  stopped,  or  diluted  sufficiently  to  make  its  digestion  easj',  and  pepsin 
and  hydrochloric  acid,  or  pancreatin  with  bicarbonate  of  soda,  should  be  used  to 
aid  digestion.  Beef-juice,  may  be  administered.  If  the  child  is  not  a  very  young 
infant  its  nutrition  may  be  greatly  increased  by  giving  strained  barley  or  wheat 
gruel.  The  digestion  of  these  vegetable  gruels  should  be  aided  by  the  use  of  liquid 
pancreatin  or  taka-diastase.  If  there  are  any  evidences  of  inactivity  of  the  liver, 
minute  doses  of  calomel  every  third  or  fourth  day  are  advantageous. 

If  mucus  is  present  in  considerable  quantity  in  the  stools  a  moderate  dose  of 
castor  oil,  varying  from  a  drachm  to  a  tablespoonful,  may  be  used  once  or  twice. 
Griping  may  be  prevented  by  the  addition  of  a  few  drops  of  paregoric. 

In  some  instances  small  doses,  such  as  1  or  2  grains  of  chloride  of  ammonium 
dissolves  in  fluidextract  of  licorice  and  water,  may  be  given  twice  or  thrice  a  day. 
(See  Cholera  Infantum.) 

If  the  illness  occurs  in  hot  Aveather,  it  may  be  impossible  to  produce  a  cure 
without  the  aid  of  a  change  in  climate.  If  the  child's  home  is  in  the  city,  removal 
to  the  seashore  may  be  absolutely  necessary;  whereas,  if  the  condition  develop 
while  at  the  seashore,  removal  to  a  moderate  altitude  of  1000  or  2000  feet  is 
advisable.     (See  Cholera  Infantum.) 

Antidysenteric  serum  may  be  given  if  an  examination  of  the  stools  reveals  the 
presence  of  the  Bacillus  dysenterice. 

CHOLERA  INFANTUM. 

Definition. — The  dividing  line  between  ileocolitis  and  cholera  infantum  is  in- 
definite and  scarcely  justified  from  an  etiological  or  pathological  stand-point,  but 
clinically  it  is  often  looked  upon  as  a  separate  ailment.     Cholera  infantum  is  an 


570  ■  DISEASES  OF  THE  IXTESTIXES 

acute  affection  of  infancy  characterized  by  profuse  watery  jMirfiing,  r,\\m\  emacia- 
tion, and  profound  depression.  It  is  so  closely  related  to  that  form  of  diarrhea 
due  to  catarrhal  enteritis  in  adults  and  to  that  met  with  in  the  ileocolitis  of  infancy 
that  it  scarcely  deserves  a  separate  consideration  from  the  stand-point  of  etiology 
and  pathology,  yet  its  symptom-complex  aids  us  to  some  extent  in  making  it  a 
distinct  entity  at  the  bedside.  The  malady  is  almost  always  met  with  in  the  hot 
months  of  the  year. 

Etiology. — The  causes  of  cholera  infantum  arc  practically  identical  \^'ith  those 
of  enterocolitis. 

Pathology  and  Morbid  Anatomy. — When  a  case  of  cholera  infantum  comes  to 
autopsy  the  mucous  membrane  lining  the  bowel  presents  a  peculiar  pallor,  which 
is  most  marked  in  the  ileum.  The  colon  may  show  areas  of  congestion.  The 
tissues  of  the  body  are  shrunken  because  of  the  profuse  purging,  the  body  is  wasted, 
the  skin  wrinkled,  and  the  eyes  sunken.  The  belly  may  be  distended  or  collapsed. 
If  enterocolitis  has  been  present  before  the  severe  choleraic  character  of  the  purging 
is  developed,  the  lesions  described  under  the  discussion  of  that  disease  may  be  found. 

Symptoms. — Cholera  infantum  receives  its  name  because  its  chief  symptoms 
are  like  those  of  Asiatic  cholera,  in  that  profuse  watery  purgiiuj,  incessant  voviiting, 
and  coUapue  soon  develop.  The  pulse  rapidly  becomes  weal;  and  feeble,  the  extrem- 
ities cold  and  the  face  pinched,  so  that  the  expression  of  the  child  may  be  shrunken 
like  that  of  a  very  aged  person.  This  anxious,  pinched  look,  with  a  peculiar  drawing 
down  of  the  mouth,  as  if  the  child  were  about  to  cry,  is  very  characteristic.  The 
fontanelles  are  depressed. 

At  first  the  child  may  be  exceedingly  restless  and  peevish,  but  if  the  attack  is 
severe  it  speedily  becomes  apathetic,  listless,  and  finally  comatose.  Although  the 
peripheral  temperature  is  low,  the  rectal  temperature  is  often  very  high,  even  to 
105°  or  106°.  There  is  often  a  mottling  of  the  skin,  due  to  the  poor  capillary  circu- 
lation. Thirst  is  excessive,  and  cannot  be  relieved  because  of  constant  \omiting. 
The  urine  is  scanty  or  suppressed.  As  the  end  approaches,  the  patient  develops 
irregular  respirations,  the  head  is  retracted,  the  temperature  is  subnormal,  and 
the  life  ends.  When  the  cerebral  symptoms  are  marked,  the  condition  is  called 
one  of  "spurious  hjdrocephalus,"  a  most  unfortunate  and  inaccurate  name. 

The  symptoms  are  not  only  those  of  exhaustion,  but  of  profound  toxemia  as  well. 

Prognosis. — Given  a  case  -of  well-advanced  cholera  infantum,  the  prognosis 
is  \'ery  grave.  It  depends  upon  the  vitality  of  the  child,  the  severity  of  the  purging 
and  vomiting,  the  degree  of  response  to  treatment,  and  the  age  of  the  patient,  for 
very  young  infants  seldom  recover  if  the  disease  is  once  well  developed. 

Treatment. — The  treatment  of  cholera  infantum  consists  first  of  all  in  the  absolute 
prohibition  of  milk  for  twelve  or  twenty-four  hours  after  the  patient  is  first  seen. 
It  matters  not  whether  the  milk  be  from  the  breast  or  from  the  bottle,  it  must 
nevertheless  be  witlilield  from  the  child.  Indeed,  it  may  be  said  that  there  is 
little  use  in  treating  these  cases  medicinally  if  milk  is  given.  This  is  particularly 
so  when  undigested  particles  of  milk  are  passed  in  the  stools  and  if  this  is  the  case 
2  to  4  drachms  of  castor  oil  is  the  purge  indicated. 

During  the  period  in  which  milk  is  forbidden,  a  rump  steak  may  be  heated 
sufficiently  to  start  its  juices,  then  squeezed  in  a  meat-press  or  lemon-squeezer, 
and  this  juice,  pure  or  diluted  with  cool  water,  may  be  given  to  the  child.  When 
these  juices  cannot  be  obtained,  or  when  for  some  reason  they  cannot  be  taken, 
whey,  barley-water,  rice-water,  or  a  water  made  by  boiling  and  straining  wheaten 
grits  may  be  used.  If  the  diarrhea  or  intoxication  is  due  to  the  Bacillus  dysenicrice 
of  either  Shiga  or  Flexner  a  useful  form  of  food  is  lactose  or  milk-sugar  as  this  is 
easily  assimilated  and  is  unfavorable  to  the  production  of  toxic  materials  by  the 
micro-organisms.  On  the  other  hand,  if  the  diarrhea  be  due  to  fermentative  organ- 
isms, lactose  will  probably  make  the  child  worse.    The  use  of  lactic  acid  bacilli  as 


CHOLERA   INFANTUM  571 

in  buttermilk  made  by  means  of  a  pure  culture,  or  in  the  form  of  the  bacilli  in 
powder  may  be  useful  when  putrefactive  changes  are  present.  They  are  particu- 
larly useful  when  tlie  child  is  so  feeble  that  temporary  starvation  is  considered 
unwise.  A  useful  preparation  is  casein  milk  made  by  first  preparing  curds-and- 
whey  in  the  usual  form  and  then  filtering  oft'  the  whey  through  a  cloth.  Push  the 
curd  through  a  fine  sieve  and  mix  it  with  one  pint  of  water  and  one  pint  of  good 
buttermilk  made  from  a  good  culture  of  lactic  acid  bacilli.  Small  amounts  of  this 
nutritious  and  therapeutic  milk  may  be  given  every  few  hours.  If  the  stools  are 
acid  in  reaction  the  lactic  acid  bacilli  are  contra-indicated. 

Over  the  abdomen  of  the  child  should  be  applied  a  spice  plaster,  composed  of  a 
tablespoonful  each  of  powdered  allspice,  cloves,  nutmeg,  and  cinnamon.  This 
should  be  moistened  with  warm  brandy  or  vinegar,  and  renewed  as  frequently  as 
it  becomes  hard  or  dry. 

The  child  should  receive  internally  j^  of  a  grain  of  podophyllin  dissolved  in  a 
few  drops  of  brandy,  and  mixed  with  a  little  water  just  before  it  is  taken,  every 
hour  until  three  or  four  doses  have  been  used ;  or,  instead,  y^  of  a  grain  of  bichloride 
of  mercury  may  be  given  in  the  same  manner.  If  the  vomiting  is  incessant,  it 
may  be  necessary  to  get  the  solution  of  bichloride  or  podophyllin  into  the  stomach 
b}^  dropping  the  medicine  into  the  mouth  of  the  child  with  a  medicine-dropper, 
only  introducing  a  few  drops  at  a  time.  It  is  of  the  greatest  importance  that 
the  liver  shall  secrete  and  expel  bile  into  the  intestine.  The  appearance  of  a  little 
bile  upon  the  diaper  of  the  child  in  place  of  the  colorless  liquid  which  has  previously 
been  expelled  is  a  most  encouraging  sign,  and  its  absence  is  correspondingly  dis- 
couraging. 

In  children,  older  than  six  or  eight  months,  good  results  sometimes  follow  the 
use  of  weak  sulphuric  acid  solutions.  Thus,  1  minim  of  aromatic  sulphuric  acid 
may  be  given  in  4  tablespoonfuls  of  cool  water  every  two  hours.  The  acid  not 
only  acts  as  an  astringent,  but  it  probably  also  aids  in  destroying  infecting  micro- 
organisms. 

If  there  is  much  distention  of  the  abdomen,  some  relief  to  the  tympany  may  be 
given  by  introducing  a  rectal  tube  through  which  the  gas  may  escape,  and  if  the 
stools  are  exceedingly  fetid  and  musty  it  is  often  advantageous  to  irrigate  the  lower 
bowel  with  normal  salt  solution  once  or  twice  a  day,  inserting  into  the  rectum  along- 
side the  nozzle  of  the  fountain  syringe  a  soft-rubber  catheter,  tlirough  which  the 
injected  material  may  readily  return.  The  tube  attached  to  the  syringe  should, 
however,  pass  up  into  the  bowel  for  eight  inches  or  a  foot;  while  the  tube  of  exit 
should  be  just  within  the  sphincter. 

If  much  tenesmus  is  present,  with  a  tendency  to  eversion  of  the  bowel,  1  or  2 
tablespoonfuls  of  olive  oil  containing  2  grains  of  iodoform  may  be  injected  once 
or  twice  a  day,  or  even  oftener,  for  its  local  anesthetic  eftect  upon  the  intestine, 
and  after  this  injection  the  anus  should  be  supported  by  the  nurse's  hand,  the  ball 
of  her  thumb,  covered  by  a  napkin,  being  placed  between  the  buttocks  to  aid  in 
the  retention  of  the  fluid. 

When  symptoms  of  collapse  ensue  the  patient  shoidd  be  surrounded  by  hot 
bottles,  but  care  should  be  taken  that  a  peripheral  low  temperature  is  not  considered 
as  representing  the  temperature  of  the  central  portions  of  the  body,  which  are  often 
highly  febrile.  When  the  peripheral  temperature  is  low,  the  central  temperature 
high,  and  the  circulation  in  the  peripheral  capillaries  is  impaired,  so  that  the  child 
is  somewhat  livid  and  its  skin  mottled,  excellent  results  will  often  be  obtained  by 
immersing  it  several  times,  for  a  fraction  of  a  minute,  in  quite  hot  water  for  the 
purpose  of  producing  a  certain  amount  of  reaction,  relieving  internal  congestion, 
and  bringing  the  blood  to  the  surface.  If  marked  fever  is  present  and  the  extremi- 
ties are  hot,  good  results  may  come  from  the  use  of  cold  sponging  with  friction. 

Some  practitioners  have  been  in  the  habit  of  employing  minute  doses  of  mor- 


572  DISEASES  OF  THE  INTESTINES 

phine,  hyporlermically,  or  by  the  mouth.  In  some  instances  this  method  of  treat- 
ment may  be  advantageous,  but  too  often  it  seems  to  increase  the  toxemia  from 
which  the  j)atient  is  sufferin<!;. 

A  very  vahiabie  method,  whicii  sliould  always  be  recollected  in  dcsi)erate  cases, 
is  the  use  of  normal  salt  solution  by  li^podermoclysis. 


APPENDICITIS. 

Definition. — Appendicitis  is  an  inflammation  involving  the  appendix  vermiformis. 

History. — Although  inflammation  of  the  appendix  vermiformis  had  been  described 
by  a  number  of  physicians  many  years  before  Reginald  Fitz,  of  Boston,  prepared 
his  classical  paper  on  this  sul)ject  in  1886,  the  importance  and  frequency  of  this 
condition  was  not  appreciated  until  he  called  attention  to  it. 

Etiology. — The  causes  of  appendicitis  may  be  divided  into  two  classes,  namely, 
those  that  depend  upon  the  anatomical  structure  and  position  of  the  appendix 
and  those  that  arise  as  the  result  of  changes  in  its  walls. 

The  appendix  vermiformis  is  a  vestige  of  what  was  a  large  and  important  portion 
of  the  alimentary  canal  in  Our  early  evolutionary  ancestry,  and,  like  most  vestiges 
of  this  character,  its  tissues  are  possessed  of  less  vital  resistance  than  are  those  of 
active  organs.  This  is  the  first  reason  why  severe  inflammatory  processes  so 
often  arise  in  it.  Again,  it  is  a  sac  the  neck  of  which  is  usually  narrower  tlian  the 
rest  of  its  cavity,  and  as  a  conseciuence  infecting  micro-organisms  find  their  way 
into  it,  and  when  imprisoned  there  by  swelling  of  the  mucous  membrane  rapidly 
attack  and  destroy  the  epithelial  lining  of  the  appendix  and  migrate  into  its  walls. 
As  is  well  known,  nothing  is  more  favorable  for  the  growth  of  micro-organisms 
that  the  presence  of  warmth,  moisture,  and  a  condition  in  which  drainage  is  im- 
possible. Nothing  is  less  favorable  to  the  vital  resistance  of  a  part  than  swelling, 
with  pressure  upon  the  bloodvessels  and  lymphatic  channels.  Still  another  anatom- 
ical cause  of  disease  in  the  ajiyjendix  is  the  fact  that  the  mesoappendix  is  \ery  short, 
and  this  results  in  the  appendix  being  curved  or  drawn  on  one  side.  The  meso- 
appendix carries  the  chief  bloodvessel  which  nourishes  the  appendix,  and  if  from 
swelling,  or  other  cause,  the  appendix  is  distorted  or  twisted,  the  circulation  of 
blood  in  the  nutrient  vessels  may  be  so  impaired  that  the  vitality  of  the  part  is 
greatly  decreased.  Again,  in  those  cases  in  which  the  appendix  is  very  long  (for 
it  varies  in  length  from  one  to  six  inches)  the  free  end  may  become  attached  to 
other  parts  and  become  greatly  displaced,  the  appendix  itself  being  twisted. 
Finally,  the  fact  that  the  appendix  lies  near,  or  on,  the  ileopsoas  muscle  may  aid 
in  provoking  appendicular  irritation,  and  this  is  probably  one  of  the  reasons  why 
appendicitis  so  often  follows  violent  rowing,  golfing,  and  bicycling. 

Among  the  causes  which  exist  in  the  appendix  itself,  in  the  sense  that  they  are 
present  in  its  cavity,  is  the  presence  of  fecal  concretions  (20  per  cent.),  and  rarely 
foreign  bodies,  of  which  a  multitude  have  been  recovered,  such  as  pins,  tacks,  seeds, 
and  other  objects  accidentally  swallowed.  Occasionally  intestinal  worms,  amebse, 
and  other  ])arasites  have  been  found.  Foreign  bodies,  however,  are  conijjaratively 
rarely  found  in  this  viscus  (less  than  4  per  cent.).  Primary  tumor  of  the  appendix, 
of  which  a  number,  mainly  carcinoma,  have  been  reported,  appears  to  be  at  least  a 
predispt)sing  cause  in  some  instances. 

In  a  very  large  proportion  of  cases,  nearly  So  per  cent.,  the  micro-organism  which 
is  directly  responsible  for  the  infiammation  is  the  Bacillus  coli  covimiinU-,  which 
is  always  present  in  the  bowel,  and  is  benign  unless  the  conditions  are  such  as  to 
make  it  malignant,  as  when  it  is  confined  in  a  swollen  and  closed  appendix.  In 
some  instances  the  streptococcus  or  the  staphylococcus  is  the  cause.  Any  micro- 
organism capable  of  exciting  inflammation  upon  gaining  access  to  the  appendix 


APPENDICITIS  573 

may  be  the  cause.  Thus,  the  pneumococcus,  the  pyogenic  staphylococcus  and 
streptococcus,  the  typhoid  bacillus,  and  even  the  ray  fungus  may  act  in  this  way. 

Errors  in  diet  may  be  a  productive  factor,  for  in  a  certain  number  of  cases  of 
appendicitis  there  is  a  history  that  the  patient  has,  a  few  hours  before  the  attack 
or  immediately  before  it,  eaten  heartily  of  ordinary  or  indigestible  food. 

The  age  of  the  patient  is  undoubtedly  an  important  factor  in  the  development 
of  the  malady.  Although  it  is  met  with  in  young  children  and  in  old  persons — 
that  is,  after  sixty  years  of  age — appendicitis  is  certainly  very  much  more  rare  at 
these  periods  of  life  than  in  the  interval.  For  this  there  is  no  adequate  explanation. 
The  period  of  greatest  frequency  is  from  the  fifteenth  to  the.  thirtieth  year,  and 
Fitz  stated  that  more  than  half  the  cases  occur  before  the  twentieth  year. 

Another  predisposing  factor  is  sex.  About  six  times  as  many  men  as  women 
have  appendicitis.  This  is  in  part  due  not  only  to  greater  physical  activity,  but 
to  the  more  frequent  causes  of  intestinal  catarrh  in  males.  It  also  depends  in 
part  upon  the  fact  that  women  have  a  second  blood  supply  to  the  appendix,  at 
least  in  many  cases,  namely,  an  artery  which  passes  from  the  right  o^-ary  to  the 
appendix  by  means  of  a  fold  of  peritoneum,  which  has  been  called  the  appendiculo- 
ovarian  ligament.  By  this  means  a  greater  blood  supply  enables  the  part  to  combat 
infection  when  the  mesenteric  vessel  is  twisted. 

Appendicitis  is  more  frequent  in  the  well-to-do  than  in  the  poorer  classes,  although 
it  might  be  supposed  that  the  greater  muscular  exertion  in  the  latter  class  would 
predispose  its  members  to  the  malady. 

Pathology  and  Morbid  Anatomy. — A  knowledge  of  the  patholog.y  of  appendicitis 
makes  it  possible  to  understand  the  symptoms  which  will  be  described  farther  on, 
for  these  depend,  to  a  large  extent,  upon  the  severity  of  the  changes  in  the  appendix, 
and  upon  the  extent  to  which  adjacent  tissues  are  diseased. 

Appendicitis  may  be  divided  for  pathological  study  into  the  catarrhal,  obliterative, 
ulcerative,  gangrenous,  and  perforative  types. 

In  the  catarrhal  type  hyperemia  and  congestion  of  the  deeper  layers  of  the  appen- 
dix may  be  present,  but  the  chief  lesion  is  in  the  mucous  membrane  lining  the  organ. 
This  results  in  a  free  secretion  of  mucus  and  in  distention  of  the  appendix,  the 
cervix  of  which  is  occluded  by  the  swelling  of  its  lining  membrane.  By  this  means 
pain  is  produced  and  colic  ensues,  partly  as  a  result  of  the  endeavor  of  the  appendix 
to  expel  its  contents  into  the  colon  and  partly  as  a  result  of  colic  in  the  large  bowel 
produced  by  reflex  irritation.  It  can  be  readily  seen  tliat  this  state  may  from  this 
point  proceed  to  recovery  by  a  decrease  in  the  constriction  of  the  neck  of  the  appen- 
dix and  the  escape  of  its  contents,  or  to  a  far  more  grave  condition  dependent  upon 
a  continuance  of  the  stoppage,  a  local  and  general  impairment  of  resistance,  and 
the  presence  of  a  virulent  micro-organism.  If  tlie  attack  has  been  preceded  by 
others,  so  that  the  vitality  of  the  part  is  already  greatly  impaired  and  altered,  the 
case  is  even  more  grave  and  the  appendix  speedily  becomes  gangrenous  or 
perforates. 

Even  in  the  mild  catarrhal  form  just  described  there  are  usually  left  behind  distinct 
traces  of  the  presence  of  the  acute  attack,  and  this  predisposes  the  patient  to  another 
seizure.  In  those  cases  in  which  the  catarrhal  process  is  severe  and  in  which  the 
submucous  tissues  are  much  affected,  it  not  infrequently  happens  that  after  the 
acute  process  passes  away  a  subacute  or  low-grade  inflammatory  condition  ensues, 
which  results  in  round-cell  infiltration  and  in  thickening  of  the  mucous  membrane 
and  submucous  tissues.  The  epithelium  lining  the  appendix  is  desquamated 
and  slight  ulceration  may  occur,  with  the  result  that  the  calibre  of  the  appendix 
may  be  greatly  decreased  in  several  places,  or  even  entirely  closed  by  the  adhesion 
of  its  opposing  surfaces.     In  this  manner  appendicitis  obliterans  is  developed. 

If  considerable  quantities  of  pus,  or  mucus,  are  imprisoned  back  of  the  constric- 
tion, pain,  tenderness,  and  attacks  of  appendicular  colic,  or  true  appendicitis,  are 


574  DISEASES  OF  THE  INTESTINES 

prone  to  recur.  When  the  inflammatory  process  is  severe  enough  to  aft'ect  the 
external  surface  of  the  appendix  the  free  end  or  side  of  it  may  })ecome  adherent  to 
the  howel  or  other  parts,  and  by  this  means  the  appendix  may  not  only  he  dis- 
torted and  held  fast,  but  the  infecting  germs  may  pass  tiirough  its  walls  and  afl'ect 
nearby  structures. 

When  the  ulcerative  type  is  present,  there  is  greater  likelihood  of  the  adjacent 
tissues  being  infected,  owing  to  the  fact  that  the  unprotected  submucosa,  with 
its  lymphvessels,  and  bloodvessels  is  a  fair  field  for  infection.  T'lceration  is 
particularly  prone  to  occur  if  a  fecal  concretion  or  other  foreign  body  is  present 
which  may  damage  the  mucosa.  Tuberculosis  or  typhoid  fe\er  may  cause  it. 
Sometimes  a  foreign  body  may  be  the  cause  of  such  deep  ulceration  that  per- 
foration occurs,  or  in  other  cases  the  floor  of  the  ulcer  is  unable  to  stand  the 
stress  of  accumulated  pus  or  mucus,  and  the  same  accident  happens. 

The  ganr/renous  type  of  appendicitis  is  the  most  important  of  all  lesions  of  the 
appendix,  not  because  it  is  the  most  frequent,  but  because  it  not  rarely  changes  the 
apparently  healthy  man  of  one  hour  into  a  corpse  within  two  days,  and  this 
without,  it  may  be,  any  history  of  previous  attacks  which  would  lead  to  the  l)clief 
that  the  appendix  was  gravely  diseased  and  unable  to  resist  infection.  When  this 
state  is  present  in  its  most  severe  type,  the  appendix  undergoes  rapid  necrosis, 
its  tissues  become  gangrenous,  and  it  may  slough  away  completely  in  so  short  a 
time  as  forty  hours,  so  that  it  may  be  impossible  to  find  it  in  the  pus  which  is  set 
free  by  the  surgeon's  knife,  only  shreds  of  tissue  being  present.  In  other  cases 
the  process  is  not  so  destructive,  but  the  organ  is  utterly  necrotic  and  decom- 
posed. In  many  instances  the  gangrenous  process  may  not  in^'oh•e  the  entire 
appendix,  but  occur  in  one  spot,  speedily  causing  perforation  and  so  endangering 
the  life  of  the  patient. 

Gangrene  of  the  appendix  arises  from  the  invasion  of  its  walls  by  virulent  infect- 
ing germs  when  its  vitality  is  impaired  by  some  unknown  cause,  or  it  follows  from 
thrombosis  or  capillary  stasis  in  its  nutrient  bloodvessels,  whereby  the  same  destruc- 
tion ensues.  Gangrenous  appendicitis  may  be  rapid,  widespread,  and  fatal,  or 
the  vital  forces  of  the  patient  may  be  sufl^ciently  vigorous  in  the  work  of  resistance 
to  wall  off  the  infected  area  by  lymph,  and  so  confine  the  morbid  process  to  the 
immediate  neighborhood  of  the  part  affected. 

The  secondary  effects  of  the  pathological  processes  just  described  are  dependent 
entirely  upon  their  severity  and  the  ability  of  the  patient  to  protect  himself  from 
general  infection.  The  acute  catarrhal  form  rarely  leaves  behind  it  anything 
more  than  some  thickening  of  the  walls  of  the  appendix,  with  an  associated  sus- 
ceptibility to  another  attack.  If  all  the  coats  have  been  involved,  the  tissues 
about  the  appendix  become  filled  with  lymph,  and  the  consequent  induration  may 
be  extreme,  the  appendix  becoming  buried  in  an  adherent  mass,  which  may  not 
only  hide  it  from  view,  but  form  with  the  adjacent  tissues  a  matrix,  which 
prevents  the  surgeon  from  finding  the  appendix  if  operation  is  attempted. 

When  the  inflammation  is  severe  enough  to  result  in  the  escape  of  infection  into 
the  adjacent  tissues,  we  not  only  have  pus  in  the  appendix,  but  in  the  surrounding 
parts  as  well,  a  perityphlitic  or  periappendicular  abscess,  and  in  those  instances 
in  Avhich  the  appendix  is  perforated  either  an  abscess  is  formed  and  walled  oft'  from 
the  general  peritoneum  by  adhesions  or  a  general  peritonitis  ensues. 

The  situation  of  the  abscess  varies  with  the  direction  in  which  the  infection 
escapes  from  the  appendix.  If  the  infection  escapes  anteriorly  the  site  of  the 
abscess  is  often  between  the  navel  and  the  anterior  superior  spine  of  the  ilium. 
When  it  escapes  on  the  surface  of  the  iliac  fascia  or  in  the  pelvis  behind  the  cecum, 
it,  of  course,  lies  behind  the  peritoneum,  not  in  the  serous  cavity,  and  retroperi- 
toneal suppuration  develops.  From  here  the  pus  may  burrow  in  as  many  ways 
as  only  pus  can  burrow,  upward  to  the  region  of  the  kidney,  downward  along  the 


APPENDICITIS  575 

psoas  muscle  into  the  thigh,  or  it  may  discharge  into  the  bladder,  the  rectum,  or 
even  into  the  scrotum. 

On  the  other  hand,  it  must  not  be  forgotten  that  appendicular  abscess  may 
develop  with  very  little  systemic  disturbance  and  exist  for  a  long  time  entirely 
unsuspected,  being  found  by  accident,  it  may  be,  when  seeking  for  some  cause  of 
distress  and  discomfort  with  impaired  health.  At  other  times  such  an  abscess, 
after  having  developed  insidiously,  produces  signs  of  septic  infection  the  source  of 
which  at  first  cannot  be  traced. 

Finally,  attention  must  be  called  to  the  possibility  and  frequency  with  which 
infection  of  the  retroperitoneal  lymphatics  and  of  the  portal  vessels  may  occur 
from  disease  of  the  appendix.  Attention  has  been  called  to  this  by  several  writers, 
notably  by  A.  0.  J.  Kelly,  and  by  Munro  in  the  Therapeutic  Gazette.  Not  only 
may  retroperitoneal  abscess  be  due  to  perforation  of  the  appendix  behind  the  peri- 
toneum, but  organisms  passing  along  the  meso-appendix  produce  pus  when  they 
reach  the  connective  tissues  in  the  retroperitoneum.  Infection  of  the  portal 
vessels  and  consequent  hepatic  abscess  is  not  common,  but  several  cases  of  this 
character  have  been  reported. 

Symptoms. — It  must  be  manifest  from  the  description  just  given  of  the  patho- 
logical changes  that  appendicitis  is  a  malady  capable  of  producing  \^ery  different 
symptoms  in  degree  and  kind.  It  is  not  possible,  for  this  reason,  to  enumerate 
a  set  of  symptoms  present  in  all  cases.  There  are,  however,  certain  symptoms 
which  are  fairlj^  constantly  present.  The  most  constant  symptom  is  jxtin  in  the 
abdomen.  This  may  be  diffuse,  or  at  least  the  patient  may  not  be  able  to  localize 
it.  Not  rarely,  if  the  physician  repeatedly  asks  that  it  be  localized,  it  is  described 
as  being  in  the  "pit"  of  the  stomach  or  in  the  epigastrium.  If  the  epigastrium 
is  pressed  upon  the  pain  may  be  increased.  This  fictitious  localization  of  the  pain 
in  the  early  stages  of  appendicitis  may  be  most  misleading.  As  a  matter  of  fact, 
however,  it  should  be  most  indicati^^e,  and  every  person  seized  with  pain  of  this 
character  should  be  suspected  of  suffering  from  appendicitis.  In  some  cases  the 
pain  is  referred  to  the  left  iliac  region,  and  it  is  only  when  the  physician  applies 
pressure  to  the  right  iliac  area  that  the  patient  appreciates  that  that  is  the  real 
centre  of  his  suffering,  and  by  manifestations  of  an  unquestionable  character  shows 
that  the  source  of  pain  has  been  discovered.  There  is  one  spot  called  "INIcBurney's 
point,"  situated  two  inches  from  the  anterior  superior  spinous  process  of  the  ilium, 
on  a  line  drawn  from  this  point  to  the  naA^el,  in  which  pain  on  pressure  can  nearly 
always  be  elicited.  McBurney's  point  corresponds  rather  with  the  origin  than 
with  the  tip  of  the  appendix. 

The  jMin  of  appendicitis  is  usually  severe  and  sharp,  and  in  some  cases  agonizing. 
It  is  usually  sudden  in  onset,  and  for  this,  and  the  other  reasons  just  given,  it  may 
be  confused  at  first  with  renal  or  gallstone  colic.  I  have  seen  more  than  one  case 
in  which  the  diagnosis  of  acute  pleurisy  had  been  made.  Occasionally  cases  are 
met  with  in  which  the  pain  is  less  spasmodic  and  more  dull  in  character,  but  they 
are  the  exception,  and  if  pain  is  not  marked  on  pressure  the  presence  of  appendicular 
tenderness  can  be  exaggerated  by  pressing  on  this  part  while  the  patient,  lying 
down,  raises  the  thigh  from  the  bed  with  the  leg  extended. 

Perhaps  the  most  important  fact  that  can  be  impressed  upon  the  mind  of  the 
student  in  connection  with  the  symptom  of  pain  in  appendicitis  is  this,  viz.,  that 
the  sudden  cessation  of  pain  in  a  case  of  appendicitis  is  not  a  good  sign,  but  an 
exceedingly  bad  one  in  most  instances,  for  it  indicates  that  the  distention  of  the 
inflamed  appendix  has  been  relieved  by  perforation  or  gangrene. 

When  the  pain  occurs  in  paroxysms,  it  is  thought  to  be  due  to  contractions  of 
the  appendix — appendicular  colic. 

Next  to  pain,  the  most  important  symptom  in  appendicitis  is  rigidity  or  fixation 
of  the  right  rectus  muscle.     Barring  voluntary  rigidity  of  this  muscle,  which  can 


576  DISEASES  OF  THE  I^ITESTINES 

usually  be  prevented  by  diverting  the  patient's  mind  from  his  abdomen,  it  is  a 
sign  of  great  reliability,  and  its  degree  often  measures  the  sc\erity  of  the  inflam- 
matory process. 

Vomiting  is  very  commonly  present  in  these  cases.  In  some  of  tlioni  it  occurs 
so  early  as  to  seem  to  usher  in  the  attack.  This  is  particularly  apt  to  be  the  case 
if  the  stomach  has  been  overloadeil  with  food  j ust  before  the  attack.  If  the  stomach 
is  empty  at  the  time  of  onset,  vomiting  is  often  alisent. 

The  febrile  vmvement  in  a  case  of  appendicitis  is  rarely  very  great.  The  tempera- 
ture varies  from  99°  to  101°,  and  occasionally  reaches  102°  in  adults.  In  children 
it  may  be  higher. 

The  pulse  is  quid:,  but  not  very  rapid,  unless  serious  abdominal  disturbance 
has  already  developed.  It  ranges  from  90  to  110  per  minute.  If  it  goes  higher 
than  this,  general  peritonitis  is  probably  present.  Distention  of  the  belly  with 
gas  is  usually  a  late  symptom,  and  if  well  marked  may  be  indicative  of  general 
peritonitis,  when  it  is,  of  course,  a  very  grave  symptom. 

After  the  malady  has  been  present  for  some  days  a  swelling  in  the  rif/ht  iliac 
region  may  appear  and  be  due  to  pus  or  to  a  large  protective  exudation  of  lymph. 
The  latter  formation  is,  however,  usually  met  with  in  relapsing  cases  rather  than 
in  primary  cases. 

Finally,  we  meet  with  cases,  usually  in  women,  but  sometimes  in  men,  in  which 
there  is  present  a  true  mucous  colitis  with,  it  may  be,  a  chronic  catarrh  of  the 
appendix.  In  these  persons  a  tiny  discharge  of  mucopus  may  daily  infect  the  colon. 
They  are  to  be  considered  as  cases  of  chronic  catarrhal  appendicitis  and  operated 
upon,  not  because  the  appendix  is  so  gravely  diseased  as  because  it  causes  disorder 
in  the  colon. 

Diagnosis. — When  the  question  arises  as  to  the  cause  of  severe  abdominal  pain, 
an  examination  of  the  blood  should  be  made.  If  a  distinct  leukocytosis  is  present, 
the  white  cells  of  the  polymorphonuclear  group  being  particularly  increased,  it  is 
indicative  of  an  acute  inflammatory  process  somewh.ere  in  the  body,  and  probably 
in  the  appendLx,  if  the  symptoms  are  appendicular.  It  is,  however,  a  great  mistake 
to  allow  the  determination  to  do  an  operation  to  rest  upon  this  sign,  for  it  has  at 
times  proved  a  "hollow  reed."  At  best  it  is  to  be  regarded  as  collateral  and  not 
direct  evidence  of  appendicitis. 

Hepatic  colic  is  separated  from  appendicitis  by  the  presence  of  a  history  of 
previous  attacks  of  colic,  by  the  presence  of  jaundice  in  some  cases,  the  presence  of 
tenderness  over  the  gallbladder,  and  by  the  fact  that  in  gallstone  colic  the  pain  is 
referred  to  the  chest  between  the  right  shoulder-blade  and  the  spine;  whereas,  in 
appendicitis  it  is  not  so  referred. 

Renal  colic  is  differentiated  from  appendicitis  by  the  pain  being  referred  to 
the  testicle,  pelvis,  or  the  inside  of  the  thigh;  by  the  fact  that  the  urine  contains 
blood,  if  not  macroscopically,  at  least  microscopically;  there  is  no  excess  of  pain 
on  pressure  over  "McBurney's  point,"  and  there  may  be  a  previous  history  of 
renal  stone.  Irritability  of  the  bladder  is  of  no  value  as  a  differential  s>niptom, 
as  it  is  often  present  in  both  renal  colic  and  appendicitis.  In  neither  form  of  colic 
is  leukocytosis  marked. 

Ovarian  or  tubal  inflammation  may  simulate  appendicitis,  but  a  pelvic  examina- 
tion will  usually  reveal  these  states.  The  possibility  of  psoas  abscess  must  also 
be  remembered. 

In  some  cases  of  intestinal  obstruction  the  pain  may  resemble  that  of  appendicitis, 
but  the  presence  of  obstinate  constipation,  the  development  of  fecal  vomiting, 
and  the  discovery  of  a  mass  in  the  belly  elsewhere  than  at  the  appendix  may  enable 
the  physician  to  make  a  differential  diagnosis. 

One  of  the  most  important  differentiations  for  the  physician  and  surgeon  is 
that  between  appendicitis  and  early  typhoid  fever.     At  first  glance  this  would 


APPENDICITIS  Oil 

seem  to  be  easy,  but  those  of  experience  know  that  it  is  often  difficult,  not  that 
typhoid  fever  often  develops  suddenly,  but  that  appendicitis  may  develop  slowly 
during  a  mild  influenzal  infection,  or  during  an  attack  of  gastro-intestinal  catarrh 
■  that  has  been  obscure  in  its  nature.  Further  than  this,  the  lymphoid  tissues  of  the 
appendix  and  nearby  parts  are  usually  involved  in  typhoid  fever,  and  may  cause 
appendicular  symptoms.  (See  Plate  I.)  These  localized  typhoid  lesions  may 
cause  pain  and  tenderness  in  the  right  iliac  area.  The  absence  of  very  severe 
pain,  the  failure  to  find  the  leukocytosis  of  acute  inflammation,  the  peculiarly 
coated  tongue,  the  presence  of  tympany,  and  the  later  development  of  rose  spots 
and  the  Widal  test  will  prove  the  case  to  be  one  of  typhoid  fever. 

Care  should  be  taken  that  pain  and  swelling  in  this  area  occurring  in  one  who 
has  tuberculosis  is  not  taken  for  appendicitis.  It  is  not  rare  to  find  these  signs  in 
consumptives  who  are  by  no  means  far  advanced  in  their  disea.se.  The  condition 
is  often  one  of  local  tuberculous  infection  of  a  chronic  type. 

The  possibility  of  acute  hemorrhagic  pancreatitis  being  present  is  to  a  large 
extent  excluded  by  the  fact  that  it  is  a  very  rare  condition,  by  the  site  of  the  pain 
and  the  onset  of  early  collapse  in  this  disease. 

•  Osier  has  pointed  out  that  in  persons  subject  to  the  erythematous  eruptions, 
severe  attacks  of  abdominal  pain  may  develop  which  give  rise  to  a  diagnosis  of 
appendicitis,  which  may  be  excluded  only  after  a  careful  study  of  the  case  with 
reference  to  this  state  and  urticaria. 

Prognosis. — The  prognosis  of  appendicitis  depends  largely  upon  the  severity  of 
the  condition.  Statistics  which  show  that  a  certain  percentage  of  all  cases  get 
well  are  of  interest,  but  they  do  not  help  the  physician  in  an  individual  case, 
because  definite  statements  as  to  the  character  of  the  statistics  are  not  given. 
A  series  of  mild  catarrhal  cases  will  give  a  recovery  percentage  of  100;  whereas, 
a  series  of  severe  gangrenous  cases  will  give  a  mortality  of  100  per  cent.  That 
recovery  frequently  takes  place  is  shown  by  the  fact  that  about  one-third  of  all 
postmortems  show  signs  of  the  existence  of  appendicular  disease  at  some  time  in 
life,  yet  there  may  be  no  history  of  such  an  illness. 

The  substance  of  our  present  knowledge  is  that  the  prognosis  in  an  ordinary 
attack  of  appendicitis  is  good  for  recovery  from  that  attack,  but  that  recurrences 
are  likely.  In  the  perforative  or  gangrenous  type  the  prognosis  is  always  grave 
and  often  fatal.  Much  depends  upon  prompt  surgical  interference.  If  this  is 
delayed,  death  is  the  result  in  the  majority  of  cases  of  this  type. 

If,  however,  all  cases  of  primary  appendicitis  of  whatever  tj-pe  are  considered 
statistically,  it  is  found  that  the  ratio  of  mortality  is  only  about  15  per  cent, 
under  medical  treatment.     (See  Treatment.) 

Treatment. — There  is  perhaps  no  more  difficult  point  for  decision  in  medical 
practice  than  that  as  to  the  treatment  for  appendicitis.  It  is  impossible  to  discuss 
the  vast  array  of  arguments  for  and  against  early  operative  interference  in  this 
brief  space. 

Given  a  case  of  appendicitis  of  the  acute  type,  the  first  thing  for  the  physician 
to  do  is  to  call  in  a  surgeon  as  a  consultant,  provided  a  surgeon  qualified  to  do  good 
abdominal  surgery,  if  it  is  required,  is  obtainable.  If  none  such  can  be  had,  the 
patient  is  far  better  off  without  than  with  operation.  As  this  is  one  of  the  great 
medicosurgical  problems  of  practice,  responsibility  should  be  divided.  If  by  non- 
surgical treatment  the  case  can  be  controlled  and  carried  through  the  acute  attack, 
the  surgeon  should  not  interfere,  for  the  mortality  of  operation  in  the  acute  stage 
is  far  greater  than  it  is  when  the  operation  is  performed  in  the  interval  betwen  the 
attacks 

The  signs,  however,  which  will  force  the  surgeon  to  immediate  operation  when 
the  patient  is  first  seen,  or  if  he  does  not  improve  under  treatment,  are:  great 
rigidity  of  the  rectus  muscle,  persistent  vomiting,  a  rapid  pulse  (above  110),  an 
37 


o7,S  D/SKASI'JS  OF   TIIK  IXTKSTI X I'S 

anxious  facies,  and,  perliaps,  as  an  indication  of  some  importance,  a  very  hi^h 
leukocytosis.  In  such  cases  the  only  salvation  of  the  patient  lies  in  immediate 
surgical  interference,  anfl  each  hour  of  delay  diminishes  the  chance  of  recovery. 
The  whole  cpiestion  is  one  of  se\'erity.  If  there  is  reason  to  believe  that  the  tissues 
are  becoming  infected  and  that  the  local  tissues  cannot  resist  the  spread  of  the 
inflammation,  then  we  must  operate. 

Many  years  ago  Fitz  showed  that  40  per  cent,  die  after  surgical  measures,  and 
11  per  cent,  after  medical  treatment;  but  this  does  not  prove  that  the  latter  is  better 
than  the  former,  but  rather  that  the  surgical  cases  did  not  get  to  the  surgeon  unless 
desperately  ill.  At  present  the  percentage  of  deaths  in  surgical  cases  is  far  less, 
chiefly  because  they  are  seen  early  enough  or  operation  is  performed  at  the  time 
of  election;  but  even  at  a  much  later  date  than  that  of  Fitz's  paper  we  find  Caley 
(1899)  recording  98  medical  cases  with  .3  deaths,  and  102  surgical  cases  with  22 
deaths.  When  we  consider  Sprengel's  statistics  of  516  cases,  232  of  which  were 
operated  on  in  the  interval  with  2  deaths,  and  284  during  the  attack  with  .57  deaths 
and  Sahli's  7000  cases  treated  medically  with  90  per  cent,  recoveries,  the  value  of 
delay,  in  mild  cases,  is  evident. 

The  plan  of  treatment  in  mild  cases  is  as  follows:  The  patient  is  reciuired  to 
take  absolute  rest  in  bed.  No  purgatives  are  given  nor  pain-relie\ing  drugs  are 
to  be  used  unless  the  pain  is  excessive,  when  enough  morphine  may  be  used  hypo- 
dermically  to  take  the  edge  off  of  the  agony,  but  never  enough  to  make  the  patient 
comfortable  or  to  make  him  sleep,  for  such  an  effect  masks  the  symptoms.  No 
food  is  to  be  given  by  the  mouth  and  no  drink  is  to  be  taken.  If  need  be,  liquid 
can  be  given  by  hypodermoclysis  or  by  the  Murphy  drip  method.  If  the  case 
has  advanced  so  far  that  there  are  signs  of  general  peritonitis  the  patient  should 
be  placed  in  the  half-sitting  up  or  Fowler's  posture  and  be  given  saline  solution 
by  the  rectum  by  means  of  the  Murphy  drip.  If  the  bowels  move,  a  bed-pan  must 
be  used.  Under  this  treatment  the  acute  inflammatory  process  may  be  arrested, 
and  the  operation  can  be  performed,  if  need  be,  after  it  has  subsided.  If  by  the 
end  of  twelve  or  twenty-four  hours  the  symptoms  are  not  rapidly  subsiding,  it  is 
necessary  to  operate  at  once.  Fowler  has  shown  that  when  operation  is  done 
within  forty-eight  hours  83  per  cent,  recover.  When  the  cases  are  left  to  the  fourth 
day  60  per  cent,  recover;  to  the  fifth  and  sixth  days,  58  per  cent;  to  the  seventh 
and  eighth  days,  50  per  cent.;  and  to  the  ninth  and  tenth  days,  only  33  per 
cent. 

This  question  of  deferring  operation  to  the  interval  between  the  attacks  is  still 
under  debate.  There  are  some  radicals  who  insist  that  operation  should  be  resorted 
to  without  waiting,  and,  indeed,  before  the  appendicitis  is  severe.  There  are 
others  who  are  content  to  wait  till  the  storm  is  past,  and  still  others  who  believe 
that,  given  a  patient  who  has  had  but  one  attack  of  moderate  severity,  he  may  go 
free  until  another,  or  a  third  attack,  makes  it  e\'idcnt  that  a  recurrence  is  likely 
to  take  place  at  any  time,  when  he  should  be  operated  u])on  in  the  interval.  As 
Dennis  well  says:  "The  i)lan  of  allowing  the  simple  catarrhal  cases  which  are  doing 
well  after  thirty-six  hours  to  recover  without  immediate  operation,  and  relegating 
them  subsequently  to  the  grouj)  known  as  interval  cases,  and  the  prompt  operation 
after  thirty-six  hours  when  the  cases  are  not  doing  well,  seems  to  hold  out  the  best 
prospects  for  recovery.  The  |)endulum  has  swung  too  far  toward  indiscriminate 
operation.  But  now  the  introduction  of  the  interval  operation  has  brought  the 
pendulum  back  to  swing  within  the  proper  limits."     (See  Peritonitis.) 

It  nmst  not  be  tht)Ught  that  patients  who  have  recurrent  appendicitis  can 
be  promised  i)erfect  comfort  by  operation,  for  not  rarely,  while  they  recover  from 
the  operation,  they  continue  to  have  tenderness  and  pain  in  the  right  groin  for 
years,  but  the\'  will  be  safe  from  a  death-dealing  nialadv. 


INTESTINAL  OBSTRUCTION  579 

INTESTINAL  OBSTRUCTION. 

Definition. — Intestinal  obstruction  is  a  term  applied  to  a  condition  of  the  jjowel 
in  which,  by  reason  of  some  mechanical  impediment  or  intestinal  paralysis,  the 
normal  movement  of  its  walls  and  contents  cannot  take  place.  In  its  acute  form 
it  occurs  as  the  result  of  no  less  than  six  causes:  first,  congenital  malformation; 
second,  invagination,  or  telescoping  of  one  portion  of  the  bowel  within  the  other, 
or  so-called  intussusception;  third,  strangulation  by  bands,  diverticula,  membranous 
adhesions,  or  by  attachment  to  other  organs,  and  by  the  slipping  of  a  coil  of  intestine 
through  an  aperture;  fourth,  as  a  result  of  twisting  of  the  bowel,  called  volviilvs; 
fifth,  from  lodgement  oi  foreign  bodies,  as  gallstones,  etc.;  and  sixth,  from  intestinal 
jMralysis  and  distention. 

Chronic  intestinal  obstruction  arises  from  stricture,  from  tumors  in  the  bowel, 
from  tumors  external  to  the  bowel,  and  from  the  impaction  of  fecal  7nasses.  (See 
Membranous  Pericolitis.) 

Under  the  name  of  Lane's  kink  a  condition  is  recognized  in  which  abdominal 
distress  is  present  as  the  result  of  fixation  by  congenital  or  inflammatory  bands 
of  the  terminal  loop  of  the  ileum. 

Congenital  Malformation. — Congenital  malformations  usually  consist  in  closure 
of  the  intestinal  tube  by  reason  of  improper  development.  Such  a  closure  may 
exist  at  any  part  of  the  alimentary  canal  from  the  esophagus  to  the  anus.  Rarely 
the  bowel  becomes  strangulated  or  incarcerated  or  twisted  because  of  some  con- 
genital defect.  A  common  congenital  defect  is  imperforate  anus  and  rectum. 
Less  frequently  there  is  atresia  at  the  pylorus.  Not  rarely  children  born  with 
this  condition  have  other  congenital  defects  in  the  alimentary  canal.  In  the 
statistics  collected  by  Martin  and  myself,  28  per  cent,  of  such  cases  showed  more 
than  one  point  of  obliteration.  In  cases  in  which  the  atresia  does  not  exist  in  the 
anus  or  rectum,  it  is  most  commonly  found  near  the  ileocecal  valve,  in  the  duo- 
denum, or  in  the  sigmoid  flexure. 

Symptoms. — The  symptoms  of  intestinal  obstruction  due  to  congenital  causes 
usually  appear  after  food  is  first  taken.  There  is  no  passage  of  meconivmi  from 
the  anus,  and  the  vomited  materials  are  often  fecal  in  odor  and  in  appearance. 
Not  rarely  violejit  peristaltic  waves  can  be  seen  through  the  abdominal  wall.  There 
is  also  paiji  and  efforts  at  defecation. 

Diagnosis. — An  examination  of  the  anus  or  rectum  w^ill  usually  repeal  the  cause 
of  the  trouble.  If  the  finger  cannot  reach  the  obstruction,  a  bougie  may  discover 
it.  In  other  cases,  water  from  a  fountain  syringe,  hung,  not  over  two  feet,  above 
the  patient's  buttocks,  may  be  allowed  to  flow  into  the  bowel  to  determine  its 
capacity. 

Prognosis  and  Treatment. — The  prognosis  is,  of  course,  exceedingly  unfavorable, 
but  if  the  closure  is  near  the  anus  a  surgical  operation  may  give  relief,  and,  as 
all  die  without  operation,  the  knife  should  always  be  resorted  to.  Death  ensues 
from  inanition  or  exhaustion. 

Intussusception. — The  invagination  in  this  condition  is  composed  of  three  layers 
of  bowel.  The  intussusceptum  is  composed  of  the  entering  and  returning  layers, 
while  the  receiving  sheath  constitutes  the  intussuscipiens.  To  the  point  where 
the  entering  layer  is  turned  sharply  upon  itself  to  form  the  returning  layer,  the 
name  "apex"  is  applied.  The  word  "neck"  is  applied  to  the  ring  which  results 
from  the  flexure  formed  by  the  returning  layer  as  it  merges  into  the  sheath. 

Intussusception  may  be  separated  into  divisions,  according  to  the  severity  of 
the  condition,  or  according  to  the  part  of  the  intestine  which  is  involved.  Rafin- 
esque  makes  three  divisions,  namely,  those  which  are  ultra-acute,  death  taking 
place  within  the  first  twenty-four  hours;  those  which  are  acute,  death  occurring 
in  the  first  week;  those  which  are  subacute,  lasting  a  month  and  upward.     From 


580  DISEASES  OF  THE  INTESTINES 

an  anatomical  stand-point,  intussusception  may  be  divided  into  the  enteric,  in 
wliich  the  small  intestine  is  alone  involved;  the  ileocecal,  in  wliich  the  ileum  and 
cecum,  together  witli  the  ileocecal  valve,  are  turned  into  the  colon;  and  the  ileocolic, 
in  whicli  the  ileum  is  prolapsed  through  the  ileocecal  valve,  the  latter  retaining 
its  proper  position,  at  least  for  a  time.  When  the  condition  is  called  "colic," 
it  involves  the  colon  only.  In  still  other  cases,  the  rectum  is  solely  affected,  forming 
the  rectal  ty]:)e  of  the  malady.  In  the  great  majority  of  cases  the  ujiper  segment 
of  the  gut  is  received  into  the  lower,  but  occasionally  the  reverse  condition  occurs, 
and  when  this  happens  the  term  "retrograde  intussusception"  is  applied.  Double 
anil  triple  intussusception  have  occasionally  been  noted. 

Etiology. — The  causes  of  intussusception  are  not  clearly  understood,  but  probably 
depend  upon  irregular  innervation  of  the  intestine,  whereby  a  sudden,  spasmodic 
contraction  of  one  portion  of  the  bowel  occurs,  the  adjacent  portion  being  relaxed. 
Intussusceptions  of  this  character  are  not  infrequently  met  with  at  the  postmortem 
table,  having  occurred  at  the  time  of  dissolution.  Polyps  of  the  intestine  may  be 
forced  along  the  lumen  of  the  canal,  thereby  dragging  the  wall  at  the  point  of 
attachment  and  causing  intussusception. 

Frequency. — In  1652  cases  of  intestinal  obstruction,  excluding  hernia,  collected 
by  Leichtenstern  and  Bryant,  657  cases,  or,  approximately,  40  per  cent.,  were  due 
to  intussusception.  It  is  evident,  therefore,  that  this  form  of  obstruction  is  not 
rare.  Intussusception  occurs  most  frequently  during  the  first  twelve  months  of 
life.  After  the  fifth  year  it  becomes  comparatively  rare  until  the  fortieth  or  fiftieth 
year,  when  it  again  increases  in  frequency.  The  ileocecal  region  is  the  favorite 
site  of  invagination  at  all  ages,  but  ileum  invagination  is  exceedingly  rare.  If  the 
colic  form  occurs,  it  is  usually  at  the  sigmoid  flexure. 

Pathology. — The  pathological  changes  resulting  from  intussusception  consist 
in  an  extravasation  of  the  blood  into  the  mucous  membrane  and  mesentery  of 
the  part  aft'ected,  and  in  an  acute  inflammatory  process  in  the  walls  of  the  intestine, 
which  particularly  aft'ects  the  serous  surfaces  of  the  entering  and  returning  layers, 
so  that  they  become  glued  to  one  another.  Not  infrequently,  however,  this  con- 
dition docs  not  arise,  and  adhesions  do  not  form.  As  a  result  of  the  strangulation 
of  the  invaginated  bowel,  it  sometimes  happens  that  this  portion  of  the  intestine 
sloughs  away,  and  if  sufficiently  strong  adhesions  ha\-e  formed  between  the  neck 
and  the  upper  portion  of  the  intussusceptum,  the  coming  away  of  this  slough  may 
result  in  the  recovery  of  the  patient.  Very  large  portions  of  bowel  have  been  known 
to  be  passed  in  this  manner.  Pampier  has  recorded  one  instance  in  which  124  cm., 
Bottcher  another  in  which  112  cm.  were  passed.  In  other  instances,  however, 
if  gangrene  of  the  bowel  develops,  perforation  and  general  peritonitis  ensue. 

Symptoms. — These  depend  upon  the  degree  of  constriction  at  the  neck  of  the 
intussusceptum.  Usually  the  first  symptom  is  ttudden  and  violent  jjain.  This 
pain  sometimes  ceases  as  suddenly  as  it  begins,  the  patient  being  in  comparative 
comfort.  After  an  interval  the  jmin  returns,  and  the  paroxysms  become  violent 
and  prolonged,  with  shorter  intervals  of  ease.  Pressure  does  not  always  elicit 
tenderness;  indeed,  at  times  it  seems  to  relieve  the  pain.  Voinitinci  is  an  even  more 
constant  symptom  than  pain,  and  usually  begins  early  in  the  attack,  but  in  adults 
it  may  be  absent.  Of  all  forms  of  intussusception  the  ileum  invagination  is  the 
one  which  is  most  frequently  accompanied  by  early  vomiting,  chiefly  because  it 
produces  the  most  complete  obstruction.  In  children  a  very  constant  symptom 
is  the  passucie  of  bloody  mucvs.  Out  of  108  cases,  analyzed  by  Martin  and  myself, 
occurring  in  the  first  year  of  life,  this  symptom  was  absent  in  only  4. 

Tenesnnts  and  beariiu/  down  is  also  connnonly  met  with.  In  about  one-half  the 
cases  the  tumor  can  be  felt  through  the  abdominal  wall,  and  under  the  pliable 
abdominal  wall  of  children  it  should  always  be  most  carefully  sought  for.  Such 
a  tumor  is  most  commonly  found  when  the  ileocecal  type  is  present.    Occasionally 


INTESTINAL  OBSTRUCTION  581 

in  the  colic  type  the  invaginated  bowel  can  be  felt  in  the  rectum.  The  movement 
of  the  bowel  may  distinctly  change  the  position  of  the  tumor. 

Prognosis. — The  prognosis  in  intussusception  is  not  very  good.  Treated  by 
the  expectant  method,  the  mortality  is  70  per  cent.,  according  to  Leichtenstern. 
The  statistics  of  Martin  and  myself  give  a  mortality  of  90  per  cent.  The  mortality 
is  greater  in  infants  than  it  is  in  older  persons.  The  sloughing  and  discharge  of 
the  intussusceptum  is  always  to  be  considered  distinctly  favorable,  and  Martin 
and  myself  found  that  in  408  children  in  whom  sloughing  had  not  taken  place 
85  per  cent,  died,  while  of  149  who  passed  a  portion  of  the  intestine  41  per  cent, 
recovered.    Sloughing  rarely  occurs  before  the  second  or  third  week  of  the  disease. 

Treatment. — The  treatment  consists  in  the  use  of  a  fountain  syringe  filled  with 
normal  salt  solution,  at  the  temperature  of  105°,  and  this  fluid  is  to  be  injected 
slowly  at  the  rate  of  4  ounces  to  the  minute.  The  pressure  in  the  hydrostatic 
syringe  should  not  be  over  two  pounds.  This  method  is  available  only  when 
the  intussusception  occurs  in  the  lower  portion  of  the  bowel.  If  it  is  in  the  ileum 
it  is  valueless.  If,  after  pressure  has  been  continued  for  the  period  of  a  half-hour, 
the  tumor  does  not  disappear  under  gentle  manipulation,  abdominal  section  must 
be  resorted  to  at  once.  The  older  statistics  in  regard  to  this  operation  were  not 
very  favorable,  most  of  them  being  gathered  in  pre-antiseptic  days.  At  the  present 
time  operation  gives  much  more  favorable  results. 

Internal  Strangulation. — Internal  strangulation  by  bands  is  the  next  most 
frequent  form  of  intestinal  obstruction,  forming  about  36  per  cent,  of  the  classified 
cases.  The  condition  occurs  most  frequently  in  males  between  the  twentieth 
and  fortieth  years,  and  seems  to  arise  in  the  majority  of  cases  from  a  former  peri- 
tonitis; although  occasionally  the  bowel  is  strangulated  by  slipping  through  the 
foramen  of  Winslow  or  through  a  slit  in  the  diaphragm.  Numerous  cases  of 
obstruction  due  to  a  Meckel's  diverticulum  have  been  reported.  The  diverticulum 
may  become  twisted  or  by  adhesions  to  neighboring  structures  form  a  constricting 
band. 

Out  of  151  reported  cases  the  small  intestine  was  involved  in  133. 

Symptoms. — The  symptoms  consist  in  sudden  agonizing  pain  which  is  constant, 
although  it  has  paroxysmal  increvients.  The  pulse  becomes  rapid  and  weak; 
the  temperature  is  abnormal;  the  wmiting  is  persistent,  and  becomes /ecai,  but  this 
condition  of  the  vomit  rarely  develops  before  the  beginning  of  the  third  day. 
Constipation  is  present,  but  fecal  matter  may  be  passed  from  the  lower  part  of  the 
bowel  once  or  twice.  If  a  large  coil  of  gut  is  involved,  a  distinct  area  of  distended 
intestine  may  perhaps  be  found.  While  the  presence  of  this  train  of  symptoms  in  a 
j'oung  child  would  be  indicative  of  intussusception,  in  an  adult  it  is  indicative  of 
strangulation  by  a  band,  for  intussusception  is  rare  in  adults. 

The  only  method  of  treatment  which  is  satisfactory  is  operative. 

Volvulus. — According  to  Brinton,  this  condition  occurs  in  8  per  cent,  of  fatal 
cases  of  intestinal  obstruction;  according  to  Treves,  in  2.5  per  cent.,  and  according 
to  Martin  and  the  writer's  statistics,  in  4  per  cent.  Sometimes  the  intestine  is 
twisted  for  three  or  four  complete  turns.  The  condition  occurs  most  frequently 
after  middle  life,  and  occurs  more  frequently  in  men  than  in  women.  In  18  cases 
collected  by  Haven,  16  were  men.  In  Martin's  and  my  own  table  of  100  cases, 
64  were  men.  The  twist  is  usually  about  the  mesentery  as  an  axis  and  involves 
the  small  intestine.  Occasionally  it  may  appear  in  the  colon;  rarely  the  stomach 
may  be  affected.  The  twisting  of  the  intestine  interfers  with  its  circulation,  and 
this,  combined  with  the  decomposition  of  the  intestinal  contents  and  the  resulting 
distention,  soon  produces  peritonitis,  and  even  perforation.  The  abdomen  is 
prone  to  become  immensely  distended. 

Symptoms. — The  symptoms  consist  in  absolute  constipation,  wmiting,  and  abdom- 
inal diitention.     Meteorism  is  constant.    The  points  in  favor  of  a  diagnosis  of 


582  DISEASES  OF  THE  INTESTINES 

volvulus  are  the  advanced  age  of  the  patient,  the  fact  that  the  disease  usually 
occurs  in  a  male,  that  the  pain  is  not  as  agonizing  as  in  other  forms  of  obstruction, 
and  tliat  the  obstructed  bowel  is  greatly  distended. 

Prognosis. — The  prognosis  is  much  more  fa\-orable  than  in  other  forms  of  intestinal 
obstruction.  When  intestinal  obstruction  is  due  to  paralysis,  the  cause  is  most 
frequently  some  injury  or  an  operation  upon  the  abdominal  contents.  The  bowel 
is  simply  dilated  or  kinked,  and  the  failure  in  peristalsis  is  due  to  paralysis  of  its 
muscular  fibres.  This  is  the  type  of  obstruction  which  all  abdominal  surgeons 
greatly  fear  as  a  sequence  of  operation  upon  the  peritoneal  contents. 

Treatment. — When  the  volvulus  is  due  to  paralysis  after  operation  it  is  to  be 
treated  by  the  administration  of  concentrated  salines  repeated  until  the  bowels 
are  moved.  When  distention  has  reached  a  very  great  flegree  and  \-omiting  is 
present,  salines  are  no  longer  useful.  The  rectal  tube  should  be  passed  in  the  hojie 
of  exciting  peristalsis  and  drawing  off  gas.  Such  cases  should  be  subjected  to 
operation. 

Obstruction  from  Foreign  Bodies  arises  from  such  articles  as  coins,  pebbles, 
knives,  and  scissors,  gallstones  aufl  enteroliths.  While  gallstones  are  usually 
small,  they  at  times  may  be  very  large,  and  are  often  greatly  added  to  by  concre- 
tions. Thus,  Leichtenstern  states  that  one  such  stone  was  five  inches  in  circum- 
ference, and  he  describes  an  enterolith  nine  inches  in  circumference.  Such  a 
stone  is  usually  formed  by  concretions  about  a  foreign  body,  as  a  cherry-stone. 
Cases  of  intestinal  obstruction  of  this  character  are,  however,  very  rare,  about 
0.2  per  cent,  of  all  cases.  The  obstruction  is  usually  found  in  the  small  intestine, 
sometimes  at  the  ileocecal  valve,  and  occurs  more  frequently  in  females  than  in 
males. 

ENTEROPTOSIS. 

Definition. — Enteroptosis  is  a  condition  in  which  the  intestines  fall  to  a  lower 
le\el  than  that  which  they  normally  occupy.  Not  only  the  intestines,  but  the 
stomach,  liver,  spleen,  and  kidneys  may  be  displaced  downward,  the  displacement 
being  due  to  stretching  or  relaxation  of  the  mesenteric  and  peritoneal  ligaments 
and  to  laxity  of  the  abdominal  wall,  so  that  it  fails  to  support  the  coiitents  of  the 
belly  cavity.  Of  the  various  names  which  have  been  applied  to  this  state,  other 
than  enteroptosis,  may  be  mentioned  splanchnoptosis,  visceroptosis,  and  "  Glenard's 
disease."  When  the  stomach  is  chiefly  aft'ected  it  is  called  gastroptosis.  Entero- 
ptosis is  a  condition,  not  a  disease. 

Etiology. — Glenard  thinks  that  overloading  the  transverse  colon  with  feces 
may  cause  so  great  a  strain  upon  that  portion  of  the  mesocolon  which  supports 
the  large  transverse  bowel,  particularly  at  its  right  fiexure,  that  this  part  may  sag 
and  so  predispose  the  rest  of  the  colon  to  drop  downward,  drawing  with  it  other 
parts.  The  objection  to  this  argument  is  that  the  right  flexure  of  the  colon  is 
practically  never  loaded  heavily  with  feces,  or,  at  least,  the  instances  in  which 
it  is  so  loaded  are  far  more  rare  than  is  enteroptosis.  Further  than  this,  the  liga- 
ments concerned  in  the  support  of  the  abdominal  contents  are  not  the  chief  source 
of  support.  Schwerdt  states  that  they  do  not  bear  more  than  one-eighth  of  the 
weight.  The  upper  organs  are  buoyed  up  by  the  lower  ones,  provided  these  are 
retained  in  a  normal  position.  Although  constipation  may  be  a  minor  factor  in 
producing  this  state,  the  chief  factors  are  relaxation  of  the  abdominal  wall  and 
the  loss  of  fat  ])roduced  by  an  acute  illness  or  some  chronic  disease,  and  occasionally 
by  old  age.  This  affection  is  not  uncommon  in  the  insane,  particularly  when  chronic 
constipation,  iiuictivity,  and  wasting  are  associated.  The  relaxation  of  the  abdomi- 
nal wall  may  also  be  due  to  loss  of  fat  and  to  repeated  pregnancies,  particularly 
if  the  woman  has,  by  wearing  corsets,  weakened  her  abdominal  muscles  and  then 


ENTEROPTOSIS 


583 


had  them  subjected  to  prolonged   distention   in   pregnancy.    Occasionally  the 
rectus  muscles  not  only  atrophy,  but  separate.     (Figs.  10.3  and  104.) 


A' 

a.< 

W^^Km  ^ 

# 

v^H^^^^HV^' 

^ 

^^^^^^ 

1^  .  ■ 

Enteroijtosis  due  to  relaxation  of  the  abdominal  wall.    Hornet's-nest  belly. 


5S4  7)7,S'7?.1,S'7?,S  OF  THE  IXTESTfXES 

To  appreciate  tlie  failure  on  tlie  part  of  the  ahdoniinal  imiscles  in  a  well-developed 
case  of  enteroptosis,  it  is  only  necessary  to  stand  hehind  the  ])atieiit  and  ])lace  the 
palms  of  the  hands  upon  the  lower  zone  of  the  alxlonien,  jiressiiig  upward  and 
inward,  when  the  entire  weight  of  the  abdominal  contents  may  he  felt  resting 
upon  the  hands.  The  complete  inability  of  the  abdominal  wall  to  give  supjjort 
is  then  appreciated. 

Enteroptosis  is  far  more  frequent  in  women  than  in  men.  Glenard  found  it  in 
women  in  306  out  of  404  cases. 

Symptoms. — The  symptoms  in  many  cases  are  by  no  means  definite.  The  patient 
is  often  regarded  as  a  chronic  dyspeptic,  as,  indeed,  she  is.  There  is  more  or  less 
constant  discomfort  in  tlie  abdomen,  and  the  intestines  may  be  in  a  state  of  peristaltic 
unrest,  so  that  borborygmi  and  rumbling  are  annoying.  At  times  the  bowels  seem 
hyperesthetic,  and  the  patient  complains,  not  of  pain,  but  of  a  sense  of  movements 
which  in  health  are  never  felt.  Some  patients  describe  the  sensation  as  if  their 
abdominal  contents  were  "falling  out"  of  them.  Some  ha\e  a  distaste  for  food; 
others  crave  it,  with  the  hope  that  it  will  relieve  the  sense  of  emptiness,  and  then 
regret  taking  it  because  its  presence  in  the  displaced  stomach  increases  the  distress. 
Constipation  is  usually  persistent,  and  the  use  of  purgati\es  may  serve  to  cause  a 
great  increase  in  rumbling  without  causing  a  satisfactory  evacuation.  The  reason 
for  this  is  evident,  for  the  fallen  bowel  presents  sacculations  or  depressions  that 
act  like  a  plumber's  trap  and  prevent  free  progress  of  the  contents  of  the  intestinal 
tube. 

Associated  with  these  symptoms  there  is  often  a  good  deal  of  nervous  unrest 
and  mental  depression,  and  not  rarely  some  vertigo  on  changing  the  posture  of  the 
body.     There  may  also  be  cardiac  palpitation  and  breathlessness. 

An  examination  of  such  a  patient  will  reveal  on  inspection,  provided  a  certain 
degree  of  leanness  or  emaciation  is  present,  that  the  abdominal  wall  is  thinner  than 
normal,  that  it  is  relaxed,  and  that  when  the  patient  stands  erect  its  muscles  are 
soft  and  without  tone.  In  health  palpation  of  the  abdominal  wall  reveals  some 
resistance,  whereas  in  this  state  it  yields  readily  to  pressure  like  the  side  of  a  partly 
filled  water-bag.  Inspection  not  rarely  reveals  the  fact  that  the  zone  of  the  abdo- 
men between  the  ensiform  cartilage  and  the  navel  is  empty,  and  that  below  the 
navel  the  abdomen  is  unduly  prominent  and  sags. 

The  appearance  of  such  a  patient  is  often  noteworthy,  for  emaciation  may  be 
so  marked  as  to  raise  the  suspicion  of  malignant  disease,  a  suspicion  which  is 
increased  by  the  anemia  which  is  present.  Rarely  the  patient  suffering  from 
enteroptosis  may  develop  jaundice  because  adhesions  constrict  the  bile-ducts. 

If  the  patient  with  enteroptosis  be  placed  upon  the  back  in  a  good  light,  and 
the  abdominal  wall  observed  at  a  distance,  peristaltic  waves  may  often  be  seen 
traversing  it.  Tapping  the  knuckles  of  intestine  through  the  abdominal  wall  with 
the  finger-tip  will  increase  or  arrest  these  movements  for  a  moment. 

Deep  palpation  may  reveal  the  liver  much  lower  than  normal.  That  this  is 
not  due  to  an  enlargement  of  this  organ  may  be  proved  by  the  discovery  that  as 
its  lower  border  passes  down  into  the  abdomen  its  upper  border  also  becomes 
lower,  the  actual  area  of  liver  dulness  on  percussion  being  the  same  as  in  health. 
The  liver  is,  however,  rarely  out  of  place,  except  in  extreme  cases. 

Distention  of  the  stomach  with  gas  from  a  Seidlitz  powder,  or  by  pumping  air 
into  it  with  an  atomizer  bulb  attached  to  a  tube,  will  reveal  its  abnormal  position, 
and  if  it  is  carefully  outlined  it  may  be  found  that  this  viscus  occupies  a  more 
vertical  position  than  in  health,  the  jjylorus  being  greatly  displaced,  while  the 
cardiac  portion  is  in  a  relatively  normal  posture  because  it  is  more  firmly  suspended. 
The  cardia  is  very  rarely  greatly  displaced,  but  Steele  has  reported  five  such  cases 
in  a  comparatively  short  time  of  observation.  Ptosis  of  the  stomach  is  not  rarely 
associated  with  dilatation  and  with  motor  insufficiency.     (For  the  measures  by 


ENTEROPTOSIS  585 

which  the  presence  of  gastroptosis  can  be  determined  see  article  on  Gastric 
Dilatation.) 

The  spleen  is  very  commonly  displaced.  It  may  be  well  forward  in  the  median 
line,  or  it  may  fall  more  directly  downward  and  be  found  as  low  as  the  pelvic  organs. 

Nephroptosis  is  described  in  the  section  devoted  to  Diseases  of  the  Kidneys. 

During  the  performance  of  deep  palpation  there  can  sometimes  be  felt  a  moder- 
ately firm  mass  lying  transversely  in  the  abdomen  in  the  epigastric  area.  This 
is  said  by  Glenard  to  be  the  colon,  but  if  this  be  the  case  the  colon  is  not  much 
displaced,  and  is  certainly  contracted  rather  than  dilated — a  condition  opposed 
to  that  stated  by  Glenard  to  be  usually  present.  Ewald  believes  that  this  mass 
is  the  pancreas  which  has  been  uncovered  by  the  enteroptosis. 

Auscultation  of  the  belly  in  these  cases  often  reveals  a  large  number  of  liquid 
sounds,  and  if  the  patient  is  shaken  there  may  be  heard  succussion  notes  and 
sounds  which  may  be  called  "slopping." 

While  some  patients  with  moderate  enteroptosis  present  many  of  the  symptoms 
just  described,  it  is  a  fact  worthy  of  note  that  others  with  very  marked  falling 
of  the  abdominal  contents  often  have  no  complaint  to  make  of  the  abdominal 
state,  and  if  they  are  told  of  it  at  once  become  mentally  "centred"  on  their  ali- 
mentary tract,  and,  if  already  neurasthenic,  speedily  drive  themselves  and  their 
medical  attendant  almost  demented  by  their  constant  discovery  of  new  symptoms. 

Treatment. — The  treatment  of  enteroptosis  is  manifestly  to  be  directed  to  the 
support  of  the  displaced  organs  and  their  replacement.  Not  rarelj-,  if  the  physician 
stands  behind  the  patient  and  presses  upon  and  lifts  the  abdominal  contents  by 
pressing  the  hands  in  front  of  the  abdomen,  relief  from  the  sense  of  abdominal 
relaxation  is  at  once  noticed. 

The  adjustment  of  a  properly  filled  abdominal  belt  or  binder  is,  therefore,  a 
valuable  aid  in  this  condition.  It  should  be  applied  every  morning  before  rising 
and  not  until  after  the  patient,  by  gentle  strokings  with  her  hands,  has  placed  the 
abdominal  contents  at  about  the  proper  level.  Its  greatest  pressure  must  be 
exercised  inward  and  upward  in  the  zone  below  the  navel.  Sometimes  the  use  of  a 
broad  flannel  binder  about  the  lower  zone  may  be  sufficient,  but  the  support  must 
be  upward  as  well  as  inward. 

Great  care  should  be  taken  as  to  diet.  Starches  and  milk,  both  of  which  are 
prone  to  produce  flatulence,  should  be  avoided.  If  starch  is  used  in  an  easily 
digested  form,  as  rice  and  cornstarch,  some  taka-diastase  should  be  given  with  it. 
Cheese  and  beans  are  absolutely  forbidden,  and  fats  are  also  harmful.  Small 
quantities  of  green  vegetables  may  be  taken,  and  roast  or  broiled  beef  and  mutton 
allowed  at  each  meal.  Eggs  are  also  permissible.  The  patient  should  be  warned 
against  eating  heavily  at  any  one  time,  since  an  overweighted  stomach  or  colon 
will  make  the  ptosis  much  worse.     If  gastric  dilatation  exists,  lavage  may  be  useful. 

In  the  way  of  drugs,  there  are  only  three  which  produce  much  benefit,  namely : 
nux  vomica  in  full  dose — say,  |  grain  four  times  a  day;  extract  of  physostigma  in  the 
dose  of  J  grain  four  times  a  day;  and  capsicum,  1  grain  three  or  four  times  a  day. 
Sometimes  it  is  well  to  combine  all  of  these  in  one  pill  or  capsule. 

In  the  way  of  digestants,  hydrochloric  acid  and  pepsin,  or  soda  and  pancreatin, 
and  taka-diastase  are  to  be  employed.  As  laxatives,  cascara  sagrada  and  aloes 
may  be  used,  1  grain  of  the  extract  of  the  former  and  -yq  grain  of  aloin  being  given 
once,  twice,  or  thrice  a  day,  according  to  the  obstinacy  of  the  bowels.  The  bitter 
fluidextract  of  cascara  given  in  capsules  is  the  best  preparation  to  employ. 

In  cases  in  which  the  symptoms  are  so  severe  as  seriously  to  impair  health  and 
comfort  and  even  the  chances  of  life,  operative  interference  is  indicated,  the  dis- 
placed organs  being  fixed  by  suturing.  Up  to  the  present  time  quite  a  number 
of  such  cases  have  been  operated  on  by  different  methods,  Duret,  in  a  case  in 
which  the  stomach  came  within  four  inches  of  the  pubis,  placed  stitches  through 


586  DISEASES  OF  THE  IXTESTINES 

the  lesser  curvature  of  the  stomach,  then  through  its  anterior  wall,  and  made  it 
fast  to  the  peritoneum  of  the  anterior  abdominal  wall.  Recovery  followed.  In 
other  cases  the  intestines  have  been  raised  by  taking  a  reef  in  the  mesentery. 
Rovsing  has  fastened  tiie  stomach  by  three  stout  sutures  ijassed  through  the  abdomi- 
nal wall  and  tiirough  the  outer  coats  of  the  stomach,  with  tiie  result  that  tlie  patient 
gained  forty  ])ounds  in  weight.  Beyea  has  taken  tucks  in  the  gastrophrenic  and 
gastrohcptic  ligaments,  with  good  results,  and  Webster  has  treated  a  large  number 
of  cases  by  excising  the  tissues  between  the  recti  muscles  and  then  stitching  the 
edges  of  these  muscles  together,  thereby  affording  support  for  the  abdominal 
contents. 

COLITIS. 

Acute  Colitis. — This  is  a  very  common  condition  and  follows  exposure  to  cold, 
particularly  if  the  abdominal  contents  have  been  the  parts  chiefly  deprived  of 
warmtli.  The  inflammatory  process  chiefly  aft'ects  the  lower  part  of  the  colon 
and  extends  to  the  rectum  as  well,  so  that  proctitis  is  developed.  The  primary 
hj'pereniia  of  inflammation  is  followed  by  an  increasing  secretion  of  mucus,  with 
the  throwing  off  of  dead  epithelial  cells  mixed  with  white  and  red  blood  corpuscles 
which  have  escaped  from  the  engorged  vessels.  If  the  process  is  ^•ery  severe,  a 
suppurati\-e  state  may  be  developed.  In  most  cases  the  tendency  is  to  rapid 
recovery,  but  if  the  inflammatory  process  persists,  one  of  two  conditions  may  be 
developed,  either  small  areas  of  necrosis  or  ulceration  occur,  or  there  is  deposited 
in  the  submucous  tissues  a  considerable  amount  of  connective  tissue,  which  may 
by  its  contraction  impair  the  function  of  the  glands  and  perhaps  narrow  the  calibre 
of  the  liowel. 

Symptoms. — The  symptoms  consist  in  severe  abflominiil  pain,  with  tenderness 
in  the  region  of  the  sigmoid  flexure,  and  in  frequent  movements  of  the  bowels,  which 
movements  soon  become  very  small,  so  that  they  finally  consist  in  nothing  but  a 
little  mucus,  which  is  passed  with  great  tenesmus. 

Treatment. — The  treatment  consists  in  the  use  of  absolute  rest  in  bed.  The 
application  of  a  mustard  plaster  over  the  sigmoid  flexure  and  the  injection  into 
the  bowel  of  4  ounces  of  starch-water,  with  40  grains  of  potassium  chlorate  and 
.'id  drops  of  deodorized  laudanum,  every  three  or  four  hours. 

Acute  infectious  colitis  has  already  been  considered  in  the  article  on  Dysentery. 

Mucous  Colitis. — Definition. — Under  the  name  of  mucous  colitis  physicians  meet 
with  a  condition  which  is,  next  to  dysentery,  the  most  common  affection  of  the 
colon,  and  in  temperate  zones  is  more  frequent.  It  affects  persons  suffering  from 
neurasthenia,  in  the  great  majority  of  cases,  and  is  met  with  in  the  overworked 
or  o\'erwrought  of  both  sexes,  but  most  frecjuently  in  women  of  from  twenty  to 
forty  years  of  age. 

The  affection  is  a  chronic  one,  often  lasting  for  several  years,  and  during  its 
continuance  causing  a  great  impairment  of  nutrition  and  much  general  ill-health. 
Not  rarely  the  irritable  state  of  the  colon  causes  constant  abdominal  distress. 
Severe  colicky  pain  is  also  present,  and  a  state  of  h,\]H'rperistaisis  of  the  small 
bowel  exists,  so  that  food  is  often  hurried  on  into  the  large  bowel  before  it  can  be 
digested  and  absorbed;  the  patient  suffering  from  lienteric  diarrhea,  not  because 
the  digestive  power  is  impaired,  but  because  the  food  does  not  remain  in  one  part 
of  the  small  bowel  long  enough  to  be  digested.  The  stools  are  not  as  frec)uent 
as  those  of  other  kinds  of  chronic  diarrhea. 

Mucus  in  considerable  amount  is  often  passed,  and  tliis  nuuiis  may  be  so  thick 
that  it  resembles  a  false  membrane,  whence  the  term  "mucomembranous  colitis." 
Not  rarely  the  jjatient  has  excessive  peristalsis  every  time  food  is  taken. 

Blood  is  almost  ne\cr  jiassed  unless  there  are  hemorrhoids  which  bleed.  There 
is  no  fe\er,  l)Ut  iimfound   mental  depressifin.     Areas  of  marked   tenderness  can 


COLITIS  587 

be  found  in  the  abdomen  on  palpation,  and  the  cutaneous  sensibility  is  often 
increased. 

Treatment. — The  treatment  of  mucous  colitis,  while  it  is  not  capable  of  producing, 
in  the  majority  of  cases,  very  marked  improvement  within  a  short  time,  is  neverthe- 
less successful  in  a  large  proportion  of  patients,  pro\ided  that  it  is  carefully  and 
persistently  carried  out,  and  if  the  patient's  mode  of  life  and  her  diet  is  arranged 
in  such  a  way  as  to  be  favorable  in  their  efi'ects.  As  the  majority  of  these  patients 
have  been  subjected  to  nervous  stress  and  are  neurasthenic,  it  is  essential  that  they 
shall  be  subjected  to  the  rest  cure,  in  order  that  by  re-establishing  nervous  tone 
and  ecjuilibrium  a  normal  intestinal  peristalsis  and  normal  digestive  functions  may 
be  established.  Without  rest  in  cases  of  this  character  other  treatment  is  commonly 
useless. 

In  order  that  the  greater  part  of  digestion  and  assimilation  may  be  carried  out 
in  the  stomach  and  duodenum,  foods  easy  of  digestion  and  readily  assimilated 
should  be  given,  and  should  consist  chiefly  in  proteids,  that  is,  broiled  or  roasted 
meats.  Green  vegetables  and  fatty  foods  should  not  be  allowed.  Easily  digested 
starches,  such  as  rice  and  cornstarch,  may  be  given,  provided  that  pancreatin 
or  taka-diastase  is  given  with  them  to  hurry  their  digestion.  All  Acgetable  foods 
which  leave  a  bulky  residue  should  be  forbidden,  as,  for  example,  oatmeal  and 
wheaten  grits.  The  patient  should  take  liquids  in  small  quantities  frequently, 
rather  then  in  large  quantities  at  long  intervals,  and  should  avoid  taking  liquids 
with  her  food.  She  should  also  avoid  taking  liquids  before  going  to  bed  at  night, 
as  not  infrequently  liquids  taken  at  this  time  seem  to  lie  in  the  bowel  unabsorbed, 
and  on  the  assumption  of  the  erect  posture  by  the  patient  in  the  morning  a  morning 
diarrhea  is  developed. 

Continuous  counter-irritation,  produced  by  frequently  repeated  applications 
of  tincture  of  iodine  over  the  whole  abdominal  surface,  should  be  maintained,  and 
if  there  is  much  tenesmus  a  suppository  containing  5  to  10  grains  of  iodoform 
may  be  inserted  into  the  rectum  in  the  morning  after  a  moA'ement  of  the  bowels, 
not  only  for  its  local  counter-irritant  effect,  but  for  the  beneficial  influence  of  the 
iodine,  when  absorbed,  upon  the  catarrhal  condition  of  the  bowel.  In  some  cases 
where  the  colon  is  chiefly  at  fault,  clysters  of  1  or  2  quarts  of  hot  normal  saline 
solution,  or  of  pure  w^ater  containing  20  grains  of  sulphocarbolate  of  zinc  to  the 
pint,  should  be  gently  given,  care  being  taken  that  the  fluid  does  not  run  in  so 
rapidly  as  to  irritate  the  bowel.  The  patient  should  lie  on  the  left  side  until  the 
sigmoid  flexure  is  filled,  then  turn  on  the  back  while  the  transverse  colon  is  filled, 
and  perhaps  after  this  turn  on  the  right  side  with  the  hope  that  the  fluid  will  enter 
the  ascending  colon. 

In  those  cases  in  which  there  is  a  history  of  repeated  mild  attacks  of  appendicitis, 
or  of  pain  in  the  right  iliac  region,  appendectomy  sometimes  produces  excellent 
results,  the  chronic  colitis  being  due  to  the  infection  of  the  colon  by  small  quantities 
of  pus  which  escape  from  the  appendix.  Probably  the  enforced  rest  which  follows 
an  operation  for  the  removal  of  the  appendix  also  is  advantageous  in  producing 
a  cure  in  these  cases.  When  there  is  relaxation  of  the  belly  wall  and  enteroptosis 
the  patient  should  wear  a  supporting  belt. 

Follicular  and  Croupous  Colitis. — Follicular  colitis,  sometimes  called  nodular 
colitis,  is  a  form  of  inflammation  of  the  colon  characterized  by  marked  swelling 
of  its  solitary  glands,  or  lymph  nodes,  rendering  these  structures  unusually  pro- 
tuberant. After  this  primary  stage  of  enlargement  necrosis  and  sloughing  ensue, 
leaving  round  ulcers,  which  are  frequently  numerous.  By  the  failure  of  these  to 
heal  the  more  chronic  state  of  ordinary  ulcerative  colitis  is  de-\'eloped. 

Ulceration  of  the  colon  is,  of  course,  also  due,  in  many  cases,  to  the  typhoid 
bacillus,  the  tubercle  bacillus,  the  Entameba  dysenterice,  and  sometimes  to  infection 
by  Shiga's  bacillus.     It  also  develops  as  a  terminal  infection  in  some  cases  of  chronic 


588  DISEASES  OF  THE  INTESTINES 

renal  disease.  Ulcerative  processes  in  the  intestines  arc  very  common  in  the  insane, 
and  they  have  been  found  associated  with  locomotor  ataxia. 

Under  the  name  of  crovpous  colitis,  a  condition  exists  in  whicii  tiic  nuicous 
membrane  of  tlie  colon  becomes  engorged  and  coated  with  a  false  membrane, 
and  the  underlying  tissues  becoming  filled  with  dead  leukocytes  and  fibrin.  As 
in  the  small  bowel,  so  here,  this  false  membrane  may  be  widely  diffused  or  occur 
in  patches.  After  the  formation  of  the  membrane  the  disease  either  disappears 
by  the  exfoliation  of  necrotic  material  or  the  deeper  coats  of  the  bowel  are  affected, 
so  that  areas  of  submucous  tissue  become  necrotic  and  are  passed  in  the  stools  as 
sloughs.  At  the  site  of  these  sloughs  healing  by  cicatrization  develops,  or  the 
process  extends  still  more  deeply  to  the  peritoneum  and  causes  serious  secondary 
lesions.  In  this  way  is  formed  a  necrotic  colitis,  the  ulcerated  areas  being  gangren- 
ous in  appearance  and  of  great  size.  A  large  number  of  pathogenic  organisms  have 
been  found  in  the  bowel  in  such  cases. 

Treatment. — This  consists  in  following  a  plan  identical  with  that  advised  for 
mucous  colitis,  and  in  addition  in  giving  an  injection  of  nitrate  of  silver  in  the 
strength  of  40  grains  to  the  cpiart  each  evening  in  place  of  the  normal  saline  already 
spoken  of.     This  should  not  be  retained. 

Pseudomembranous  Colitis. — This  is  a  condition  in  which  not  only  the  large 
intestine,  l)ut  the  small  bowel  as  well  is  affected  by  a  superficial  necrosis,  which 
may  be  diffuse,  but  is  more  commonly  distributed  in  patches.  The  process  closely 
resembles  croupous  colitis,  and  by  some  writers  the  two  conditions  are  held  to  be 
identical.  The  false  membrane  consists  of  dead  epithelium,  mucus,  fibrin,  and 
white  blood  cells  which  have  passed  out  of  the  bloodvessels.  In  some  cases  the 
false  membrane  is  almost  purely  mucin-bearing  and  quite  fibrin-free;  the  latter 
element  is  only  exceptionally  abundant.  Not  rarely  the  submucous  tissues  may 
be  infiltrated  by  serum  and  leukocytes. 

Pseudomembranous  enteritis  develops  in  the  course  of  a  number  of  the  acute 
infectious  diseases,  in  pyemia  and  septicemia,  in  persons  \vho  suff'er  from  chronic 
Bright's  disease,  and  occasionally  after  the  taking  of  poisons  which  cause  gastro- 
intestinal irritation.  It  is  important  to  recall  the  fact  that  this  pseudomembranous 
condition  is  not  diphtheritic  in  the  sense  that  it  is  due  to  the  Klebs-Loefffer  liacillus, 
and  that  the  proportion  of  fibrinous  exudate  is  far  less  than  in  the  memlirane  of 
that  specific  disease  called  diphtheria.  Perhaps  the  most  common  cause  of  this 
lesion  is  the  ingestion  of  poisonous  quantities  of  arsenic,  for  this  drug  is  eliminated 
by  the  mucous  membrane  of  the  alimentary  canal  and  in  the  process  a  necrosis  of 
the  lining  epithelium  takes  place. 

SPRUE  (psmosis). 

Definition. — Sprue  {Atrophic  Enteritis  of  the  Tropics)  is  not  a  distinct  morbid 
entity;  it  is  but  a  terminal  condition  of  many  devitalizing  and  depressing  factors. 
Sprue  may  be  defined  as  a  chronic  catarrhal  inflammation  of  the  entire  alimentary 
tract  tending  ultimately  to  most  extensive  atrophy  of  the  gastro-intestinal  glandu- 
lar structures,  characterized  clinically  by  three  cardinal  symptoms — sore  mouth, 
flatulency,  and  diarrhea. 

Sprue  is  a  disease  of  the  entire  tropical  world.  The  Malayan  Archipelago, 
particularly  the  Philippine  Islands,  South  China,  Amoy,  Ceylon,  Java,  and  the 
Malayan  Peninsula  are  the  regions  of  its  greatest  development. 

It  is  not  seen  in  subtropical  or  temperate  zones,  imlcss  in  imported  cases,  with 
the  exception  of  Japan  and  northern  China.  It  has  been  known  by  many  names, 
all  of  them  referring  to  one  or  another  of  the  pecuhar  clinical  manifestations  of 
the  disease.  Thus,  it  has  been  called  "diarrhea  alba,"  "aphthie  tropica-,"  "Ceylon 
sour  moutii,"  and  "white  flux."     The  name  sprue  was  given  to  it  by  tiie  Dutch, 


SPRUE  589 

wlio  found  it  a  A'eritable  plague  in  their  Javanese  possession.  Since  the  United 
States  has  acquired  colonies  in  the  sprue  region,  imported  cases  have  become  fairly 
numerous  throughout  this  country,  and  their  consideration  is  of  great  interest  to 
the  general  practitioner. 

Etiology. — Extensive  studies  of  the  disease  have  failed  to  show  any  specific 
etiological  factor.  There  is  some  argument  whether  sprue  should  be  consiflered  a 
specific  disease  or  whether  it  should  be  considered  as  a  terminal  state  following 
other  lesions.  Sambon  maintains  the  former.  Extensive  studies  l)y  army  surgeons 
in  Manila  show  that  the  latter  \'iew  is  the  correct  one.  The  disease  commonh' 
develops  in  the  tropics,  but  may  lie  dormant  for  years  after  the  return  of  the  colonist 
to  his  home  in  the  temperate  zone. 

The  conditions  that  predispose  to  the  development  of  sprue  are  the  following: 
The  large  majority  of  cases  follow  chronic  amebic  dysentery  and  its  sequelae, 
chronic  ulceration  of  the  colon  and  abscess  of  the  liver,  with  prolonged  suppuration. 
Following  dysentery  the  intestinal  parasites,  and  chief  of  these  the  uncinaria,  are 
common  antecedents  of  sprue.  Next  is  the  general  deterioration  in  chronic  malarial 
poisoning,  and  lastly  syphilis  is  a  cause.  To  these  must  be  added  the  physical 
deterioration  incident  to  prolonged  residence  in  liot  climates,  e^-en  when  no  acute 
illness  is  sufi'ered,  and  the  following  depressing  conditions:  childbirth  and  mis- 
carriage, chronic  disease  of  the  kidnej's,  suppurating  lesions  anywhere,  excessive 
fatigue,  long  marches,  and  prolonged  campaigns.  Some  writers  report  the  develop- 
ment of  sprue  as  following  the  prolonged  administration  of  iodides  and  mercury. 
Numerous  organisms  have  been  described  as  the  cause  of  sprue  and  several  parasites, 
particularly  the  strongyloides.  Amebse  are  almost  constantly  found  and  various 
bacilli  of  the  typho-colon  group,  but  these  must  all  be  considered  remnants  of  the 
preceding  pathological  condition  rather  than  direct  causes  of  the  disease  itself. 

Pathology. — Postmortem  examination  shows  complete  loss  of  subcutaneous 
and  mesenteric  fat.  The  tissues  and  cavities  are  extremely  dry;  the  small  intes- 
tine presents  extreme  thinning  of  its  walls  with  atrophy  of  the  mucosa  and,  in 
some  cases,  entire  destruction  of  the  glandular  structures.  The  serous  coat  is 
normal.  Swelling  and  ulceration  of  Peyer's  patches  are  seen,  and  in  many  cases 
the  colon  presents  the  usual  appearances  of  recent  or  present  dysentery.  Paren- 
chymatous changes  occur  in  the  pancreas,  liver,  and  kidneys,  and  occasional  areas 
of  fatty  degeneration  are  present. 

Symptoms. — Sprue  is  essentially  a  very  chronic  disease.  The  average  duration 
is  from  one  to  two  years,  although  cases  lasting  ten  years  or  more  are  not  by  any 
means  unusual.  The  patient  is  emaciated  and  anemic.  The  complexion  is  muddy 
and  sallow.  There  is  great  lassitude  and  weakness,  and  mental  irritabilitj-  with 
pronounced  disinclination  for  physical  and  mental  labor.  The  disease  passes 
through  numerous  stages  of  amelioration  and  numerous  recrudescences,  but  its 
general  tendency  is  always  downward.  The  principal  symptoms  of  sprue  are  sore 
viouth,  diarrhea,  and  flatulence. 

The  mouth  lesio7is  of  sprue  are  constant  and  striking.  On  examination  the 
tongue  is  found  unusually  clean.  The  organ  is  small,  pointed,  and  somewhat 
yellowish.  Along  the  dorsum  of  the  tongue,  along  its  edges,  and  on  the  under 
side,  particularly  along  the  frenum,  there  are  numerous,  fine,  minute  ulcers,  with 
a  thin,  aphthous  pellicle.  These  aphthous  spots  may  also  be  present  on  the  uvula 
and  palate,  ^^ery  commonly  the  tongue  is  co\'ered  with  very  superficial  erosions 
from  one-eighth  to  one-fourth  of  an  inch  in  diameter,  frequently  coalescing  and 
resulting  in  a  serpiginous  appearance.  Where  these  marked  lesions  are  temporarily 
absent,  the  tongue  still  has  an  unusually  clean,  dry,  glazed  appearance,  and  looks 
very  much  as  though  it  had  been  recently  varnished.  The  condition  in  older 
patients  may  be  very  much  accentuated  and  extensive  fissures  may  develop.  The 
patient  complains  of  soreness  that  may  be  limited  only  to  the  tongue,  or  may 


590  DISEASES  OF  THE  INTESTINES 

invoKe  the  palate  or  uvula,  or  the  entire  mouth.  He  particularly  eomjjlains 
of  huniiiif;  or  a  stin^ins  pain  on  taking  salt  or  highly  seasoned  food.  Occasionally 
the  pain  is  also  present  on  deglutition,  and  the  progress  of  the  food  bolus  on  its 
way  to  the  stomach  is  indicated  hy  a  burning  and  stiiifiiur/  pain  in  tlir  (/iillrt,  showing 
that  the  esophagus  is  in  the  same  condition  as  the  mouth.  Naii-^ea  and  vomitinq 
are  sometimes  present  in  advanced  cases,  the  vomiting  coming  on  without  reference 
to  the  time  of  taking  food.  Eructations  and  waterhrash  are  present;  the  appetite 
is  very  variable,  sometimes  being  entirely  absent,  at  other  times  ravenous. 

Flatulence  is  quite  marked.  The  patient  is  swollen  until  the  abdomen  is  tense 
and  drum-like.  In  this  condition  the  appearance  of  the  very  much  emaciated 
figure,  with  extremely  thin  arms  and  legs,  and  large,  inflated  abdomen,  is  very 
characteristic.  The  flatulence  is  always  aggravated  by  taking  food  and  is  accom- 
panied by  a  constant  sense  of  oppression  and  a  gnawing  and  burning  pain  in  the 
stomach. 

Diarrhea  is  the  most  distinctive  and  constant  symptom.  There  may  be  only 
one  or  two  mo\'ements  daily  or  there  may  be  as  many  as  ten  or  twelve.  They  are 
usually  passed  without  pain;  they  A'ary  very  much  in  their  character,  but  are 
nearly  always  liquid  or  semiliquid.  They  are  frothy,  white,  and  ha^•e  a  fetid, 
mouse-like  odor.  Manson  describes  them  as  looking  like  recently  stirred  white- 
wash. They  are  usually  remarkably  large.  Their  reaction  is  commonly  acid. 
Microscopically  they  are  found  to  contain  bowel  structure,  a  few  red  blood  cells, 
and  intestinal  parasites,  of  which  amebse  are  the  most  frequent. 

As  the  disease  advances  emaciation  and  asthenia  become  extreme.  The  skin 
is  dry  and  scurfy,  the  patient  is  unable  to  assimilate  or  retain  food,  and,  in  many 
instances,  he  involuntarily  abstains  from  it  on  account  of  the  se\-ere  pain  in  the 
mouth  and  throat.  In  all  marked  cases  there  is  secondary  anemia,  the  red  blood 
corpuscles  being  reduced  as  low  as  1,000,000,  with  some  degree  of  poikilocytosis 
and  no  leukocytosis. 

Diagnosis. — Diagnosis  presents  no  difficulties,  when  the  existence  of  such  a 
disease  as  sprue  is  known  and  its  cardinal  symptoms  are  remembered.  Incomplete 
cases  in  which  one  or  the  other  symptom  may  predominate  or  be  absent  may  give 
rise  to  some  difficulties. 

Sprue  in  particular  must  not  be  confounded  with  chronic  dysentery,  although 
it  is  difficult,  in  cases  where  sprue  develops  from  dysentery,  to  definitely  mark 
the  period  where  the  one  disease  begins  and  the  other  ends. 

Prognosis. — If  treatment  is  instituted  before  the  atrophy  of  the  bowel  is  too  far 
a(hanccd,  cure  is  the  rule.  If,  however,  so  much  of  the  secreting  surface  of  the 
bowel  is  destroyed  as  to  make  assimilation  impossible,  death  is,  of  course,  inevitable. 

Treatment. — Treatment  consists  in  putting  the  patient  on  absolute  milk  diet. 
He  should  preferably  be  kept  in  lied  and  milk  administered  in  small  feedings. 
The  quantity  is  increased  as  rapidly  as  possible,  the  mouth  synijitoms  and  the 
appearance  of  unchanged  milk  in  the  bowel  movements  being  the  inrlex  as  to  the 
quantity  to  he  taken.  If  there  be  any  increase  in  the  amount  of  soreness  of  the 
mouth,  the  milk  must  be  reduced  for  a  time  and  later  gradually  increased,  until 
the  patient  is  taking  from  four  to  six  quarts  daily.  This  regimen  must  be  persisted 
in  from  four  to  six  weeks  after  the  mouth  symptoms  disappear  and  the  bowel 
movements  become  solid.     Then  soft  diet  should  be  resumed  very  carefully. 

Where  milk  cannot  be  taken,  pure  meat  diet  may  be  used  or  an  exclusive  diet 
of  meat-juice.  Success  has  also  attended  the  exclusive  use  of  a  fruit  diet.  Recent 
observations  have  shown  the  value  of  fruit,  particularly  of  berries,  in  the  treatment 
of  sprue  as  well  as  chronic  dysentery.  ^Nlanson  reports  the  case  of  a  man  over 
fifty  years  of  age,  at  which  time  of  life  the  prognosis  in  cases  of  sprue  is  exceedingly 
grave.  The  patient  was  first  treated,  with  little  benefit,  with  milk  diet  and  other 
special  diets;  finally  the  patient  was  put  on  a  diet  of  strawberries.     The  stools 


DILATATION  OF  THE  COLON  591 

at  once  improved  and  the  patient  was  soon  restored  to  health.  This  was  not  the 
only  case  in  which  recovery  followed  the  use  of  strawberries.  jNIanson  considers 
this  a  decided  advance  in  the  treatment  of  sprue.  Medicinally  salol  and  Dover's 
powder  may  be  given  for  control  of  the  diarrhea.  For  their  tonic  and  reconstructive 
properties  iron  and  arsenic  should  be  used.  These  drugs  have  been  shown  to  be 
of  particular  advantage  in  this  disease  when  used  by  hypodermic  injection. 


DILATATION  OF  THE  COLON. 

Hale  White  places  dilatation  of  the  colon  in  four  divisions.  The  first  of  the.se  is 
that  type  of  dilatation  which  is  due  to  acute  distention  from  the  accumulation  of 
gas.  This  is  not  rarely  met  with  in  severe  infectious  diseases,  as  in  the  pneumonia 
of  drunkards  and  in  severe  cases  of  typhoid  fever  with  toxemia.  The  distention 
of  the  colon  under  these  circumstances  often  interferes  with  the  action  of  the 
lungs  and  heart  by  mechanical  pressure  against  the  diaphragm.  The  zone  of  the 
abdomen  between  the  umbilicus  and  the  ensiform  cartilage,  and  between  the  right 
and  left  hypochondrium  is  distinctly  bulging  and  tympanitic  on  percussion.  Tym- 
panites of  this  kind  possesses  a  double  significance:  first,  it  is  an  evil  in  itself  by 
reason  of  the  pressure  which  it  produces,  and,  second,  its  presence  is  evil  in  that  it 
indicates  a  lowered  vitality  and  an  inability  of  the  intestine  to  expel  gas  which 
otherwise  would  not  be  allowed  to  accumulate,  and  which  in  health  would  not  form. 

The  treatment  of  this  form  of  tympanites  consists  in  the  application  of  a  hot 
turpentine  stupe  over  the  abdomen  and  the  injection  into  the  rectum  of  6  ounces 
of  milk  of  asafetida  containing  1  drachm  of  oil  of  turpentine,  the  two  fluids  being 
thoroughly  mixed  in  order  to  prevent  the  turpentine  from  damaging  the  bowel. 
In  other  cases,  where  it  is  considered  advisable  to  stimulate  the  circulation  at  the 
same  time  that  the  gas  is  expelled,  and  when  it  is  feared  that  the  turpentine  may 
be  absorbed  and  irritate  the  kidneys,  excellent  results  will  follow  the  use  of  this 
quantity  of  milk  of  asafetida  with  the  addition  of  |  to  1  ounce  of  Hoffmann's 
anodyne.  Pituitrin  may  be  given  hypodermically.  A  few  years  ago  it  was  suggested 
by  Ogle,  and  others,  that  puncture  of  the  bowel  through  the  abdominal  wall  should 
be  performed  in  those  cases  in  which  the  gas  could  not  be  dislodged  and  when  it 
was  causing  dangerous  pressure.  While  this  adA'ice  is  theoretically  good,  practically 
it  is  of  little  value.  I  have  tried  it  in  a  number  of  instances,  and  it  has  either  failed 
entirely  or  has  permitted  but  a  small  quantity  of  gas  to  escape  from  a  single  knuckle 
of  intestine,  the  bowel  contracting  in  such  a  manner  as  to  prevent  most  of  the  gas 
from  finding  its  way  to  the  aspirating  needle.  If  a  fine  needle  is  used  but  little 
gas  can  escape,  while  if  a  coarse  needle  is  emplo.yed  a  sufficiently  large  puncture 
may  be  made  in  the  bowel  to  permit  of  the  escape  of  gas  or  liquid  into  the  peritoneal 
cavity  after  the  needle  is  withdrawn. 

When  obstinate  constipation  is  present,  and  the  sigmoid  flexure  is  filled  with 
feces,  an  ordinary  soapsuds  enema,  followed  by  1  ounce  of  sulphate  of  magnesium 
in  4  ounces  of  water  and  2  ounces  of  glycerin,  may  be  injected. 

The  second  group  of  cases  depends  upon  the  accumulation  of  foreign  bodies. 
These  are  so  rare  in  human  beings  as  to  be  scarcely  worthy  of  consideration.  Occa- 
sionally, however,  the  dilatation  may  be  due  to  the  presence  of  enormous  gallstones 
which  have  been  still  further  increased  in  size  by  fecal  additions.  Such  cases  are 
to  be  treated  by  operation. 

The  third  form  is  that  due  to  obstruction  of  the  lower  part  of  the  colon,  so  that 
fecal  accumulation  and  secondary  ulceration  may  occur.  The  obstruction  may 
be  due  to  volvulus,  to  a  band  or  to  a  coil  of  adherent  small  intestine.  It  is  also 
due  to  stricture  or  to  syphilitic,  cicatricial,  or  neoplastic  growths,  particularly 
cancer.     These  cases  are  very  rare,  and  the  treatment  is  operative. 


502  D/SEASI<:S  OF  THE  PKRITOSF.r M 

Finally,  in  tlie  fourth  type  we  find  cases  of  so-called  idiopathic  dilatation  of 
the  colon,  which  are  also  exceedingly  rare.  Many  years  ago  Formad  rc[)orted  an 
extraordinary  case  of  this,  character,  and  Hale  White  has  collected  several  from 
iiteratnre.  In  most  of  these  instances  the  enormously  dilated  colon  is  loaded  with 
arcumvilatcd  fecal  matter. 

Treatment  can  be  of  little  value  in  the  last  type  of  cases,  for  a  congenital  defect 
in  the  muscular  and  other  tissues  forming  the  wall  of  the  intestine  is  responsible 
for  the  condition.  Relief  may,  perhaps,  be  given  by  making  an  artificial  anus  at 
the  sigmoid  flexure. 

Membranous  Pericolitis. — -Closely  associated  witli  these  types  of  cases  are  those 
in  which  much  abdominal  discomfort  arises  from  membranous  pericolitis  or  Jack- 
son's membrane.  Whether  this  is  a  congenital  defect  or  the  result  of  inflammation 
is  not  known.  The  false  membrane  runs  across  the  ascending  colon  to  the  proximal 
part  of  the  transverse  colon.  It  tends  to  cause  stasis  in  the  ileum  as  well  as  in 
the  large  bowel  and  often  causes  acute  angulation  of  tiie  hepatic  flexure.  Its 
diagnosis  can  only  be  made  by  careful  fluoroscopic  examination  after  the  taking 
of  bismuth  or  by  exploratory  operation. 

Adhesions,  Displacements,  and  Redundancy  of  the  Colon. — During  recent  years 
medical  literature  has  teemed  with  articles  on  these  conditions  chiefly  written 
by  surgeons.  There  can  be  no  doubt  that  adhesions  in  the  neighborhood  of  the 
caput  coli  often  are  the  cause  of  distressing  symptoms  and  if  they  can  be  broken 
up  by  surgical  interference,  and  can  be  prevented  from  forming  again  tlie  patient 
is  greatly  benefited  by  operation.  This  holds  true  in  some  cases  of  adhesion  else- 
where. Concerning  displacements  it  may  be  said  it  is  questionable  if  they  are 
really  abnormalities,  for  the  more  we  study  .r-ray  pictures  of  the  intestines  the 
more  sure  are  we  that  they  move  about  over  a  wide  area  without  indicating  that 
their  function  is  impaired.  Little  can  be  done  for  them  surgically  although  much 
is  attempted.  (See  Enteroptosis).  As  to  redundancy  here  again  it  is  questionable 
if  surgery  should  be  resorted  to.  We  do  not  know  as  yet  how  many  people  have 
sigmoid  flexure  which  are  longer  than  they  should  be  without  symptoms  to  justify 
us  in  operating,  because  a  given  patient  with  abnormal  symptoms  is  found  where  a 
sigmoid  is  an  inch  or  two  longer  than  the  anatomical  average.  There  is  no  more 
reason  for  operating  on  a  sigmoid  flexure,  because  instead  of  its  being  eight  to  ten 
inches  long  it  is  found  to  be  twelve  inches  long,  than  there  is  for  operating  on  a 
spermatic  cord  because  in  a  given  case  one  testicle  hangs  lower  than  the  other  to 
a  degree  greater  than  the  average.  Some  cases  are  lienefited  by  operative  inter- 
ference, many  cases  are  not.  As  my  colleague  Gibbon  has  well  said,  in  discussing 
this  subject,  "  h.  great  many  things  in  surgery  are  easily  done  that  ought  not  be 
done." 


DISEASES  OF  THE  PERITONEUM. 

ACUTE  PERITONITIS. 

Definition. — Peritonitis  is  a  term  applied  to  inflammation  of  the  serous  membrane, 
tlic  peritoneum,  lining  the  abdominal  cavity  and  covering  in  its  reflections  the 
organs  which  this  cavity  contains. 

Etiology. — Within  comparati\-ely  recent  years  it  was  generally  considered  that 
acute  jieritonitis  was  usually  idiopathic,  but  with  an  increasing  knowledge  of 
the  methods  by  which  infection  occurs,  we  have  come  to  learn  that  all  cases  of 
peritonitis  are  due  to  an  infection  which  has  come  to  the  peritoneum  through 
primary  disease  or  the  presence  of  infecting  organisms  in  other  organs.     Nearly 


ACUTE  PERITONITIS  593 

half  a  century  ago  Ilaberslion  t'ouiHl,  in  an  analysis  of  5(J1  autopsies  after  death 
from  peritonitis,  that  over  50  per  cent,  resulted  from  some  primary  disease  not 
involving  the  peritoneum,  and  Kelynack,  in  studying  124  cases  of  acute  peritonitis, 
found  that  everyone  of  them  developed  the  disease  as  a  secondary  lesion. 

It  may  be  true  that  exposure  to  cold  and  severe  strain  are  productive  of  jwritoni- 
tis,  but  if  this  is  the  case  it  is  only  because  these  influences  diminish  the  vital 
resistance  of  the  peritoneum. 

The  two  great  causes  of  peritonitis  are  appendicitis  and  disease  of  the  Fallopian 
tubes.  In  both  of  these  instances  it  is  due  to  the  extension  of  an  inflammatory 
process,  which  in  turn  arises  chiefly  from  the  spread  of  infecting  micro-organisms. 

The  method  by  which  pathogenic  micro-organisms  are  enabled  to  pass  through 
the  walls  of  an  inflamed  appendix  has  already  been  spoken  of  in  the  article  on 
Appendicitis,  and  it  is  worthy  of  note  that  any  cause  which  seriously  interferes  with 
the  health  of  even  a  small  part  of  the  intestinal  wall  may  permit  the  escape  of 
micro-organisms  into  the  general  peritoneal  cavity.  Of  the  micro-organisms  which 
commonly  produce  peritonitis  under  these  circumstances,  the  Bacillus  coli  com- 
miinw  is,  perhaps,  the  most  frequent,  but  a  large  number  of  other  micro-organisms 
are  often  present,  and  there  is  every  reason  to  believe  that  they  are  active  in  the 
production  of  the  inflammatory  process.  Next  to  the  Bacillus  coli  communis 
stands  the  Streptococcus  and  the  Pneumococcus,  the  Staphylococcus  albus,  and  the 
Bacillus  pyocyaneus.  The  Bacillus  aerogenes  capsulatus  is  also  not  infrequently 
present.  Occasionally  the  Bacilhts  typhosus  seems  to  be  responsible  for  the 
process. 

When  infection  takes  place  by  means  of  the  Fallopian  tubes,  the  peritonitis 
may  be  due  to  the  gonococcus;  but  in  the  majority  of  instances  the  inflammatory 
process  is  not  due  to  this  organism,  but  to  the  streptococci  or  staphylococci  which 
are  associated  with  it;  the  presence  of  which,  perhaps,  enables  the  gonococcus  to 
become  pathogenic  in  this  serous  membrane.  Bumm,  however,  believes  that 
the  escape  of  the  gonococcus  into  the  peritoneum  is  not  usually  follewed  by  evil 
results.  On  the  other  hand,  pure  cultures  of  the  gonococcus  have  beon  obtained 
from  the  abdominal  cavity  in  two  cases  of  acute  general  peritonitis  by  Young  and 
Gushing. 

Subacute  or  chronic  peritonitis  is  often  due  to  the  Bacillus  tuberculosis  and  acute 
miliary  tuberculosis  of  the  peritoneum,  which  is  usually  looked  upon  as  a  form  of 
acute  peritonitis,  is  necessarily  the  result  of  the  infection  by  the  tubercle  bacillus. 
In  the  acute  peritonitis  following  labor,  the  so-called  septic  peritonitis,  the  strepto- 
coccus is  the  chief  factor.  Cases  of  peritonitis  due  to  the  pneumococcus  have  been 
frequently  recorded. 

While  we  know,  therefore,  that  peritonitis  in  its  acute  forms  is  a  secondary 
infection,  it  must  not  be  forgotten  that  in  a  very  large  number  of  cases  the  peri- 
toneum is  capable  of  resisting  infection  and  of  destroying  micro-organisms  which 
may  gain  access  to  it.  Indeed,  the  vital  resistance  of  this  membrane  when  in 
health  is  very  remarkable,  and  a  number  of  investigators  have  shown  that  it  is 
possible  to  place  in  the  peritoneal  cavity  considerable  quantities  of  septic  material 
without  serious  result,  provided  this  serous  membrane  is  not  subjected  at  the  same 
time  to  insult  whereby  its  vitality  is  decreased. 

Certain  diseases  which  greatly  decrease  vital  resistance  greatly  increase  the 
susceptibility  to  peritonitis,  as,  for  example,  typhoid  fever,  Bright's  disease,  and 
advanced  arteriosclerosis. 

Peritonitis  in  children,  of  course,  develops  as  a  result  of  the  causes  already 
enumerated.  It  also  is  sometimes  seen  in  young  infants  suffering  from  congenital 
syphilis,  and  in  those  who  have  intestinal  obstruction.  In  still  other  cases  it 
follows  infection  of  the  umbilicus  after  birth.  In  still  others  it  is  due  to  an  extension 
of  infection  in  empyema,  and  a  few  cases  are  on  record  in  which  sewer-gas  poisoning 
38 


594  DISEASES  OF  THE  PERITONEUM 

has  seemed  to  produce  an  epidemic  of  this  character  amoiii;  children  exposed  to  its 
influence. 

Strumpell  states  that  a  form  of  k)caiized  peritonitis  in  the  left  groin  is  occasionally 
met  with  in  cliildren,  that  it  is  prone  to  be  purulent,  and  that  the  pus  usually 
escapes  throiiu'li  tlie  rectum. 

Pathology  and  Morbid  Anatomy.  —The  characteristic  appearance  of  tlie  peritoneum 
in  primary  acute  j)critonltis  is  liyperemia,  with  a  diminution  in  the  normal  glossiness 
of  the  membrane  involved.  This  is  followed  by  a  more  or  less  copious  fibrinous 
exudate,  which  may  be  well  distributed,  or  appear  chiefly  in  patches,  upon  the 
parietal  and  visceral  peritoneum.  In  many  cases  there  is  but  little  fluid  exudate, 
the  small  ciuantities  present  being  found  in  pockets  formed  by  the  coils  of  intestine 
which  become  agglutinated.  In  other  instances  the  fluid  portion  of  the  exudation 
is  very  much  more  copious,  and  the  quantity  of  fibrin  thrown  out  is  also  of  consider- 
able amount,  so  that  it  is  not  only  found  well  distributcfl  over  the  surface  of  the 
membrane,  but  free  flakes  may  be  found  floating  in  the  serous  exudate  as  well. 

When  the  infection  is  due  to  pyogenic  micro-organisms,  and  particularly  in 
those  cases  in  which  the  vital  resistance  of  the  patient  is  very  low,  a  septic  peritoni- 
tis speedily  develops.  It  is  usually  very  diffuse  in  such  cases,  the  entire  peritoneum 
being  involved.  The  cjuantity  of  exudate  is  moderately  large,  and  is  often  offensive 
in  character,  forming  what  has  been  called  "putrid  peritonitis."  In  other  cases 
when  the  vital  resistance  is  not  so  depressed,  the  presence  of  pyogenic  micro-organ- 
isms produces  a  peritonitis  in  which  pus  alone  is  present.  This  form  of  peritonitis 
may  be  widespread,  but  is  often  localized — the  so-called  loculated  or  circumscribed 
peritonitis  or  peritoneal  abscess — nature  being  able  to  wall  oft'  the  area  of  acute 
infection  by  a  plastic  exudate,  which  prevents  the  infection  from  becoming  well 
distributed  throughout  the  peritoneum.  In  those  cases  of  septic  peritonitis  in 
which  death  occurs  early,  the  physician  may  be  surprised  on  opening  the  abdomen 
at  autopsy  to  find  that  but  little  change  has  taken  place  in  the  appearance  of  the 
peritoneum  and  its  contents.  Save  for  some  duskiness  of  the  peritoneum  and  the 
presence  of  sanious  fluid,  the  abdominal  contents  may  seem  to  the  naked  eye  to 
be  but  little  altered. 

Occasionally  we  meet  with  what  is  known  as  hemorrhagic  peritonitis,  which 
may  follow  severe  septic  infection,  and  in  cancerous  and  tuberculous  cases,  with 
ulceration,  the  fluid  in  the  abdominal  cavity  may  be  blood-stained. 

Localized  peritonitis,  such  as  has  already  been  referred  to,  is  most  frecpiently 
found  in  connection  with  diseases  of  the  pelvic  organs  in  women  and  with  cases  of 
appendicitis.  It  may  be  considered  the  rule  rather  than  the  exception,  for  the 
disease  to  be  limited  by  an  inflammatory  exudate  in  such  cases.  Other  forms 
of  localized  peritonitis  which  are  not  so  frequently  met  with  depend  upon  an  exten- 
sion of  infection  from  the  gall-bladder,  from  perforation  or  infection  through  a 
gastric  ulcer,  and  occasionally  we  find  a  suppurative  peritonitis  in  the  lesser  peri- 
toneum as  the  result  of  disease  of  the  pancreas  or  fat-necrosis.  In  other  instances 
tills  condition  arises  as  the  result  of  renal  calculus  and  nephritic  abscess. 

Symptoms. — There  are  few  diseases  which,  when  well  developed,  produce  a 
train  of  symptoms  more  characteristic  than  are  those  of  acute  peritonitis.  This 
holds  true,  however,  only  when  the  disease  is  well  advanced,  and,  indeed,  is  so 
severe  that  there  is  grave  doubt  as  to  the  patient's  recovery.  In  most  cases  of 
peritonitis,  when  the  physician  is  first  called  to  the  patient,  severe  'pain  in  the 
abdomen  is  the  chief  condition  which  is  complained  of.  The  pulse  is  usually 
ciuick,  small,  and  hard,  and  the  belly  wall  tender  on  palpation,  and  distinctly 
rigid.  The  face  will  be  found  to  wear  an  expression  of  an.vieU/,  which  seems  to 
be  far  out  of  proportion  to  the  length  of  the  illness  and  its  severity.  In  many 
instances,  even  when  the  ])ains  are  exceedingly  severe,  the  patient  considers  that 
he  is  suffering  from  acute  indigestion,  but  acute  indigestion  is  often  relieved  by 


ACUTE  PERITONITIS  595 

pressure,  and  is  usually  accompanied  by  tumidity  of  the  abdomen;  wliereas,  jjeri- 
tonitis  is  characterized  by  great  abdominal  tenderness  and  by  a  Hat  or  scaphcjid 
appearance  of  the  belly  wall.  The  jmlse  is  tense  and  rapid.  The  fever  is  usually 
not  very  high.  It  often  does  not  go  above  102°,  and  frequently  not  over  101°. 
Vomiting  is  frequently  present. 

After  the  pains  have  been  present  for  a  few  hours,  the  exquinte  tenderness  of 
the  abdomen  makes  the  weight  of  the  bedclothes  insupportable,  and,  in  order  to 
obtain  some  relief  for  the  abdominal  tension,  the  patient  usually  lies  on  his  back, 
with  the  knees  up,  and  supports  the  bedclothes  over  his  abdomen  by  his  liands, 
looking  with  dread  upon  the  approach  of  the  attendant  lest  he  touch  the  abdomen 
or  jar  the  bed.  Thirst  which  cannot  be  relieved,  because  of  constant  retching, 
may  add  to  the  patient's  distress,  and  hiccough  of  a  very  persistent  and  exhausting 
character  often  develops. 

As  the  disease  progresses,  the  belly,  which  has  been  tense  and  scaphoid,  becomes 
hard,  not  from  muscular  spasm,  but  from  abdominal  distention.  In  the  flanks 
percussion  may  reveal  some  flatness  due  to  the  accumulation  of  the  exudate  in 
these  parts.  The  face  not  only  is  anxious  in  appearance,  but  rapidly  becomes 
yinched  and  peaked,  the  eyes  appear  sunken,  the  nostrik  are  thin  and  drawn,  the 
skin  pale  and  livid,  and  the  tongue  dry  and  parched,  the  typical  "  Hippocratic  facies." 
The  jndse  at  this  stage  is  exceedingly  rapid,  running,  and  wiry,  and,  as  the  end 
approaches,  loses  its  tense  character.  A  cold  sweat  may  break  out  about  the 
wrists  and  on  the  forehead. 

The  bowels  are  usually  obstinately  confined,  but  in  some  instances  diarrhea  may 
be  present,  particularly  if  diarrhea  has  been  a  symptom  of  the  cage  prior  to  the 
development  of  the  peritonitis.  The  respirations  are  usually  a  little  quickened, 
but  are  shallow  and  superficial,  in  order  that  the  abdominal  movement  may  be  as 
slight  as  possible.  A  remarkable  fact  in  connection  with  these  cases  is  the  preserva- 
tion not  only  of  consciousness,  but  the  development  of  intense  mental  actiiniy, 
which  in  some  cases  persists  up  to  the  moment  of  death,  the  patient  showing  an 
acuteness  of  mind  which  is  startling.  In  some  instances  during  the  last  hours 
there  may  be  a  mild  delirium,  or  even  slight  stupor. 

In  septic  cases  pain  is  absent  in  the  majority  of  instances,  but  the  temperature 
in  the  early  stages  may  be  much  more  febrile  than  in  the  ordinary  types  of  the 
disease.  Sometimes  it  is  distinctly  like  that  of  early  septicemia.  By  the  time 
that  the  septic  inflammation  is  well  developed,  however,  the  fever  usually  falls 
to  the  neighborhood  of  normal,  and  it  may  reach  subnormal. 

Careful  examination  of  the  abdomen  in  cases  of  well-developed  peritonitis  not 
only  reveals  the  local  symptoms  already  described,  but  it  may  also  show  localized 
patches  of  tympany  where  gas  has  accumulated  in  the  coils  of  intestine,  which  are 
more  or  less  fixed  in  one  position  by  inflammatory  adhesions.  These  coils,  partly 
because  of  the  inflammation  and  partly  because  of  distention,  may  soon  become 
paralyzed,  so  that  distention  increases. 

When  the  peritonitis  is  due  to  a  perforation  of  the  intestine  or  of  the  stomach, 
the  accumulation  of  gas  in  the  peritoneal  cavity  may  mask  the  area  of  liver  dulness 
or  completely  obhterate  it.  At  one  time  this  was  considered  a  very  valuable  sign 
in  the  diagnosis  of  perforation  with  secondary  peritonitis,  but  we  now  know  that 
in  many  instances  this  symptom  is  absent. 

Complications  and  Sequelae. — Peritonitis  usually  runs  such  a  rapid  course,  either 
to  recovery  or  death,  that  complications  are  rarely  met.  The  most  important 
and  most  frequent  complication  of  a  serious  nature  is  pneumonia.  In  100  cases 
of  peritonitis  observed  in  the  London  Hospital,  Treves  found  that  no  less  than 
17  developed  pneumonia  or  pleurisy  after  the  peritonitis  began.  Retention  of 
urine  is  frequent. 

As  a  second  intestinal  obstruction  may  develop  as  the  result  of  adhesions  or 


596  DISEASES  OF  THE  PERITONEUM 

by  strangulation  of  the  bowel,  produced  by  the  slipping  of  a  knuckle  of  intestine 
through  an  opening  under  a  band  or  a  false  ligament,  or  by  the  development  of  a 
twist  of  the  bowel  through  interference  with  its  peristaltic  movement. 

Diagnosis. — The  diagnosis  of  acute  diffuse  peritonitis  is  usually  readily  made, 
even  in  its  early  stages.  In  its  late  stages  its  symptoms,  except  in  the  septic 
form,  are  so  characteristic  that  the  diagno.sis  can  be  made  on  a  most  superficial 
examination  of  the  patient. 

In  certain  cases  of  typhoid  fever  in  the  early  stages,  wlien  the  inflammatory 
process  in  the  intestines  is  acute,  there  may  be  a  good  deal  of  abdominal  i)ain  and 
considerable  tenderness.  The  apathetic  expression  of  the  face,  the  higher  tem- 
perature of  typhoid  fever  in  the  stage  of  onset,  the  tumid  belly,  and  the  coated 
tongue,  with  red  edges,  will  aid  in  its  differentiation. 

The  separation  of  intestinal  obstruction  from  peritonitis  is  exceedingly  difficult; 
but  as  they  often  are  coincident,  the  one  following  the  other,  and  the  treatment 
of  such  cases  the  same,  differentiation  is  unnecessary.  The  rapid  onset  of  severe 
pain  of  a  cramp-like  character,  the  complete  absence  of  any  movement  of  the 
bowels,  the  presence  of  intestinal  unrest,  and  in  intussusception  the  palpation  of  a 
mass  may  make  the  diagnosis  possible. 

Certain  cases  of  hysteria  at  times  present  symptoms  so  characteristic  of  peritonitis 
that  even  the  most  skilful  may  be  misled.  Every  symptom  may  be  presented, 
yet  the  patient  always  recovers. 

Acute  hemorrhagic  pancreatitis  may  also  so  closely  resemble  peritonitis  that  a 
diagnosis  is  impossible,  but  this  malady  is  exceedingly  rare.  In  it  there  may  be  a 
preceding  history  of  gallstone  disease,  whereas  in  peritonitis,  unless  perforation 
of  the  gallbladder  has  occurred,  there  is  no  such  history. 

The  pain  of  gallstone  colic  and  renal  colic  is  so  localized  that  much  difficulty 
in  diagnosis  does  not  exist,  as  a  rule. 

In  cases  of  perforation  of  the  stomach  with  secondary  pyopneumothorax  sub- 
phrenicus,  the  differentiation  may  be  exceedingly  difficult,  save  that  swelling  in 
the  epigastrium  and  a  history  of  gastric  ulcer  may  be  present. 

When  perforation  of  the  stomach  has  occurred  without  the  formation  of  abscess, 
so  that  the  gastric  contents  and  gas  escape  into  the  peritoneum,  great  tympany 
and  modification  of  the  area  of  liver  dulness  is  found.  Not  infrequently  in  sub- 
phrenic abscess  a  pleural  eft'usion  exists,  so  that  serum  may  be  drawn  from  this 
level  and  pus  from  the  level  below  the  diaphragm. 

Occasionally,  in  children  suffering  from  pleurisy,  pericarditis,  and  pneumonia, 
violent  pain  is  complained  of  in  the  abdomen,  which  may  mislead  the  physician, 
if  he  be  not  on  his  guard. 

A  high  leukocyte  count  indicates  only  an  inflammatory  process  somewhere  in 
the  body. 

Prognosis. — The  prognosis  in  every  case  of  well-developed  acute  diffuse  peritonitis 
is  distinctly  unfavorable.  If  the  physician  has  reason  to  believe  that  the  peritonitis 
is  localized,  the  outlook  becomes  more  promising.  A  good  deal  depends,  too,  uj)on 
the  cause  of  the  peritonitis,  and  upon  the  character  of  the  infecting  micro-organism. 
Thus,  if  is  follows  perforation  of  the  stomach  or  bowels,  and  it  is  not  walled  off 
from  the  general  peritoneal  cavity,  and  again,  if  a  skilful  surgeon  is  not  at  hand  to 
operate  at  once,  the  prognosis  is  hopeless.  When  the  infection  after  perforation 
is  localized,  the  mortality  is  not  so  great,  but  this  form  of  localized  peritonitis  is 
far  more  fatal  than  that  form  which  is  due  to  appendicitis. 

The  duration  of  life  in  fatal  cases  of  peritonitis  varies  very  greatly.  Death 
may  come  as  early  as  thirty-six  or  forty-eight  hours,  or  may  be  deferred  for  a 
week  or  ten  days,  or  even  longer. 

Treatment. — The  treatment  depends  so  entirely  upon  the  cause  of  the  peritonitis 
that  it  behooves  the  physician  to  study  the  case  most  carefully.     If  seen  shortly 


ACUTE  PERITONITIS  597 

after  the  onset  of  the  malady,  the  physician  should  at  once  consider  the  possibility 
of  perforation  of  some  portion  of  the  alimentary  canal  being  responsible,  and  should 
examine  carefully  into  the  history  of  the  patient  as  to  the  possible  presence  of 
gastric  ulcer  or  intestinal  ulcer  due  to  typhoid  fever  or  dysentery.  If  the  patient 
is  an  adult,  careful  consideration  of  the  possibility  of  extension  of  inflammation 
from  the  gall-bladder  should  be  followed.  It  is  hardly  necessary  to  state  that  as 
appendicitis  and  diseases  of  the  Fallopian  tubes  are  the  most  common  causes  of 
peritonitis,  the  condition  of  these  two  parts  should  be  most  carefully  inquired  into, 
both  as  to  previous  history  of  the  patient  and  as  to  the  physical  signs  which  may 
be  present.  If  the  peritonitis  is  diffuse  and  has  followed  perforation  or  strangula- 
tion, the  salvation  of  the  patient  depends  upon  immediate  surgical  interference, 
unless,  perchance,  shock  prohibits  operation,  when  it  is  permissible  to  wait  two 
or  three  hours,  in  the  hope  that  by  the  use  of  external  heat  and  stimulants  the 
patient  may  be  enabled  to  better  bear  surgical  measures.  If,  on  opening  the  belly, 
a  diffuse  general  peritonitis  is  found,  it  would  seem  best,  in  the  majority  of  cases, 
to  resort  to  the  plan  suggested  by  J.  B.  Murphy,  namely,  to  remove  the  appendix 
if  it  can  be  reached,  close  the  perforation  if  it  exists,  introduce  a  drainage  tube  into 
the  pelvis,  place  the  patient  in  a  semirecumbent  posture  and  give  a  quart  of  normal 
saline  solution  by  the  rectum  every  two  or  three  hours. 

When  it  is  due  to  appendicitis,  the  age  and  general  physical  condition  of  the 
patient  must  largely  influence  the  decision  as  to  operative  interference.  I  agree 
with  McCosh,  who  states  that  in  aged  persons,  particularly  if  they  have  been 
dissipated,  medical  treatment  gives  better  chances  than  surgical  interference, 
while  the  reverse  holds  true  in  young  persons.  If  a  surgeon  of  experience  cannot 
be  obtained,  medical  treatment  will  always  give  the  best  results. 

The  question  as  to  the  procedure  which  should  be  followed  if  the  cause  lies  in 
the  appendix  has  already  been  discussed  in  the  article  on  that  disease. 

The  profession  has  passed  through  three  periods  of  fashion  in  regard  to  the  drug 
treatment  of  peritonitis  itself.  Forty  years  ago  it  was  extensively  taught  that 
general  peritonitis  should  be  treated  by  the  administration  of  massive  doses  of 
opium,  which  were  not  only  sufficient  to  relieve  pain  completely,  but  also  to  produce 
mental  quiet.  Under  the  leadership  of  Alonzo  Clark,  of  New  York,  enormous 
doses  were  sometimes  given,  as  much  as  258  grains  of  opium  being  given  in  a  day; 
and  while  it  is  undoubtedly  a  fact  that  patients  with  peritonitis  are  able  to  take 
large  doses  without  being  poisoned,  this  plan  of  treatment  received  its  death-blow 
with  the  discovery  that  nearly  all  cases  of  peritonitis  are  due  to  an  infection,  and 
that  the  source  of  infection  must  be  discovered,  and,  if  possible,  removed  or  drain- 
age at  least  established.  The  use  of  opium  has  therefore  become  obsolete  because 
it  masks  the  symptoms,  and  is  thought  to  ha^'e  no  definite  influence  upon  the  prog- 
ress of  the  disease,  save  that  it  diminishes  the  suffering  of  the  patient.  It  is  prob- 
ably safe  practice  to  administer  a  sufficient  quantity  of  morphine  or  opium  to 
diminish  agony,  but  not  enough  to  mask  the  symptoms  or  make  the  patient  so 
comfortable  that  he  will  refuse  operative  interference  when  the  physician  thinks 
it  advisable. 

Soon  after  the  infectious  nature  of  peritonitis  was  recognized,  the  profession 

went  to  the  extreme  of  purging  with  saline  cathartics,  and  even  with  vegetable 

cathartics,  all  cases  in  which  symptoms  of  acute  peritonitis  were  manifest.    There 

■  is  no  doubt  that  this  method  was  used  to  excess,  and  at  the  present  time  we  know 

that  it  is  unnecessary  and  probably  harmful. 

Counter-irritation  applied  over  the  abdomen  in  the  shape  of  a  large  number  of 
leeches  may  be  useful  in  sthenic  cases.  In  other  instances  a  light  mustard  plaster 
may  be  used  for  relief.  In  still  others  an  ice-bag  has  been  employed.  It  is  useless. 
Thirst  may  be  relieved  by  the  use  of  small  pieces  of  ice,  or,  better  still,  by  rinsing 
the  mouth  with  glycerin  1  part  and  water  3  parts,  to  which  has  been  added  a  few 


598  DISEASES  OF  THE  PERITONEUM 

drops  of  lemon-juice.  Liquids  should  not  be  swallowed,  as  they  increase  the  ten- 
dency to  vomiting.  If  thirst  is  excessive,  fluid  may  he  supplied  to  the  tissues  by 
hypodermoclysis  or  by  the  rectal  drip  method.  As  a  rule,  the  patient  does  not 
live  long  enough  in  well-developed  peritonitis  to  make  the  question  of  feeding  an 
important  one.  If  the  focus  of  infection  is  removed  by  operation,  the  feeding 
is  that  used  after  all  abdominal  sections. 

CHRONIC  PERITONITIS. 

Chronic  peritonitis  occurs  in  four  forms,  namely:  a  local  adhesive  process;  a 
diffuse  process;  one  characterized  by  a  proliferation  of  inflammatory  material  and 
connective  tissue;  and  in  a  hemorrhagic  form  as  a  complication  of  severe  disease  in 
adjacent  organs  or  malignant  disease  of  the  serosa. 

The  local  adhesive  type  is  often  found  in  the  neighborhood  of  such  organs  as  the 
liver,  spleen,  and  stomach,  when,  as  a  result  of  an  acute  inflammatory  process 
in  the  visceral  peritoneum  covering  the  organ,  an  adhesion  takes  place,  and,  per- 
haps, thick  fibrous  bands  develop.  In  many  of  these  cases  this  condition  is  not 
even  suspected  during  life.  In  the  neighborhood  of  the  pelvic  organs  this  type 
of  peritonitis  is  exceedingly  common,  and  is,  perhaps,  the  most  frequent  peritoneal 
lesion  met  with  by  the  gynecologist.  Sometimes  intestinal  obstruction  results 
from  a  slow,  chronic,  inflammatory  process,  which  glues  a  knuckle  of  intestine 
to  the  omentum  or  the  anterior  wall  of  the  peritoneum. 

In  the  diffuse  hut  chronic  type  of  peritonitis  a  condition  closely  resembling  that 
of  fibrous  tuberculous  peritonitis  develops,  so  that  the  peritoneal  cavity  is  prac- 
tically obliterated,  and  the  coils  of  intestine  are  often  matted  together  so  that  it 
is  impossible  to  separate  them.  The  parietal  layer  of  the  peritoneum  is  greatly 
thickened,  and  all  the  abdominal  organs  seem  to  be  constricted  and  drawn  by  the 
cicatricial  process. 

Closely  allied  to  the  last  tj-pe  is  the  proliferative  form,  in  which  the  changes  are 
not  very  different,  except  that  there  is,  in  addition,  a  considerable  c^uantity  of 
serum  in  the  abdominal  cavity.  Sometimes  this  may  be  present  in  such  quantities 
that  the  belly  is  greatly  distended.  The  omentum  is  rolled  up  as  a  window-shade 
is  rolled  up,  and  extends  across  the  upper  zone  of  the  abdomen  in  a  round  mass. 
The  intestines  may,  or  may  not,  be  adherent  to  one  another,  the  presence  of  the 
fluid  serving  to  separate  them  and  to  jjreA-ent  dense  adliesions  taking  place.  At 
times  some  of  the  fluid  may  be  divided  oft'  into  pockets  by  the  adhesions.  This 
form  of  proliferative  peritonitis  is  usually  due  to  tuberculosis,  and  not  infrequently 
complicates  alcoholic  cirrhosis  of  the  liver,  but  it  is  generally  believed  that  in  some 
cases  it  may  arise  from  other  causes  than  tuberculosis.  Even  if  the  cause  is  not 
tuberculosis  the  condition  may,  however,  very  closely  resemble  it  on  palpation, 
because  nodules  may  be  found.     (See  Tuberculosis  of  the  Peritoneum.) 

In  cases  of  carcinoma  of  the  viscera  a  chronic  form  of  peritonitis  associated  with 
the  exudation  of  blood-stained  or  hemorrhagic  serum  is  occasionally  met  with. 
Indeed,  the  obtaining  of  such  serum  from  a  case  of  ascites  is  always  to  be  considered 
as  indicative  of  that  form  of  peritonitis  depending  upon  malignant  growth.  As  a 
rule,  the  chief  lesions  are  found  in  the  pelvis,  or  there  may  be  present  a  general 
carcinomatosis  of  the  peritoneum.  In  other  cases  the  pelvic  viscera  may  be 
coated  with  fibrinous  exudate,  which  undergoes  connective-tissue  changes,  and 
becomes  highly  vascularized. 

Friedreich  has  described  a  form  of  chronic  hemorrhagic  peritonitis  which  follows 
repeated  resort  to  paracentesis  abdominis,  the  entire  peritoneal  surface  being 
granular,  reddened,  and  dotted  with  extravasations  of  blood. 

Chronic  Adhesive  Sclerotic  Peritonitis. — This  is  a  very  rare  state,  apparently  met 
with  more  frequently  in  Germany  than  in  the  United  States.     It  was  described 


ASCITES  599 

by  Virchow  in  1853,  and  in  more  recent  times  by  Riedel.  It  consists  in  an  extensive 
subperitoneal  fibroid  infiltration  or  sclerosis,  without  ascites  and  without  serous, 
or  serofibrinous,  or  purulent  fluid  in  the  abdomen.  In  other  words,  it  is  rather  a 
disease  primarily  involving  the  subperitoneal  connective  tissue  than  a  true  chronic 
peritonitis.  This  hyperplasia  results  in  a  sclerotic  process,  which  in  turn  produces 
contractions  and  retractions,  and,  by  the  formation  of  adhesions,  fastens  organs  to 
the  abdominal  wall.  The  symptoms  are  those  of  the  chronic  fibroid  t\-pe  of  tuber- 
culosis peritonitis  already  described,  but  the  condition  is  not  due  to  tuberculosis. 
Wetherill  states  that  the  peritoneum  shrinks  so  that  when  abdominal  section  is 
performed  it  is  impossible  to  approximate  its  edges  on  closing  the  wound. 

For  a  description  of  the  so-called  "iced  liver  of  Pick"  see  Adhesive  Pericarditis. 

MORBID  GROWTHS  OF  THE  PERITONEUM. 

Cancer  of  the  Peritoneum. — This  is  an  exceedingly  rare  condition  as  a  primary 
lesion.  In  all  probability  when  it  does  occur,  it  is  an  endothelioma  rather  than  an 
epithelioma. 

Carcinoma  and  carcinomatosis  of  the  peritoneimi  are  usually  if  not  always 
secondary  to  cancer  of  some  contained  viscus.  The  primary  growth  may  be 
so  small  as  to  escape  superficial  examination  even  at  autopsy,  and  is  commonly 
in  the  stomach,  pancreas,  or  biliary  passages,  or,  less  frequently,  in  the  rectum; 
in  the  female  the  pelvic  organs  are  by  far  the  commonest  site  of  the  prinary  growth. 
On  accoimt  of  the  pervious  nature  of  the  diaphragmatic  lymphatics,  the  pleiu-se, 
pericardium,  and  peritoneum  may  be  simultaneously  affected,  or  invasion  of  one 
may  be  quickly  followed  by  extension  to  the  others. 

The  symptoms  of  either  the  primary  or  secondary  carcinoma  of  the  peritoneum 
are  emaciation,  ascites,  and,  it  may  be,  the  disco\"ery  of  iwdides,  or  of  a  furled 
omentum,  such  as  occm-s  in  certain  t^'pes  of  peritoneal  tuberculosis.  The  fact 
that  the  fluid  is  often  hemorrhagic  has  already  been  referred  to.  In  the  colloid 
cases  the  peritoneum  may  be  filled,  not  with  fluid,  but  with  a  jelly-like  substance, 
which  is  so  firm  that  it  will  not  fluctuate. 

Other  Growths  of  the  Peritoneum. — Hydatid  cyst  of  the  peritoneum  is  occasionally 
found,  although,  as  a  rule,  it  develops  in  the  abdominal  organs  rather  than  in  the 
peritoneum  itself.  A  cyst  the  size  of  an  orange  has  been  reported  by  Jones  as 
occiuring  in  the  mesocolon.  It  was  successfully  removed.  Rein  has  reported  a 
multiple  hydatid  cyst  occiu-ring  in  the  omentum  of  a  woman  in  the  third  month 
of  pregnancy.  She  was  operated  on  and  reco^'ered.  Other  instances  have  been 
reported  by  various  clinicians,  the  largest  number  of  cases  collected  being  those  of 
Moneger,  who  has  reported  32.  He  tells  us  that  such  cysts  are  nearly  always 
secondary  to  rupture  of  cysts  in  neighboring  organs,  and  there  is  usually  a  history 
of  violent  pain  at  the  time  of  rupture.  Perhaps  the  most  extraordinary  case  is 
that  reported  by  INIacDonald,  who  has  reported  the  case  of  a  man  with  thirty 
hydatid  cysts  of  the  peritoneiun.  Other  cysts  of  the  mesentery  are  chylous, 
dermoid,  serous,  and  sanguineous. 

Very  rarely  sarcoma  and  cystic  adenoma  aft'ect  the  peritoneimi. 

ASCITES. 

Definition. — ^Ascites  is  a  symptom,  not  a  disease.  The  term  ascites  is  applied 
to  the  accumulation  of  serous  fluid  in  the  abdominal  ca^^ty.  In  some  cases  the 
quantity  of  fluid  is  very  small,  but  in  others  it  amounts  to  several  gallons. 

The  fluid  in  ascites  is  usually  of  a  light  straw  color,  and  does  not  coagulate 
when  exposed  to  the  air. 


600  DISEASES  OF  THE  PERITONEUM 

Etiology. — The  intra-abdominal  causes  of  ascites,  as  just  stated,  are  atrophic 
cirrliosis  of  the  liver,  tuberculous  peritonitis,  and  morbid  growths,  which,  by 
pressure  upon  bloodvessels,  or  b\'  producini;  clianftos  in  the  peritoneum,  result 
in  a  transudation  of  fluid.  A  thrombophlebitis,  or  otiier  form  of  venous  obstruc- 
tion, may  also  cause  ascites.  Thrombosis,  tuberculosis,  or  neoplastic  invasion 
of  the  thoracic  duct,  or  its  obstruction  by  parasites  (filarise),  or  other  causes,  and 
also  wounds  of  the  duct  or  of  the  receptaculum,  or  larger  lymjih-vessels  or  chyle- 
vessels  may  produce  an  ascites  the  fluid  of  which  contains  chyle.  In  cases  of 
chronic  Bright's  disease  of  the  parenchymatous  type,  ascites  is  often  present  as 
part  of  the  general  anasarca. 

Symptoms. — When  the  abdomen  of  a  patient  suffering  from  ascites  is  exposed, 
it  is  seen  to  be  greatly  enlarged,  this  enlargement  being  chiefly  in  the  lower  and 
lateral  zones,  although  if  the  intestines  are  by  chance  distended  by  gas  the  upper 
and  middle  zone  may  be  much  enlarged.  The  line  of  the  ribs  is  usually  sharply 
defined,  by  reason  of  the  fact  that  they  do  not  yield  readily  to  the  pressure  and 
are  held  in  place  by  the  diaphragm. 

If  the  ascites  be  due  to  hepatic  cirrhosis,  the  venules  about  the  navel  will  often 
be  found  engorged  (see  Cirrhosis  of  the  Liver),  and  in  all  forms  of  ascites  due  to 
venous  obstruction  the  veins  under  the  skin  in  the  right  and  left  hypogastrium 
and  groins  may  be  surcharged  with  blood  in  an  endeavor  to  establish  a  collateral 
circulation,  and  so  relieve  deep  pressure  in  the  venous  trunks. 

The  signs  of  fluid  in  the  abdominal  cavitj'  are  dulness  on  percussion  in  the  flanks, 
and  in  the  suprapuljic  region  when  the  patient  is  semirecumbent,  with  tympany 
over  the  anterior  and  middle  zone  of  the  abdomen  extending  upward  to  the  epigas- 
trium, owing  to  the  intestines  being  floated  up  against  the  anterior  abdominal 
wall  by  the  fluid  beneath.  If  the  hand  of  the  nurse  is  placed  with  its  ulnar  edge 
upon  the  middle  line  of  the  abdomen,  the  left  hand  of  the  physician  placed  on  the 
right  flank,  and  the  right  hand  used  to  lightly  strike  the  left  flank,  distinct  fluc- 
tuations will  be  felt  by  the  left  hand,  the  impulse  being  transmitted  by  the  fluid 
from  one  side  to  the  other,  the  hand  of  the  nurse  being  used  to  pre\-ent  the  trans- 
mission of  this  impulse  by  way  of  the  abdominal  wall.  Changing  the  patient's 
position  from  the  recumbent  to  the  erect  posture  will  change  the  area  of  dulness 
on  percussion  and  the  shape  of  the  abdomen,  owing  to  the  alteration  in  the  position 
of  the  fluid.  Palpation  will  reveal  fluctuation  if  the  belly  is  not  too  tense.  Per- 
cussion will  give  a  tympanitic  note  in  the  epigastrium  when  the  patient  is  sitting 
up  and  flatness  below  the  navel  and  at  the  sides  of  the  abdomen. 

A  patient  who  has  ascites  to  any  considerable  degree  is  usually  iniahle  to  lie 
with  the  head  low,  because  if  this  attitude  is  assumed  the  pressure  of  the  fluid 
against  the  diaphragm  is  such  that  breathing  is  interfered  with.  For  this  reason 
he  usually  sits  propped  up  in  bed  or  in  a  reclining  chair.  The  face,  which  is  usually 
thinner  than  in  health  and  somewhat  haggard,  forms  a  striking  contrast  to  the 
large  abdomen,  which  is  "aldermanic"  in  appearance,  and  if  the  legs  be  dropsical 
as  well,  the  massiveness  of  the  lower  half  of  the  trunk,  as  compared  to  the  upper 
half  and  to  the  neck  and  face,  presents  a  striking  picture.  Not  rarely  the  face 
bears  the  expression  known  as  the  "abdominal  facies." 

Dyspnea  may  not  be  noticeable  when  the  patient  is  at  absolute  rest,  but  it  not 
rarely  happens  that  so  slight  an  exertion  as  conversation  will  develop  this  symptom, 
particularly  if,  in  addition,  there  be  some  tendency  to  edema  at  the  bases  of  the 
lungs.  As  a  rule,  men  are  more  uncomfortable  when  suffering  from  ascites  than 
are  women,  because  their  respiration  is  naturally  more  diaphragmatic  than  that 
of  women,  whose  respiratory  movement  is  chiefly  costal. 

Diagnosis. — Ascites  must  be  difl'ercntiatcd  from  distention  of  the  abdomen 
due  to  a  large  ovarian  cyst.  This  can  usually  be  accomplished  by  palpation, 
percussion,  and  vaginal  examination.     Inspection  of  a  case  of  a  cyst  will  usually 


ASCITES 


601 


reveal  somewhat  greater  distention  of  one  side  of  the  abdomen  tlian  the  other. 
The  area  of  dulness  on  percussion  will  not  be  in  the  lower  zone  of  the  abdomen 
alone,  but  will  extend  upward  toward  the  ribs  and  will  include  part  of  the  area  in 
the  anterior  and  middle  zone  of  the  belly,  which  in  ordinary  ascites  is  tympanitic. 
Change  of  posture  with  cyst  does  not  greatly  change  the  area  of  dulness.  Further 
than  this,  a  large  ovarian  cyst  of  this  character  will  usually  be  tense  and  will 
offer  more  resistance  when  the  abdomen  is  palpated  with  both  hands. 


Case  of  enormous  ascites  due  to  atn'pliic  hepatic  cirrhusi^. 

From  enlargement  of  the  spleen  in  chronic  leukemia  ascites  may  be  differentiated 
by  reason  of  the  fact  that  in  this  disease  the  area  of  dulness  is  chiefly  in  the  upper 
zone  instead  of  in  the  lower  zone  of  the  belly,  that  tympany  is  usually  not  present 
in  the  middle  line  if  the  spleen  extends  so  far,  and  that  the  edge  of  the  spleen  can 
be  readily  palpated.  In  some  cases,  however,  in  which  the  spleen  is  enlarged 
in  leukemia,  ascites  is  also  present,  and  it  may  be  impossible  to  feel  the  edge  of  the 
spleen  until  some  of  the  fluid  is  removed.  This  removal  may  be  more  difficult 
than  in  an  ordinary  case  of  ascites,  because  the  spleen  may  be  so  close  to  the  anterior 
abdominal  wall  and  may  extend  so  far  down  toward  the  pubis  that  ordinary  para- 
centesis cannot  be  readily  performed  without  danger  of  puncturing  the  spleen. 
Ascites  must  also  be  separated  from  great  enlargement  of  the  liver,  as  in  hyper- 
trophic cirrhosis.  Here,  again,  the  presence  of  dulness  in  the  right  upper  zone  of 
the  abdomen  and  the  ability  to  feel  the  lower  edge  of  the  large  liver  will  aid  mate- 
rially in  the  differentiation.  In  both  enlargement  of  the  spleen  and  enlargement  of 
the  liver  the  area  of  dulness  and  of  tympany  is  not  materially  altered  by  changing 
the  posture  of  the  patient  as  it  is  in  ascites. 

Treatment. — The  treatment  of  ascites  depends  to  some  extent  upon  its  cause. 
If  it  is  due  to  interference  with  the  circulation  by  pressure,  as  in  atrophic  hepatic 
cirrhosis,  little  can  be  done  except  to  remove  the  fluid  by  paracentesis,  for  the 
purpose  of  giving  the  patient  relief  from  distention.  If  it  is  due  to  cardiac  disease 
an  improvement  in  the  condition  of  the  heart  by  the  use  of  digitalis  and  rest,  and 
the  judicious  administration  of  saline  purges,  may  remove  the  fluid.     In  renal 


602  DISEASES  OF  THE  IJVER 

disease  tlie  use  of  purgatives  may  also  be  of  value,  liut  jiaraceiitesis  has  usually 
to  he  resorted  to  if  the  fluid  is  present  in  large  amount.  In  ]K'ritoneal  tuberculosis 
paracentesis  may  be  of  value,  t)ut  the  best  method  of  producing  cure  is  to  resort 
to  abdominal  section,  permitting  the  fluid  to  escape  through  the  incision,  and  then 
maintaining  drainage. 

Before  performing  yaracentesis  ahdotitiniti  the  patient  should  l)e  made  to  evacuate 
his  bladder,  in  order  that  by  no  possibility  can  it  be  punctured  by  the  trocar. 
If  the  patient  be  a  woman,  great  care  should  be  taken  that  an  ovarian  cyst  is  not 
punctured.  Puncture  of  a  papillomatous  cyst  not  infrequently  results  in  the 
early  death  of  the  patient. 


DISEASES  OF  THE  LIVER. 


INFLAMMATION  OF  THE  LIVER. 


Acute  Hepatitis  or  Hepatic  Abscess. — Definition. — Acute  exudate  hepatitis  is  a 
state  of  inflammation  of  the  liver  in  which,  after  a  stage  of  hyperemia  with 
exudation,  the  area  involved  undergoes  necrosis,  and  abscess  results. 

Etiology. — Inflammation  of  the  liver,  severe  enough  to  result  in  suppuration, 
may  arise  from  injury,  from  inflammation  of  the  portal  vein  or  of  the  bile-ducts, 
or  from  adhesions  to  neighboring  organs  which  are  infected  and  from  which  infection 
may  spread,  as,  for  example,  in  cases  of  gastric  ulcer. 

Suppuration  within  the  substance  of  the  liver  beneath  its  capsule  or  in  the  bile 
passage  occurs  under  many  varying  conditions. 

Traumatic  Abscess. — Liver  abscess  may  result  from  traumatism.  The  trauma- 
tism may  be  a  severe  blow  or  contusion,  or  a  penetrating  wound  in  or  near  the 
liver  from  a  bullet,  knife,  or  other  weapon.  Traumatic  abscess  of  the  liver  is 
usually  single.  When  it  occurs  as  a  result  of  contusion  in  the  absence  of  direct 
infection,  the  injury  acts  by  lessening  resistance  and  permitting  colonization  of 
pyogenic  bacteria  brought  to  the  organ  by  the  portal  vein  or  hepatic  artery. 

Pyemic  Abscesses. — Pyemic  abscesses  are,  as  a  rule,  multiple.  One  group 
of  cases  arises  from  pyogenic  embolism  of  the  portal  vein.  There  is  phlebitis 
or  thrombophlebitis  of  the  portal  trunk  or  its  branches,  the  infection  being  due 
to  ulcerations  in  the  colon  and  rectum,  or  to  appendicitis,  ulcerations  and  suppura- 
tive processes  about  the  neck  of  the  bladder,  and  typhoid  fever.  Another  group 
of  cases  arises  from  embolism  of  the  hepatic  artery,  as  in  ulcerative  endocarditis 
and  other  pyemic  conditions.  Infection  may  also  reach  the  liver  through  the 
lym])hatics.  Abscess  may  also  arise  from  the  direct  extension  of  infection  from 
the  gallbladder  and  the  biliary  ducts.  Ascarides,  liver  flukes,  echinococcus,  and 
the  Balantidiinn  coK  may  also  cause  abscess  of  the  liver,  and  it  has  also  been 
observed  as  a  sequel  to  measles,  epidemic  influenza,  and  ulcer  of  the  stomach. 

Amebic  Abscess  of  the  Liver. — In  the  consideration  of  the  etiology  of  tropical 
abscess,  we  find  predisposing  and  direct  causes.  As  a  predisposing  cause,  the 
passive  congestion  of  the  liver  which  exists,  to  some  extent,  in  a  large  proportion 
of  colonists  in  the  tropics,  must  be  remembered.  Other  predisposing  factors  in 
the  production  of  tropical  abscess  are  malaria  and  exposure  to  cold  and  wet.  Abuse 
of  alcohol  is  probably  an  important  predisposing  cause.  In  Waring's  careful 
study  of  the  subject  of  abscess  of  the  liver,  he  found  a  clear  history  of  the  abuse 
of  alcohol  in  G5  per  cent,  of  the  cases. 

The  direct  cavse  of  tropical  abscess  is  the  eiitumcha;  dysenieriw  which  may  or 
may  not  have  previously  excited  intestinal  lesions.  Various  observers  have  found 
that  tropical  abscess  of  the  liver  has  been  preceded  by  dysentery  in  from  72  to 


INFLAMMATION  OF  THE  LIVER  603 

97  per  cent,  of  all  cases.  Woodward,  in  3680  dysentery  autopsies,  found  liver 
abscess  in  779,  or  21  per  cent.  Boston  collected  data  of  2430  autopsies,  with 
486  abscesses,  or  20  per  cent.  Legrand,  of  Alexandria,  found  that  in  109  cases  of 
hepatic  abscess  which  occurred  in  children  31  were  due  to  dysentery.  Hepatic 
suppuration  may  develop  very  shortly  after  the  dysentery,  or  may  be  delayed  for 
years.     (See  Dysentery.) 

Pathology  and  Morbid  Anatomy. — Abscess  of  the  liver  usually  occurs  either  in 
one  or  two  large  purulent  collections  or  in  a  number  of  small  abscess  cavities. 

The  siii(/le  large  abscess  is  usually  the  result  of  dysentery,  and  the  infection 
reaches  the  liver  through  the  veins,  which  closely  anastomose  with  the  hemorrhoidal 
plexus.  If  the  cause  be  dysentery  of  the  amebic  type,  the  ameba  is  found  in  the 
wall  of  the  abscess,  and  less  constantly  in  the  abscess  contents.  In  still  other 
cases  an  examination  of  the  pus  reveals  the  presence  of  the  Bacillus  coli  communis, 
or  the  Streptococcus  pyogenes  or  a  pyogenic  staphylococcus.  In  still  other  cases,  if 
the  abscess  be  very  chronic,  the  pus  may  be  sterile. 

In  tropical  abscesses  the  lesion  is  solitary  in  about  60  per  cent,  of  the  cases; 
it  is  single,  from  coalescence,  or  double  in  about  15  per  cent,  of  the  cases,  and 
the  remainder  are  multiple.  The  abscesses  vary  in  size  from  a  pigeon's  egg  to  a 
cocoanut. 

The  single  abscess  may  be  very  large,  and  may  fill  an  entire  lobe  of  the  liver.  The 
right  lobe  is  usually  affected,  and  as  the  abscess  gradually  nears  the  surface  of  the 
organ  it  may  burst  through  the  capsule  into  the  peritoneal  cavity,  or,  as  is  far 
more  common,  the  advancing  inflammatory  zone  causes  the  surface  of  the  liver  to 
become  adherent  to  adjacent  structures,  so  that  when  rupture  takes  place  the  pus 
breaks  into  the  bowel,  as  in  a  case  recently  under  my  care,  or  through  the  diaphragm 
into  the  pleura,  or  even  into  the  lung,  so  that  the  pus  from  the  liver  escapes  b.y 
the  respiratory  tract. 

Accumulations  of  pus,  in  burrowing  a  way  for  escape,  often  cause  extraordinary 
effects,  and  cases  are  on  record  in  which  the  pus  from  one  of  these  abscesses  has 
escaped  into  the  pericardium,  and  even  into  the  pelvis  of  a  kidney.     Still  other 
instances  have  occurred  in  which  the  pus  has  found  its  way  into  the  great  veins  ■ 
of  the  abdomen  or  into  the  gallbladder.     Rupture  externally  is  not  common. 

The  pus  from  such  an  abscess  is  often  very  offensive,  and  it  generally  differs 
from  ordinary  pus  in  appearance,  being  thin  instead  of  creamy,  reddish  instead  of 
yellow,  and  oftentimes  it  is  quite  green  from  the  presence  of  bile.  Sometimes, 
however,  the  pus  is  quite  like  that  commonly  found  in  abscesses. 

The  lining  of  the  abscess  cavity  is  shaggy,  because  of  the  pieces  of  dead  hepatic 
tissue  which  hang  upon  it  (Fig.  106).  In  abscesses  of  long  standing  more  or  less 
imperfect  encapsulations  of  the  pus  may  occur. 

Large  multiple  abscesses  are  sometimes  met  with  as  the  result  of  suppuration 
about  an  echinococcus  cyst. 

Small  multiple  abscesses  are  usually  pyemic — i.  e.,  of  metastatic  origin.  Septic 
emboli,  or  micro-organisms,  from  septic  foci  elsewhere  are  carried  by  the  blood 
into  the  liver  and  cause  multiple  areas  of  necrosis  and  suppuration.  The  liver 
therefore  presents  not  one  large  abscess,  but  a  large  number  well  distributed 
through  its  tissues.  These  abscesses  vary  in  size.  Several  small  necrotic  cavities, 
which  may  hold  several  drachms  of  pus,  may  be  present,  or  a  number  may  coalesce 
to  form  one  large  abscess.  Although  each  abscess  seems  isolated,  it  is  usually  in  . 
communication  through  a  branch  of  the  portal  vein  with  others,  so  that  by  this 
vascular  pathway  the  whole  gland  is  riddled  with  pus.  The  pus  may  vary  from 
foul,  reddish,  or  greenish  material  to  the  character  of  what  used  to  be  called,  in 
preantiseptic  days,  "laudable  pus." 

When  the  infection  takes  place  along  the  bile-ducts,  as  the  result  of  the  entrance 
of  micro-organisms,  the  introduction  of  which  is  facilitated  by  the  presence  of 


604 


DISEASES  OF  THE  LIVER 


gallstones,  it  is  often  found  that  the  pus  is  not  only  distrihutcd  widely  through 
the  organ,  but,  in  addition,  that  the  gallbladder  is  full  of  pus  as  well,  so  that  the 
entire  biliary  tract  is  involved  in  the  suppurative  process. 


Liver,  amebic  abscess  of  right  lobe;  case  of  dysentery.     Note  the  shaggy  necrotic  wa!!  and  that  tlie 
abscess  has  approached  the  superior  surface  of  the  organ. 


Chart  showing  septic  fever  and  marked  leukocytosis  in  case  of  hepatic  abscess.    Fall  in  leukocytes 
after  abscess  is  drained.     (Bassett-Smith.) 


Small  multiple  abscesses  may  be  due  not  only  to  the  ordinary  or,<,'anisms  of 
sui)puration,  but  to  infection  by  the  Entameha  dijfsenteriw. 


INFLAMMATION  OF  THE  LIVER  605 

Symptomatology^ — The  symptoms  of  hepatic  suppuration  are  usually  marked. 
In  some  cases,  liowever,  even  with  the  existence  of  large  abscesses,  the  lesion  is 
latent,  and  the  disease  is  not  suspected  until  rupture  of  the  abscess  occurs.  The 
chief  symptoms  are  fever,  sepsis,  enlargement  of  the  liver,  and  pain. 

The  pain  is  felt  not  only  in  the  right  hypochondrium,  but  in  the  region  of  the 
right  shoulder-blade,  and,  as  the  abscess  approaches  the  surface  and  causes  inflam- 
mation of  the  peritoneum,  the  pain  may  be  sharp  and  even  severe. 

There  is  loss  of  weight  and  strength  and  pronounced  feebleness  in  muscular  effort. 
Dyspeptic  symptoms  become  marked.  There  is  anorexia,  nausea,  morning  vomiting, 
with  a  heavily  coated  tongue.  The  patient  becomes  anemic  and  gradually  takes  on 
a  peculiar  subicteric  color.  The  fever  begins  early  and  is  the  most  constant  symp- 
tom. At  first  it  does  not  run  high,  but  later  an  evening  temperature  of  from 
104°  to  105°  is  not  uncommon.  The  fever  is  irregular  or  intermitting  in  type. 
It  is  preceded  by  a  chill  and  then  followed  by  a  sweat.  These  sweats  are  very 
severe  and  contribute  greatly  to  the  depression  and  exhaustion  of  the  patient. 
They  follow  the  fastigium  of  the  fever  and  are  prone  to  come  on  during  sleep, 
whether  it  be  by  day  or  night;  so  that  they  may  be  properly  called  sleeping  sweats 
rather  than  night  sweats. 

Enlargement  of  the  liver  is  constant.  It  is  symmetrical,  and  in  extreme  cases 
may  reach  as  high  as  the  third  rib  in  front  and  may  extend  as  far  down  as  the  crest 
of  the  ilium,  or  over  as  far  as  the  umbilicus.  The  right  hypochondrium  may  appear 
full  and  bulging,  and  there  may  be  an  apparent  fulness  or  sleekness  of  the  right 
side,  and  in  marked  cases  obliteration  of  the  lower  intercostal  spaces. 

When  pus  approaches  close  to  the  surface  it  is  always  preceded  by  an  edema 
of  the  skin  overlying  the  abscess,  and  in  cases  -Bith  large  abscess  fluctuation  may 
be  present.    Auscultation  over  the  liver  may  reveal  peritoneal  or  liver  friction. 

Occasionally  sharp  paiji  is  felt  in  the  esophagus,  when  a  food  bolus  passes  the 
level  of  the  diaphragm.  A  dry,  hacking,  unproductive  cough  is  very  commonly 
present  and  frequently  leads  to  error  by  directing  attention  to  the  lungs  rather  than 
to  the  liver. 

The  decubitus  of  the  patient  is  characteristic.  He  lies  on  his  right  side  with 
that  shoulder  drawn  down  and  knee  drawn  up  to  relieve  the  tension  on  the 
abdominal  muscles. 

Jaundice  is  not  common  and  only  appears  when  the  enlarged  liver  or  abscesses 
make  pressure  on  the  bile-ducts.  Pressure  on  the  portal  vein  may  cause  a  moderate 
degree  of  ascites. 

Pneumonia  of  the  right  base  often  occurs  when  the  abscess  is  high  up  in  the 
dome  of  the  liver. 

Diagnosis. — The  condition  which  in  all  probability  most  closely  resembles  hepatic 
abscess  is  infection  of  the  gall-duct  or  gallbladder,  produced  by  the  presence  of  a 
stone  or  stones,  for  here,  too,  there  is  septic  absorption,  high  fever,  chills,  sweats, 
and  tenderness  about  the  liver,  although  pus  may  not  be  actually  present.  In 
this  condition,  however,  there  is  a  history  of  gallstone  colic  in  some  instances,  and 
of  jaundice.  Further,  the  emaciation  and  anemia  are  not  so  marked,  nor  is  the 
liver  so  generally  increased  in  size.  A  marked  leukocytosis  is  present  in  either 
case. 

The  absence  of  marked  swelling  of  the  spleen,  of  any  history  of  malarial  infection, 
and  the  lack  of  the  malarial  parasite  in  the  blood,  combined  with  the  fact  that 
the  fever  does  not  yield  to  quinine,  all  go  to  prove  the  febrile  state  not  malarial. 
The  blood  condition  may  also  aid  in  the  diagnosis.  There  is  usually  a  marked 
leukocytosis,  which  ranges  from  12,000  to  53,000.  Unfortunately,  this  symptom 
is  not  constant,  but  when  it  does  occur  it  makes  a  clear  distinction  between  this 
disease  and  malaria.  Other  conditions  that  simulate  liver  abscess  are  hepatic 
colic  with  fever,  suppuration  in  and  about  the  gallbladder,  suppuration  in  or  near 


606  DISEASES  OF  THE  LIVER 

the  right  kidney,  suhtHaphragniatic  abscess,  empyema  or  pneumonia  of  tiic  riji;ht 
base,  and  ulcerative  endocarditis. 

An  empyema  or  pleural  efFusion  on  the  right  side  can  be  excluded  by  tiie  decrease 
in  \ocal  resonance  and  vocal  fremitus  caused  by  that  state,  and  by  the  presence 
of  Skodaic  resonance  just  above  the  area  of  dulness  on  percussion. 

It  is  important  to  remember  that  amebic  abscess  may  be  present  without  diarrhea 
or  dysentery,  the  ameba%  nevertheless,  being  present  in  the  stools  and  in  the  liver. 

In  all  obscure  cases  attended  l)y  the  signs  of  hepatic  disease  and  sepsis,  an  effort 
should  be  made  to  establish  the  condition  of  the  liver  by  exploratory  operation. 

Prognosis. — The  prognosis  of  abscess  of  the  liver  depends  on  two  factors,  the 
number  of  abscesses  and  the  time  when  the  case  is  brought  to  operation.  80  to 
90  per  cent,  of  single  abscesses  brought  to  early  operation  should  recover,  but  often 
operation  is  postponed  too  long.  In  cases  of  spontaneous  rupture  into  the  colon 
50  per  cent,  recover.  The  prognosis  is  not  so  good  where  ru])ture  takes  place  into 
the  lung  or  pleura.  Recovery  occasionally  takes  place  when  two  and  three  abscesses 
are  present. 

In  162  fatal  cases  of  hepatic  abscess  the  mortality  is  given  as  due  to  the  following 
causes:  severity  of  the  accompanying  dysentery,  12.5  cases;  bursting  of  al)scess 
into  the  peritoneum  12  cases,  into  the  pleura  11  cases;  gangrene  of  the  abscess 
wall,  .3  cases;  rupture  of  adhesions,  2  cases;  pneumonia,  2  cases;  and  rupture  into 
the  pericardium,  1  case.  The  prognosis  in  multiple  abscess  is  hopeless,  for  manifest 
reasons. 

Treatment. — The  treatment  of  hepatic  abscess  consists  in  sustaining  the  patient's 
strength  by  good  food  and  by  iron  and  arsenic,  and,  if  the  abscess  is  single,  by 
opening  and  draining  it  as  soon  as  its  existence  is  determined  unless  it  be  due  to 
the  AmehoB  dysenterios,  when  it  is  to  be  punctured,  aspirated  and  injected  with 
quinine  solution  or  one  of  emetine  without  drainage  (see  Dysentery). 

Exploratory  puncture  should  not  be  practised  unless  the  surgeon  is  i)rcpared 
to  go  ahead  and  operate  at  once.  If  ordinary  pus  be  found,  puncture  may  spread 
infection  by  permitting  a  leak  along  the  wound.  This  is  especially  a  danger  with 
large  needles,  and  large  needles  must  be  used  on  account  of  the  thickness  and 
viscosity  of  the  abscess  contents  in  some  cases. 

CIRRHOSIS  OF  THE  UVER. 

Definition. — Cirrhosis  of  the  liver  is  a  state  in  which  there  is  an  overgrowth 
of  connective  tissue  of  the  gland.  In  some  instances  this  overgrowth  results  in 
an  atropl\y  and  shrinkage  of  the  organ  (atrophic  cirrhosis);  in  others  the  iiv(>r 
becomes  greatly  enlarged  (hypertrophic  cirrhosis). 

Recently  Kretz,  MacCallum,  Kelly,  and  others  have  called  attention  to  regenera- 
tive changes  in  the  liver  cells  as  being  a  prominent  feature  of  cirrhosis.  They  do 
not  regard  the  normal  liver  as  made  up  of  distinct  lobules  but  as  consisting  of 
continuous  mantles  of  cells  surrounding  the  bloodvessels.  In  cirrhosis,  following 
degenerative  changes,  these  cells  regenerate  and  rearrange  themselves  and,  accord- 
ing to  Kretz,  cirrhosis  is  consequently  to  be  regarded  as  a  focal  recrudescent  chronic 
atrophy  of  liver  cells  modified  by  parenchymatous  regeneration  and  not  as  a  disease 
entity.  He  believes  that  practical  exten.sion  of  our  knowledge  on  this  suliject 
is  to  come  from  investigating  the  causes  of  degeneration  of  liver  cells  rather  than 
from  attempts  further  to  differentiate  and  classify  so-called  tyjies  of  developed 
cirrhosis. 

Cirrhosis  of  the  liver  derives  its  name  from  the  Greek  word  5-'",""C,  meaning 
yellow  or  tawny.  The  term  cirrhosis  was  first  applied  by  Laennec,  because  the 
liver,  when  cirrhotic,  is  yellow  or  tawny  in  color.  Cirrhosis  is  an  unfortunate  term, 
in  that  it  in  no  way  describes  the  pathological  state  which  is  present.     Further 


CIRRHOSIS  OF   THE  LIVER 


607 


than  tliis,  tlie  word  cirrhosis  is  now  appHed  to  pathological  states  of  other  organs 
in  wliicli  no  yellow  line  is  seen. 

Atrophic  Cirrhosis. — The  liver  in  cases  of  atrophic  cirrhosis  is  often  enlarged 
in  the  early  stage  of  the  disease,  but  after  this  primary  change  it  unrlergoes  a 
diminution  in  size,  so  that  eventually  it  is  much  smaller  than  normal.  This  primary 
enlargement,  which  does  not  always  occur,  is  perhaps  due  to  hyperemia,  cellular 
infiltration,  and  edema.  The  characteristic  picture  of  atrophic  cirrhosis  is,  there- 
fore, that  of  a  small,  contracted  liver,  tawny  in  hue,  and  possessing  a  roughened 
surface,  which  in  some  cases  may  be  so  irregular  as  to  be  called  "hob-nail"  liver, 
because  of  its  resemblance  to  a  rough  shoe,  the  sole  of  which  is  filled  with  hob-nails 
(Fig.  108). 

Atrophic  cirrhosis  of  the  liver  is  a  not  uncommon  malady  in  adults,  and  it  is  by 
far  the  most  frequent  of  all  the  types  of  cirrhosis  which  aft'ect  this  organ. 


Liver,  advanced  cirrhosis;  typical  hob-nailed  organ.    A,  gallbladder. 


Etiology. — The  causes  of  atrophic  cirrhosis  of  the  liver  are  chronic  alcoholism 
and  other  chronic  intoxications,  of  which  lead  is  certainly  one  of  the  most  important. 
There  is  good  reason  to  believe  that  prolonged  gastro-intestinal  indigestion  and 
disorders  of  nutrition,  such  as  gout  and  its  allied  states,  may  exert  a  similar  effect. 
Experimental  cirrhosis  has  been  produced  in  animals  by  acetic,  lactic,  butyric, 
and  valerianic  acid,  all  of  which  are  present  in  cases  of  gastro-intestinal  disorder. 
Syphilis  may  cause  it  (see  Syphilis  of  the  Liver),  and  hepatic  cirrhosis  has  been 
known  to  develop  after  severe  infectious  fevers.  Cardiac  disease,  with  great  and 
prolonged  hepatic  congestion,  may  also  produce  cirrhotic  changes,  and  it  is  a 
noteworthy  fact  that  cirrhosis  may  be  present  as  a  part  of  a  general  fibroid  process 
involving  the  bloodvessels  and  the  kidneys.  Mallory  summarizes  the  etiology 
under  five  types  of  cirrhosis,  namely,  toxic,  infectious,  pigment,  syphilitic,  and 
alcoholic. 

Pathology  and  Morbid  Anatomy. — In  cirrhosis  of  the  liver  the  dominant  lesion 
is  an  increase  in  its  connective  tissue.  This  overgrowth  varies  very  greatly  in 
different  cases.     Although  the  fibrous  overgrowth  may  penetrate  the  lobules,  it  is 


608  DISEASES  OE  THE  IJVER 

principally  increased  at  the  [jeriphery  of  these  structures.  Again,  it  may  be 
equally  distributed  throughout  the  entire  liver  or  affect  certain  areas  very  much 
more  than  others,  and,  finally,  the  overgrowth  of  fibrous  tissue  may  be  so  great 
that  bands,  both  large  and  small,  may  traverse  the  liver  substance,  separating 
it  into  masses  of  compressed  glandular  tissue. 

The  fil)rous  tissue  formed  in  this  process,  like  fibrous  tissue  formed  elsewhere 
in  the  body,  undergoes  cicatricial  contraction,  and  by  this  means  fatty  degeneration 
or  atrophy  of  the  liver  cells  composing  the  lobules  is  facilitated.  These  changes 
are  due,  not  only  to  the  pressure  exerted  on  the  lobules,  so  that  their  cells  are 
flattened  and  deformed,  but  also  to  the  effects  produced  on  the  circulation  of  blood 
in  the  liver. 

It  will  be  recalled  that  the  hepatic  artery  carries  to  the  liver  the  blood  which 
is  to  nourish  its  cells,  just  as  the  bronchial  arteries  carry  the  blood  which  is  to 
nourish  the  lungs.  The  blood  from  the  branches  of  this  vessel  in  performing  its 
nutritive  function  pass  through  tlae  so-called  interlobular  vessels,  and  from  these 
into  the  intralobular  vessels,  which  carry  blood  from  the  digestive  organs. 

The  overgrowth  of  fibrqus  tissue  in  the  interlobular  spaces,  in  the  fibrous  sheath 
of  the  interlobular  veins,  and  sometimes  even  between  the  cells  about  the  intra- 
lobular veins  results  in  obstruction  to  the  flow  of  blood.  The  arterial  supply  is 
little  affected,  but  the  venous  flow  is  interfered  with,  and  in  this  manner  the  cells 
suffer,  not  only  from  the  pressure  of  the  fibrous  tissue,  but  from  the  pressure  in 
the  vessels.  Nor  is  this  all,  for  the  fibrous  tissue  obstructs  tlie  smaller  bile-ducts 
and  so  prevents  the  escape  of  bile,  with  the  result  that  atrophy  takes  place  from 
retained  secretion,  and  tlae  tissues  of  the  liver  become  bile-stained. 

Many  pathologists  adhere  to  the  view  that  the  destruction  of  the  parenchyma 
of  the  organ  takes  place  first,  and  that  the  overgrowth  of  the  connective  tissue 
already  described  is  secondary  to  this  change. 

The  remote  effects  of  the  interference  with  the  circulation  of  blood  in  the  liver 
is  catarrh  of  the  stomach  and  duodenum,  due  to  the  olistruction  of  the  blood  in 
the  portal  veins.  This  state,  finally,  may  cause  \'aricosities  in  the  gastric  or 
esophageal  vessels,  and  hematemesis  may  ensue,  or  it  may  cause  fatal  hemorrhage 
from  the  bowels  because  of  similar  varicosities  in  the  intestinal  wall.  The  marked 
portal  obstruction  leads  to  transudation  from  the  peritoneal  vessels,  constituting 
the  ascites  of  liepatic  cirrliosis. 

Not  rarely  in  well-developed  cases  of  hepatic  cirrhosis  the  veins  of  the  abdominal 
wall  will  be  found  enlarged  in  an  endeavor  to  supplement  the  deep  abdominal  veins 
in  the  transfer  of  blood  from  the  portal  area  to  the  vessels  of  the  thorax.  Still 
another  state,  called  the  "cajnd  medusa:,"  is  the  development  of  a  bimch  of  enlarged 
veins  about  the  umbilicus.  This  has  been  generally  considered  as  due  to  the  stasis 
in  the  paraumbilical  vein  or  in  the  umbilical  vein,  which  has  not  closed,  as  it  usually 
is  after  birth.  As  a  result  a  collateral  circulation  is  establislied  by  an  anastomosis 
with  the  internal  mammary,  epigastric,  and  cutaneous  veins. 

From  the  description  which  lias  just  been  given  of  the  effect  of  cicatricial  con- 
traction, it  is  easily  seen  why  the  liver  presents  upon  its  surface  so  many  excrescences 
or  projections  (the  so-called  "hob-nail  liver"),  for  parts  of  the  gland  are  pressed 
out  of  place,  and  other  parts  pulled  in,  hx  the  ever-growing  fibrous  l)ands.  (See 
Fig.  108.) 

The  atrophy  of  the  parenchyma  of  the  liver  in  the  true  atrophic  form  causes  a 
very  great  diminution  in  the  size  of  the  organ,  so  that  the  organ  may  be  less  than 
one-half  its  natural  dimensions. 

The  spleen  is  usually  enlarged,  and  arteriosclerotic  clianges  are  often  present. 
Secondary  fibroid  changes  in  the  pancreas  have  also  been  described. 

In  the  so-called  fatty  cirrhosis,  in  which  the  deposit  of  fat  is  more  pronounced 
than  the  cicatricial  contraction  of  fibrous  tissue,  the  gland  may  not  be  decreased 


crRRHOsrs  of  the  liver  nno 

in  size,  and  it  may  be  much  larger  than  the  normal.     Such  a  li\cr  is  rarely  hoh- 
nailed,  but  smooth,  or  but  slightly  roughened. 

Peritoneal  and  pleural  tuberculosis  is  a  not  uncommon  complication  of  atrophic 
cirrhosis  of  the  liver. 

Symptoms. — The  symptoms  of  atrophic  cirrhosis  of  the  liver  are,  to  a  large 
degree,  dependent  upon  the  obstruction  to  the  circulation  of  blood  in  the  intra- 
lobular and  interlobular  vessels,  and  if  the  effects  of  this  obstruction  are  relieved, 
or  prevented  from  developing,  by  the  establishment  of  an  efficient  collateral  circula- 
tion, there  may  be  no  symptoms  at  all  for  many  months,  or,  indeed,  for  years. 
Occasionally  we  meet  with  cases  in  which  an  extreme  degree  of  atrophy  of  the 
liver  seems  to  be  present  with  no  symptoms  of  any  importance,  and  yet  the  patient 
is  taking  far  more  alcohol  than  is  good  for  him.  It  is  scarcely  conceivable  that  the 
establishment  of  a  collateral  circulation  can  be  responsible  for  the  absence  of  all 
systemic  disturbance,  but  there  is  no  other  explanation  for  it. 

When  obstruction  to  the  flow  of  blood  in  the  portal  vessels  is  produced  gastric 
catarrh  develops,  and  this  causes  indigestion  and  distress  in  the  epigastrivm,  with 
morning  nausea  and  wmitijig.  Usually  the  patient  loses  strength  and  is  prone  to 
become  spare  and  lean  if  previously  stout. 

The  occurrence  of  hemorrhage  from  the  stomach,  and  bowel  has  already  been 
mentioned  when  discussing  the  secondary  lesions  of  the  disease,  as  has  also  the 
presence  of  enlarged  abdominal  veins  and  the  caput  medusw  on  the  abdominal  wall. 
Thayer  has  called  attention  to  the  fact  that  in  some  cases  a  distinct  venous  hum 
or  thrill  may  be  heard  or  felt  in  the  epigastrium  just  above  the  umbilicus.  In 
some  cases  these  signs  are  even  more  marked  in  the  space  just  below  the  xyphoid 
cartilage.  Where  anemia  is  marked,  another  murmur  or  venous  hum,  due  to  the 
state  of  the  blood,  is  heard  to  the  right  of  the  navel  over  the  inferior  vena  cava. 
(See  also  the  article  on  Hematemesis.)  The  skin  of  the  trunk  is  often  more  sallow 
and  yelloAV  than  normal,  but  it  is  rarely  discolored  by  a  true  jaundice.  At  times 
the  temperature  may  be  subnormal,  and  at  others  slightly  febrile. 

In  some  cases  which  have  manifested  few  or  none  of  these  symptoms,  the  patient, 
with  little  warning,  develops  a  state  of  delirivm,  which  is  often  of  a  noisy  and 
joyous  type,  but  he  soon  sinks  into  a  state  which  proceeds  to  coma,  and  then  to 
death.  To  tliis  state  the  term  "  hepatic  coma"  has  been  applied.  It  was  thought 
at  one  time  to  be  due  to  cholesteremia,  but  this  view  has  now  been  cast  aside 
without  any  satisfactory  explanation  of  the  state  being  offered.  I  have  so  often 
seen  this  condition  follow  free  drainage  of  ascites  that  I  believe  this  operation 
predisposes  to  its  development. 

The  physical  signs  of  atrophic  cirrhosis  consist  in  an  inability  to  palpate  the 
lower  margin  of  the  liver  by  ordinary  effort,  and  in  the  small  area  of  hepatic  dulness 
on  percussion.  In  those  cases  in  which  ascites  is  marked,  it  is  often  impossible 
to  discover  the  state  of  the  liver  until  the  fluid  is  withdrawn. 

Some  have  held  that  the  ascites  is  really  the  result  of  an  associated  low-grade 
peritonitis. 

Hess  has  lately  directed  attention  to  obliterating  endophlebitis  of  the  hepatic 
veins  as  producing  symptoms  almost  identical  with  those  of  cirrhosis.  Most  of 
the  23  cases  on  record,  as  also  the  one  he  reports,  were  diagnosed  cirrhosis  of  the 
liver.  The  signs  leading  one  to  suspect  obliteration  of  the  hepatic  veins  are  absence 
of  the  history  of  a  cause  of  cirrhosis,  pain  over  the  hepatic  area  or  localized  in  the 
upper  abdomen,  and  rapid  swelling  of  the  liver  and  development  of  ascites. 

Prognosis. — The  prognosis  as  to  the  duration  of  life  depends  entirely  upon  the 
degree  of  obstruction  to  the  circulation  and  upon  the  severity  of  the  patient's 
symptoms.  If  ascites  is  well  developed  and  the  emaciation  marked  the  outlook 
for  more  than  a  few  months  of  life  is  bad,  yet  there  are  cases  on  record  in  which 
repeated  tappings  have  resulted  in  the  prevention  of  recurrence  of  ascites  and  in 
39 


(ill)  DISEASES  OF  THE  LIVER 

the  apparent  recovery  of  the  ])aticnt.  Prohahly  in  these  cases  the  ascites  was 
not  due  to  the  cirrhosis,  or  the  relief  of  pressure  has  permitted  the  establishment 
of  a  collateral  circulation.  The  occurrence  of  hemorrhages  is  always  a  most  grave 
omen,  yet  patients  often  live  for  months  after  severe  bleedings. 

Treatment. — The  treatment  consists  in  removing  the  cause  of  the  disease,  if  it 
l)c  alcohol,  and  in  an  endeavor  to  prevent  intestinal  fermentation  and  disorder 
by  mild  jnirgatives,  digestive  stimulants,  acids,  and  antiseptics.  Each  morning 
the  patient  should  have  the  bowels  well  moved  by  a  glass  of  hot  Ilunyadi  or  Carlsbad 
water,  and  while  this  is  acting  he  should  receive  a  few  drops  of  Fowler's  solution 
for  the  nausea  and  lack  of  appetite  at  breakfast.  During  breakfast,  luncheon,  and 
supper  he  should  take  a  capsule  made  up  as  follows: 

I^ — Pancreatin, 
Taka-diastase, 
Sodii  bicarbonat aa     gr.  ij. — M. 

S. — Take  with  each  meal. 

In  some  cases  the  catarrhal  state  of  the  stomach  and  bowels  is  benefited  by  the 
use  of  small  doses  of  iodide  of  potassium,  .5  grains  three  or  four  times  a  day,  or  of 
ammonium  chloride  in  the  same  amount. 

Within  the  last  few  years  it  has  been  proposed  by  Talma  and  others  that  an 
endeavor  be  made  to  relieve  the  obstructive  symptoms  of  atrophic  cirrhosis  by 
establishing  a  collateral  circulation  by  surgical  procedure.  The  anterior  surface 
of  the  liver,  of  the  spleen,  and  of  the  parietal  peritoneum  and  intestines  are  rough- 
ened by  being  rubbed  with  surgical  gauze,  and  the  omentum  is  attached  to  the 
parietal  peritoneum  of  the  anterior  abdominal  wall  by  sutures.  By  this  means 
it  is  hoped  to  cause  adhesions  through  which  the  collateral  circulation  may  be 
established.  The  operation  is  not  devoid  of  danger  because  of  the  malnutrition 
of  the  patient  and  seems  to  have  lost  popularity. 

Ascites  should  be  treated  by  tapping.  (See  Ascites.)  The  use  of  violent  hydra- 
gogue  cathartics,  in  the  hope  that  the  quantity  of  fluid  will  be  materially  decreased, 
is  not  very  successful,  as  a  rule,  and  may  weaken  the  patient.  It  is,  however, 
important  to  keep  the  bowels  opened  freely  to  avoid  distention  and  pressure. 

Hypertrophic  Cirrhosis. — Definition.  —  Hypertrophic  cirrhosis  is  a  condition 
in  which  the  liver  is  very  much  enlarged,  its  surface  is  smooth,  jaundice  develops, 
but  ascites  is  absent.  It  is  called  by  the  French  cirrhose  hypertro2)hiqve  avec  ictere, 
or  hypertrophic  cirrhosis  with  jaundice. 

Etiology. — The  causes  of  this  malady  are  unknown.  Alcohol  is  not  a  factor. 
In  the  cases  I  have  seen  a  history  of  severe  and  prolonged  malarial  infection  has 
been  present  in  several  instances.  It  is  a  disease  of  young  adult  and  early  middle 
life,  but  cases  occur  in  children  of  tender  years. 

Pathology  and  Morbid  Anatomy. — An  essential  difl'erence  between  atrojihic  and 
hypcrtniphic  cirrhosis  is  that  in  the  former  the  connective  tissue  which  is  developed 
undergoes  contraction,  whereas  in  the  hypertrophic  form  it  remains  more  cellular 
and  does  not  contract.  The  second  difference  lies  in  the  fact  that  in  hypertrophic 
cirrhosis  there  is  a  very  considerable  increase  of  connective  tissue  about  the  biliary 
ducts  (biliary  cirrhosis),  with  comparatively  little  or  no  increase  of  this  tissue 
about  the  bloodvessels.  For  these  reasons  we  do  not  find  any  marked  decrease 
inthc  blood  sup])ly  of  the  gland,  l)ut  we  do  find  jamidice  because  the  biliary  ducts 
are  obstructed.  In  the  atrophic  form,  therefore,  venous  obstruction  causes  ascites; 
in  the  hypertrophic  form  biliary  obstruction  causes  jaundice,  but  there  is  usually 
no  ascites.  Between  these  two  types  of  cirrhosis  intermediate  cases  develop,  in 
which  sufficient  overgrowth  of  connective  tissue  about  the  bloodvessels  may  be 
present  to  cause  ascites,  for  in  hypertrophic  cirrhosis  there  is  an  overgrowth  of 
connective  tissue  about  the  interlobular  vessels,  and  even  between  the  cells  of  the 
lobules. 


CIRRHOSIS  OF  THE  LIVER  611 

Although  the  Hver  is  enlarged,  it  does  not  present  the  hob-nailed  appearance 
of  atrophic  cirrhosis  because  contractions  do  not  occur.  On  cross-section  it 
presents  a  firm  surface  of  a  yellowish-green  hue,  and  strands  of  connective  tissue 
can  be  seen  traversing  it. 

It  has  been  shown  that  in  some  instances  hypertrophic  cirrhosis  is  a  secondary 
condition  arising  from  disease  of  the  bile-ducts,  and  that  in  others  it  is  a  primary 
state  without  connection  with  any  direct  cause  yet  discovered.  As  a  consequence, 
some  writers  have  divided  this  disease  into  two  types  and  have  asserted  that  these 
are  separate  entities.  The  pathological  changes  in  the  two  cases  are  so  nearly 
identical  that  this  separation  is  not  justifiable.  To  the  primary  form  the  term 
"Hanot's  cirrhosis"  has  been  applied.  In  this  form  there  is  pigmentation  of  the 
skin  in  addition  to  jaundice,  there  is  usually  more  pain  than  in  the  commoner 
variety,  and  the  spleen  is  usually  very  large.  It  is  better  to  call  such  cases 
instances  of  Hanot's  type  of  hypertrophic  cirrhosis. 

Symptoms. — The  predominant  symptom  of  this  disease  is  enlargement  of  the 
liver,  which  often  extends  to  a  lower  level  than  that  of  the  navel  and  far  to  the 
left  of  the  middle  line.  When  the  liver  is  palpated  it  is  found  to  be  hard  and  its 
surface  fairly  smooth,  its  edges  rounded,  and  its  movement  heavy  and  difficult 
when  it  is  pressed  upon.  Percussion  reveals  the  fact  that  it  not  only  extends 
downward,  but  upward  far  above  the  ordinary  hepatic  level,  and  laterally  even  to 
the  sixth  rib,  pushing  the  diaphragm  and  lung  before  it.  The  spleen  is  usually 
considerably  enlarged.  Jaundice  is  generally  present  and  varies  from  a  faint 
lemon-yellow  to  a  dark  olive  hue,  but  it  is  a  noteworthy  fact  that  the  stools  are 
not  without  bile,  as  in  ordinary  jaundice.  The  urine,  of  course,  contains  bile. 
At  times  attacks  of  severe  hepatic  pain  develop,  and  the  liver  may  seem  more 
enlarged  than  usual  at  these  periods.  Pruritus  is  often  a  most  persistent  symptom, 
and  xanthoma  may  be  developed  to  an  extraordinary  degree.  In  a  case  now  under 
my  care  the  yellow  xanthomatous  patches  about  the  eyes  formed  a  striking  contrast 
to  the  dark  olive  hue  of  the  rest  of  the  face.  More  or  less  disturbance  of  digestion, 
due  to  gastric  catarrh,  from  an  impaired  circulation  in  the  stomach,  is  nearly 
always  present. 

Diagnosis. — An  enlarged  liver,  like  that  seen  in  hypertrophic  cirrhosis,  is  also 
seen  in  leukemia,  but  the  association  of  profound  anemia  and  pallor  of  the  skin 
separate  it  from  the  condition  now  under  consideration.  Great  enlargement 
of  the  liver  also  occurs  in  heart  disease  from  hepatic  congestion,  and  in  cases  of 
adherent  pericardium.  The  state  of  the  heart  makes  the  diagnosis  possible  in 
these  instances.  Malignant  growth  of  the  liver  can  often  be  differentiated  by  the 
presence  of  a  primary  growth  in  the  gallbladder  or  stomach,  and  by  the  nodules 
felt  in  the  liver  substance. 

Prognosis. — The  prognosis  as  to  cure  is  hopeless.  As  to  duration  of  life,  it 
varies  from  one  to  ten  years.  Death  comes  from  some  terminal  infection,  from  a 
hemorrhage  into  the  bowel  or  stomach,  or  from  an  ever-increasing  feebleness. 
At  times  coma  develops. 

Treatment. — There  is  no  treatment  for  the  disease  itself.  The  digestion  should 
be  kept  in  good  order  by  the  line  of  treatment  outlined  for  this  function  under 
Atrophic  Cirrhosis. 

Syphilitic  Cirrhosis. — Syphilis  may  produce,  in  its  inherited  form  or  tertiary 
stage,  a  remarkable  degree  of  cirrhotic  change  in  the  liver.  The  overgrowth  of 
connective  tissue  in  this  type  projects  itself  everywhere  between  the  lobules  and 
between  their  cells,  or  forms  large  bands  which,  as  they  contract,  produce  extra- 
ordinary irregularities  in  its  surface,  so  that  the  organ  appears  to  be  as  well  covered 
with  knobs  as  a  tuberous  root  is  covered  by  projections;  a  polylobed  organ.  (See 
Syphilis.) 

Because  of  the  frequency  of  syphilis,  this  form  of  cirrhosis  is  not  very  rare. 


612  DISEASES  OF  THE  LIVER 

The  importance  of  recognizing  it  lies  in  the  fact  that  while  we  cannot  cure  the 
state  already  developed,  by  active  antisyphilitic  treatment  we  may  l)e  able  to 
arrest  or  delay  its  progress,  and  in  this  sense  the  prognosis  is  better  than  in  the 
non-syphilitic  type.  In  some  cases,  however,  this  peculiar  nodular  formation 
does  not  occur,  and  the  course  of  the  disease  may  be  identical  with  ordinary  atrophic 
cirrhosis.  Sometimes  tumors  due  to  the  formation  of  gummata  can  be  felt.  The 
symptoms  differ  in  no  way  from  those  of  ordinary  cirrhosis,  except  when  giunniata 
are  present. 

Treatment. — The  treatment  of  syphilitic  cirrhosis,  while  it  presents  greater 
op])()rtuiiities  than  are  offered  by  therapeutic  measures  in  ordinary  cirrhosis,  cannot 
be  expected  to  produce  very  remarkable  alterations  in  the  li\er.  Wonderful  as 
are  the  effects  of  the  iodides,  salvarsan,  and  mercury  in  the  treatment  of  syphilis, 
they  camiot  regenerate  tissues  which  have  been  destroyed,  and  the  most  that  we 
can  expect  from  them  is  that  they  will  do  something  to  arrest  the  progress  of 
the  disease,  and,  perhaps,  cause  a  removal  of  some  of  the  cells  which  have  been 
proliferated,  but  which  have  not  as  yet  become  organized  tissue.  In  those  cases  in 
which  there  are  any  evidences  of  active  syphilis,  it  is  hardly  necessary  to  state  that 
specific  treatment  should  be  carried  out  most  thoroughly.     (See  Syphilis.) 

PERIHEPATITIS  (CAPSULAR  CIRRHOSIS). 

Inflammation  of  the  capsule  of  the  liver  and  of  the  tissues  immediately  lieneath 
it,  when  it  occurs  in  a  chronic  form,  may  be  associated  with  chronic  jieritonitis 
and  with  hepatic  cirrhosis.  More  rarely  it  develops  as  a  result  of  chronic  pleurisy 
on  the  right  side.  The  thickening  which  ensues  may,  by  its  contraction,  result  in 
deformity  of  the  surface  of  the  liver.  This  effect  is  increased  by  the  fact  that 
abnormal  projections  of  connective  tissue  dip  downward  from  the  capsule  into  the 
liver  substance  and  divide  it  into  masses  of  parenchyma,  which  undergo  atrophy 
from  pressure.  The  condition  is,  therefore,  in  some  cases,  at  least,  not  very  different 
from  that  met  with  in  ordinary  atrophic  syphilitic  cirrhosis. 

The  condition  is  very  rare  and  is  thought  by  Hale  White  to  be  due  to,  or  a 
sequence  of,  contracted  kidney.  Unlike  most  instances  of  chronic  contracted 
kidney,  the  patient  often  has  marked  ascites  because  of  the  state  of  the  liver.  As 
already  stated,  it  sometimes  happens  that  the  capsule  of  the  liver  is  secondarily 
involved  in  cases  of  chronic  peritonitis,  particularly  in  cases  of  adherent  peri- 
cardium and  chronic  inflammatory  changes  in  the  mediastinima.  (See  Adherent 
Pericardium  and  Mediastinitis.) 

AFFECTIONS  OF  THE  HEPATIC  BLOODVESSELS. 

These  consist,  aside  from  those  already  considered  when  discussing  the  subject 
of  cirrhosis,  in  three  chief  changes. 

Hyperemia  occurs  physiologically  whenever  the  liver  is  actively  engaged  in 
disposing  of  foodstuff's.  Pathologically,  it  probably  takes  place  when  an  extra 
amount  of  stimulating  food  and  irritant  drink  are  taken.  Neither  condition  is 
capable  of  being  diagnosticated. 

A  much  more  imjiortant  state  is  the  congestion  due  to  cardiac  disease,  or  to  other 
causes  which  retard  the  egress  of  blood  from  the  gland.  W'e  find,  therefore,  that 
all  the  causes  which  tend  to  result  in  interference  with  the  free  flow  of  blood  in 
the  inferior  vena  cava  above  the  liver  may  cause  hejja tic  congestion.  Insufficiency 
of  the  tricuspid  valves  of  the  heart,  pulmonary  emphysema,  fibroid  lung,  bronchiec- 
tasis, and  valvular  disease  of  the  left  side  of  the  heart,  with  secondary  obstruction 
in  the  right  side,  all  produce  it. 

The  congestion  is,  of  course,  due  not  to  an  increase  of  blood  in  the  portal  vein 


AFFECTIONS  OF  THE  HEPATIC  BLOODVESSELS  613 

but  in  the  hepatic  veins.  As  a  result  of  this,  the  centre  of  each  lobule  is  congested, 
and  its  periphery  contains  relatively  less  blood.  Frequently  the  cells  in  the  areas 
of  greatest  congestion  are  pigmented.  As  a  result  of  this,  the  homogeneous  hue 
of  the  normal  liver  is  altered,  and  it  presents  what  is  called  a  "  nutmeg"  appearance, 
particularly  if  the  cells  at  the  periphery  become  still  paler  from  fatty  changes. 
In  some  cases,  however,  nothing  more  than  the  appearance  of  intense  congestion 
is  present.  When  the  continued  pressure  by  the  excess  blood  and  the  consequent 
malnutrition  causes  atrophy  of  hepatic  cells,  the  condition  is  known  as  "red  atro- 
phy" of  liver. 

During  life  the  congested  liver  is  usually  much  larger  than  normal,  and  may 
attain  enormous  dimensions,  but  not  rarely,  when  the  congestion  has  lasted  for  a 
long  time,  it' grows  smaller  than  it  is  in  health,  and  its  surface  may  be  roughened, 
so  that  it  may  somewhat  resemble  the  roughened  surface  seen  in  early  stages  of 
atrophic  cirrhosis.     In  fact  the  connective  tissue  is  usually  increased. 

A  third  vascular  lesion  is  thrombosis  of  the  portal  vein.  The  formation  of  this 
thrombus  may  be  due  to  pressure  on  the  vein  produced  by  a  tumor,  by  gallstones, 
by  traumatism,  and  in  some  instances  it  maj^  arise  from  septic  infection.  When 
the  thrombus  forms  from  pressure,  and  is  not  infectious,  it  may  become  organized 
and  gradually  close  the  vessel  permanently.  This  does  not  necessarily  work 
much  havoc  in  the  liver,  because  the  nutrition  of  this  organ  is  carried  out  by  the 
branches  of  the  hepatic  artery,  which  speedily  enter  into  anastomosis  with  the 
neighboring  vessels.  While  the  liver  itself  may  not  suffer  very  greatly,  the  abdomi- 
nal circulation  is  usually  much  disturbed  by  obstruction  of  the  portal  vein,  and 
the  spleen,  the  kidneys,  and  the  veins  of  the  entire  abdominal  network  become 
engorged,  so  that  ascites  usually  occurs  and  hematemesis  or  bloody  stools  may  be 
produced. 

If  the  thrombus  is  infectious  {suppurative  pylephlebitis),  the  pathological  and 
clinical  picture  is  quite  different,  for  in  this  case  the  clot  does  not  act  as  a  mechanical 
obstruction  alone,  but  as  a  source  of  septic  infection.  Necrosis  and  suppiu-ation 
take  place  in  the  wall  of  the  infected  vessel  and  in  the  hepatic  tissues  around  it. 
The  thrombus  may  break  down  and  minute  pieces  of  the  infected  mass  pass  into 
smaller  divisions  of  the  portal  vein,  and  so  spread  the  disease  until  multiple  abscess 
of  the  liver  develops. 

The  sources  from  which  such  septic  infections  arise  are  found  in  ulcer  of  the 
stomach  and  bowels,  appendicitis  and  suppuration  of  the  lymph  nodes  in  the 
mesentery.  Another  origin  is  suppurative  angiocholitis.  (See  Abscess  of  the 
Liver.)     In  infants  infection  may  take  place  by  way  of  the  umbilicus. 

Symptoms. — The  symptoms  of  congested  liver  consist  in  finding  its  lower  margin 
below  the  ribs  to  an  abnormal  degree  and  distinct  tenderness  on  pressure,  particularly 
in  the  epigastrium.  Pain  in  this  region  is  often  complained  of  by  the  patient  even 
when  he  is  at  rest.  If  tricuspid  regurgitation  is  present,  the  liver  may  have  systolic 
expansile  pulsation,  which  must  not  be  confounded  with  movement  of  the  liver 
due  to  direct  transmission  of  the  impulse  of  the  apex  beat  of  the  heart.  In  some 
cases  distinct  evidences  of  gastro-intestinal  catarrh  develop,  and  the  congestion 
of  the  gastric  vessels  may  be  so  great  as  to  cause  rupture  and  hematemesis.  Ascites 
due  to  the  interference  with  the  venous  return  in  the  lower  parts  of  the  body,  and 
edema  of  the  legs  from  the  same  cause  may  be  present. 

Treatment. — ^The  treatment  consists  in  unloading  the  gastroduodenal  and  hepatic 
glands  and  bloodvessels  by  a  full  dose  of  the  blue  mass  (10  grains),  followed,  by 
a  saline  purge.  This  is  to  be  followed  by  the  use  of  digitalis  to  support  the  heart, 
and,  if  the  arterial  tension  is  high,  by  the  administration  of  nitroglycerin,  to  lower 
the  arterial  pressure  and  so  relieve  the  heart  of  work.  (See  Valvular  Disease 
of  the  Heart.) 


614  DISEASES  OF  THE  LIVER 

AMYLOID  LIVER. 

Amyloid  disease  of  the  liver  occurs  as  the  result  of  severe  and  prolonged  suppura- 
tive changes  in  other  parts  of  the  body,  as  in  chronic  bone  disease,  in  pulmonary 
tuberculosis,  and  in  syphilis,  particularly  if  the  latter  disease  has  caused  suppuration 
over  a  long  period  of  time.  The  liver  is  usually  very  large  and  may  be  easily  felt 
far  below  the  ribs,  presenting  a  smooth  surface.  Occasionally  an  amyloid  liver 
is  small.  When  it  is  cut  across  it  is  found  to  be  hard  and  infiltrated  by  amyloid 
material,  which  stains  a  mahogany  hue  when  it  is  touched  with  a  watery  solution 
of  iodine. 

Symptoms. — The  symptoms  are  not  typical.  Indeed,  it  may  be  said  that  the 
changes  in  the  liver  produce  no  manifestations  that  call  attention  to  hepatic  disease, 
for  there  is  no  jaundice  and  no  pain,  neither  is  there  any  ascites.  The  presence 
of  enlargement  of  the  liver,  with  a  smooth  surface  of  the  gland,  and  the  presence 
of  a  suppurative  focus,  combined  with  an  absence  of  any  of  the  signs  of  hypertrophic 
cirrhosis  and  morbid  growth,  make  the  diagnosis  easy. 

Treatment. — There  is  no  treatment  for  amyloid  liver,  except  the  removal,  if 
possible,  of  the  suppurating  area,  which  is  the  underlying  cause  of  the  disease,  and 
in  the  maintenance  of  as  great  a  degree  of  health  as  possible  by  the  use  of  fresh  air, 
sunshine,  iron,  arsenic,  and  good  food. 

FATTY  LIVER. 

Fatty  liver,  like  fatty  heart,  occurs  in  two  forms,  namely,  as  a  true  fatty  degenera- 
tion of  the  hepatic  cells  and  as  an  infiltration  of  fat  between  the  cells.  The  true  fatty 
degeneration  without  cirrhosis  is  rarely  met  with,  except  as  a  result  of  the  ingestion 
of  some  poison,  such  as  phosphorus,  antimony,  iodoform,  sulphate  of  copper, 
or  carbolic  acid.  A  similar  change  is  present  in  acute  yellow  atrophy  of  the  liver. 
In  uncomplicated  fatty  infiltration  the  liver  is  enlarged  and  smooth.  On  autopsy 
it  is  pale  and  yeljow  and  renders  the  incising  knife  greasy.  Its  specific  gravity 
is  so  low  that  the  organ  may  almost  float  in  water.  No  distinctive  hepatic  symp- 
toms are  present. 

Often  fatty  infiltration  is  part  of  general  obesity,  and  the  large  deposit  of  fat 
in  the  abdominal  wall  and  in  the  tissues  near  the  liver  make  a  diagnosis  difficult. 

Large,  fatty,  cirrhotic  livers  have  been  recorded,  and  fatty  liver  accompanying 
alcoholism,  severe  anemia,  and  cachexia,  as  in  tuberculosis,  also  occurs.  In  such 
cases  the  change  is  thought  to  be  due  to  faulty  oxidation. 

TUMORS  OF  THE  LIVER. 

The  most  important  morbid  growth  in  the  liver  is  carcinoma.    It  is  rarely  primary. 

Secondarij  carcinoma  is  quite  common  and  is  nearly  always  due  to  metastasis 
from  the  alimentary  viscera,  as  from  carcinoma  of  the  gallbladder,  of  the  stomach, 
of  the  pancreas,  or  of  the  intestines.  In  rare  instances  the  metastasis  is  from  more 
distant  organs,  as  the  uterus  or  mammary  gland. 

Carcinoma  of  the  liver  rarely  occurs  as  a  solitary  nodule.  Usually  it  is  in  the 
form  of  multiple  growths,  which  vary  in  size  from  a  small  seed  to  an  orange.  When 
these  growths  are  immediately  subcapsular  they  appear  as  large  protuberances 
on  the  surface  of  the  organ,  which  may  be  felt  as  nodules  through  the  belly  wall, 
or  they  lie  buried  in  the  tissue  of  the  liver  and  present  a  disk-like  surface  upon  the 
level  of  the  capsule,  so  that  they  may  be  felt  in  thin  persons  as  a  slightly  flattened 
or  umbilicated  elevation.  The  nodules  are  sometimes  very  hard,  at  other  times 
quite  soft,  and  in  the  centre  softening  mav  take  place,  so  that  an  apparent  cvst  is 
formed  (Fig.  109). 


TUMORS  OF  THE  LIVER  G15 

The  liver  is  sometimes  enormously  enlarged  and  may  extend  far  below  the  navel, 
thereby  causing  great  distention  of  the  belly.  A  very  rare  form  of  hepatic  cancer 
is  that  in  which  the  liver  diminishes  in  size  with  the  development  of  the  growth. 

Sarcoma  of  the  liver  is  rarely  encountered. 

Cavernous  angiomata  have  been  described,  and  cysts,  single  and  large,  or  multiple 
and  small,  have  been  found  in  this  organ.  The  latter  are  congenital,  the  so-called 
"cystic  disease  of  the  liver."     (See  also  Hydatid  Disease.) 

Symptoms. — The  evidences  of  tumor  of  the  liver  may  be  so  easily  observed  in 
many  cases  that  there  is  no  difficulty  in  making  a  diagnosis,  particularly  if  emacia- 
tion, anemia,  and  profound  cachexia  are  present.  In  other  cases  the  fact  that 
the  patient  is  still  well  nourished,  and  the  growths  deeply  situated,  may  render  it 
impossible  to  discover  the  existence  of  a  mass  by  palpation.  In  some  instances  there 
is  present  nothing  more  than  a  vague  sense  of  distress  in  the  hypochondrium,  with 
loss  of  weight  and  strength.  In  still  others,  if  the  gall-ducts  are  obstructed, 
jaundice  may  come  on,  and  if  the  pancreas  is  involved,  fatty  stools  may  be  present, 
or  glycosuria  is  found.  Pain  may  be  severe,  but  usually  it  is  not.  At  times  the 
veins  of  the  leg  on  the  right  side  may  be  obstructed  by  a  thrombus,  or  a  phlebitis 
may  be  present.     Moderate  fever  may  occur. 


Liver,  secondary  carcinoma.    Even  the  smaller  nodules  show  more  or  less  umbilication,  which  is 
marked  in  the  larger  masses. 

Diagnosis. — The  diagnosis  requires  that  we  exclude  hypertrophic  cirrliosis, 
which  can  be  done  by  the  more  rapid  development  of  the  enlargement  of  the  liver 
in  carcinoma,  and  by  the  presence  of  cancerous  cachexia.  From  echinococcus 
cyst  it  must  be  separated,  by  the  fact  that  the  cyst  usually  fluctuates,  or,  at  least, 
is  not  so  hard  as  is  nodular  cancer.  From  gumma  of  the  liver  other  tumors  can 
be  differentiated  only  by  the  history  of  the  patient  and  the  response  to  antisyphilitic 
treatment. 

Prognosis. — When  the  growth  is  malignant,  the  outlook  is,  of  course,  hopeless 
as  to  recoverv. 


GIG  DISEA.^ES  OF  THE  LIVER 

Treatment. — If  the  growth  is  a  gumma,  antisyphilitic  treatment  is  of  great  vaUie. 
(See  Syphilis.)  If  it  is  a  cyst  or  non-mahgnant,  surgical  interference  is  a  possible 
source  of  reUef.  If  it  is  malignant,  no  efficient  treatment  except  tlic  relief  of  ])ain 
can  be  instituted. 


ACUTE  YELLOW  ATROPHY  OF  THE  LIVER. 

Definition. — Acute  yellow  atrophy  of  the  liver  is  a  condition  characterized  by 
marked  fatty  degeneration  of  the  organ  and  violent  headache  and  delirium.  It  is 
a  very  rare  disease. 

Etiology. — The  causes  of  acute  yellow  atrophy  are  unknown,  but  it  occurs  more 
frequently  in  women  than  in  men,  and  has  been  associated  in  many' instances 
with  the  puerperal  state.  A  micrococcus  has  been  found  in  the  liver  in  some  cases, 
but  the  suspected  bacterial  origin  of  the  disease  has  not  been  proved.  Some 
pathologists  regard  it  as  a  local  state  representing  a  general  infection,  and  others 
as  a  distinctly  local  disease,  but  its  toxic  nature  is  generally  admitted. 

Pathology  and  Morbid  Anatomy. — The  changes  which  take  place  in  the  liver  are  a 
rapid  decrease  in  its  size  due  to  necrosis,  fatty  degeneration,  and  cellular  fragmenta- 
tion. So  rapid  may  be  the  process  that  after  three  or  four  days  the  organ  is  not 
one-half  its  normal  size.  The  gland  is  soft  and  its  capsule  shrivelled,  as  if  it  were 
too  large  for  the  organ.  If  an  incision  is  made  into  the  viscus  the  lobules  will  be 
found  almost  destroyed,  and  the  cut  surface  is  mottled,  softened,  and  gray,  red, 
or  yellow,  according  to  the  stage  of  the  disease.  In  the  gray  areas  the  forms  of 
the  hepatic  cells  are  recognizable,  and  their  protoplasm  is  granular  in  appearance. 
In  the  yellow  areas  the  cells  are  more  or  less  filled  with  fatty  globules  and  yellow 
pigment,  and  in  the  red  areas  the  cell  outline  may  be  lost,  and  only  cell  debris, 
or  the  remains  of  broken-down  cells,  may  be  found.  The  spleen  is  usually  enlarged, 
the  kidneys  are  the  seat  of  parenchymatous  degeneration,  and  the  heart  muscle 
is  also  degenerated.  Hemorrhagic  extravasations  may  occur,  not  only  in  the  liver, 
but  in  the  stomach,  bowels,  bladder,  and  kidneys  as  well.  When  death  has  been 
long  delayed,  evidences  of  universal  tissue  degeneration  may  be  found. 

If  the  urine  is  examined,  it  will  be  found  loaded  with  bile  and  an  excessive  quantity 
of  leucin  and  tyrosin,  or,  perhaps,  only  one  of  these  products.  Leucin  appears  in 
round  disks,  and  the  tyrosin  in  needle-shaped  crystals,  which  are  usually  bunched 
together. 

Symptoms. — The  symptoms  of  tliis  malady  sltg  jaundice,  severe  headache,  vomiting, 
and  finally  deliriiivi,  fibrillary  muscular  tremors,  conmilsions,  and  death.  As  a 
rule,  there  is  little  or  no  fever,  but  cases  with  high  temperature  have  been  recorded. 
Petechial  spots  and  large  hemorrhages  may  develop  beneath  the  skin. 

Diagnosis. — The  development  of  what  might  be  called  fulminating  jaundice 
in  a  woman  during  the  puerperium  should  awaken  a  suspicion  of  this  disease  at 
once,  but  such  an  onset  does  not  necessarily  prove  the  presence  of  acute  yellow 
atrophy,  unless  there  is  marked  decrease  in  the  size  of  the  liver,  and  leucin  and 
tyrosin  are  present  in  the  urine.  Even  these  additional  signs  are  not  pathogno- 
monic. Particular  care  must  be  taken  that  the  coma  of  hypertrophic  cirrhosis 
is  not  taken  for  acute  yellow  atrophy  of  the  liver,  for  sometimes  hypertrophic 
cirrhosis  belies  its  name,  in  that  the  liver  is  not  greatly  engorged,  and  acute  yellow 
atrophy  may  occur  without  the  liver  being  greatly  decreased  in  size. 

Prognosis. — Death  nearly  always  occurs.   A  few  cases  are  said  to  have  recovered. 

Treatment. — Beyond  the  use  of  mild  purgatives,  diuretics,  and  stimulants  there 
is  no  treatment  for  this  maladv. 


ACUTE  CATARRH  OF  THE  BitE-DUCTS  6l7 


DISEASES  OF  THE  BILIAEY  TRACT. 

1.  Acute  Catarrh  of  the  Bile-ducts,  Acute  Cholangitis  or  Catarrhal  Jaundice. — 
As  its  name  indicates,  tliis  is  a  condition  in  wliich  the  mucous  membnuie  lining  the 
gall-ducts  becomes  inflamed  and  swollen,  and  its  secretion  thick  and  tenacious. 
These  two  conditions  produce  partial  or  complete  occlusion  of  the  ducts,  which  in 
turn  results  in  biliary  stasis  and  jaundice.  In  the  liver  itself  marked  pigmentation 
also  occurs,  because  of  the  accumidation  of  pigment  granules  in  its  cells.  When 
the  inflammatory  process  affects  the  gallbladder,  it  is  called  catarrhal  cholecystitis. 
Acute  catarrh  of  the  bile-ducts  is  the  cause  of  most  attacks  of  jaundice  which  last 
for  a  few  days. 

Etiology. — This  condition  nearly  always  arises  from  a  primary  catarrh  of  the 
duodenum,  which  extends  to  the  common  bile-duct.  It  may  follow  exposure  to 
cold,  particularly  if  the  exposure  follows  heavy  eating  and  drinking.  It  usually 
accompanies  the  presence  of  gallstones  if  they  arise  in  or  enter  the  common  or 
hepatic  duct.  It  also  is  a  result  of  infection  in  many  cases,  as  in  influenza,  or  more 
rarely  in  pneumonia.  Still  more  rarely  jaundice  occurs  after  a  severe  fright  or  a 
paroxysm  of  intense  anger.  Any  cause  which  interferes  with  the  circulation  in  the 
liver  and  duodenum  may  also  indirectly  produce  this  state,  as,  for  example,  mitral 
stenosis. 

In  nearly  all  cases  the  inflammation  does  not  extend  beyond  the  lower  part  of 
the  large  ducts. 

Symptoms. — The  symptoms  vary  very  greatly.  In  some  persons  a  well-marked 
jaundice  develops,  with  such  slight  general  symptoms  that  the  patient  does  not 
know  he  is  ill  until  he  sees  his  reflection  in  a  glass  or  a  friend  remarks  upon  his 
yellow  hue.  In  other  cases  the  patient  may  feel  and  seem  wretchedly  ill,  probably 
because  he  has  in  the  intestine  certain  substances  which,  in  the  absence  of  bile, 
develop  toxic  materials  which  the  torpid  liver  does  not  destroy.  Headache  is 
often  marked,  and  profound  iveakness  may  be  felt.  The  stools  are  piitty  color 
because  of  lack  of  bile,  and  the  xirine  is  the  hue  of  porter,  because  of  the  presence 
of  this  secretion  in  excess.  The  color  of  the  skin  varies  from  a  faint  lemon  to  a 
much  deeper  hue,  but  the  deep  olive-green  jaundice  of  chronic  hepatic  disease 
is  not  met  with.  The  pulse  and  respiration  are  remarkably  sloiv,  owing  to  the 
pathological  action  of  the  retained  biliary  salts.  The  temperature  may  be  sub- 
normal,  but  if  the  condition  is  due  to  an  acute  infection  it  may  reach  102°  or  more. 
The  liver  on  palpation  and  percussion  is  usually  found  to  be  moderately  enlarged, 
about  two  to  three  fingers'  breadth  below  the  ribs,  and  it  is  often  tender  on  pressure. 

Catarrhal  jaundice  usually  lasts  from  a  few  days  to  several  weeks.  After  the 
patient  has  been  ill  for  some  days  he  usually  loses  weight  very  rapidly.  There  is 
no  mild,  brief  acute  illness  which  causes  a  greater  loss  of  weight  in  a  few  days  than 
this  afFection. 

Diagnosis. — The  development  of  jaundice  in  persons  under  forty  without  any 
signs  of  grave  disease  renders  a  diagnosis  of  acute  catarrh  of  the  bile-ducts  probable. 
In  older  persons,  particularly  if  the  jaundice  develops  gradually,  the  possibility 
of  malignant  growth  being  present  must  be  excluded.  In  other  cases  when  jaundice 
comes  on  suddenly,  the  cause  may  be  gallstones,  and  in  such  instances  a  history 
of  colic  may  be  given.  If  distinct  enlargement  of  the  gallbladder  is  present,  the 
probability  of  carcinoma  is  great.     (See  Tumors  of  the  Gallbladder.) 

Prognosis. — In  cases  of  acute  catarrh  of  the  simple  form  the  prognosis  is  always 
good. 

Treatment. — In  acute  catarrh  of  the  bile-ducts  the  treatment  consists  in  placing 
the  patient  in  bed,  and  in  the  application  of  hot  compresses  over  the  liver,  renewing 
the  compresses  as  rapidly  as  they  become  warm.     In  some  instances  it  is  advan- 


618  DISEASkS  OF  THE  BILIARY   TRACT 

tageous  to  wet  the  compresses  with  hot  water  which  contains  a  drachm  of  dihite 
nitromuriatic  acid  to  the  pint;  or,  in  otlier  cases,  for  tlic  purpose  of  producing 
counter-irritation,  a  turpentine  stupe  may  he  employed. 

Tlie  kidneys  should  he  kept  acting  freely  by  the  administration  of  large  cjuantities 
of  Vichy  water,  or  in  other  instances  Poland  water,  if  Vichy  water  is  not  to  be  had. 
In  some  instances,  if  the  kidneys  are  inactive,  it  is  advantageous  to  add  to  the 
water  10  grains  of  bicarbonate  of  potash  in  each  glass. 

If  the  bowels  are  at  all  confined,  as  they  are  prone  to  be,  they  are  best  moved 
by  one  of  the  saline  purgatives,  of  which  sodium  phosphate  is  usually  considered 
most  advantageous.  This  may  be  given  in  quantities  varying  from  20  grains  to  a 
drachm  in  half  a  glass  of  hot  water  every  two  hours  until  the  bowels  are  thoroughly 
moved. 

The  administration  of  calomel  in  the  early  stages  of  catarrhal  jaundice  is  not 
rational.  The  object  of  the  physician  is  to  re-establish  biliary  flow,  and  the 
difficulty  which  exists  is  that  the  liver  is  unable  to  get  rid  of  the  bile  which  it 
secretes.  To  stimulate  this  gland  to  a  greater  secretion  of  bile  by  calomel,  when 
its  ducts  are  blocked,  is  manifestly  not  good  therapeutics. 

After  the  acute  stages  of  jaundice  have  passed  by,  it  is  often  advantageous  to 
give  broken  doses  of  calomel,  in  order  to  overcome  the  natural  inactivity  of  the 
liver  after  acute  inflammation  in  its  bile-ducts,  and  these  should  be  followetl  by 
the  doses  of  phosphate  of  sodium,  already  named. 

Patients  with  jaundice  frequently  insist  upon  getting  up  and  going  about.  This 
is  not  a  safe  thing  for  them  to  do,  as  it  is  entirely  possible  for  them,  if  the  cause 
be  gallstones,  to  convert  an  attack  of  acute  catarrhal  jaundice  into  one  of  acute 
cholecystitis. 

In  regard  to  diet,  the  patient  had  better  subsist  upon  nutritious  broths,  thickened 
it  may  be  with  barlej^  or  rice,  partly  digested  with  pancreatin,  and  well  flavored 
with  salt.  Milk  is  usually  not  well  digested  by  patients  suffering  from  this  con- 
dition, particularly  if  it  contains  any  considerable  quantity  of  cream.  All  fatty 
articles  of  food  should  be  avoided,  as  the  emulsification  of  fats  in  the  intestines 
in  the  absence  of  bile  is  imperfectly  carried  out. 

2.  Chronic  Catarrh  of  the  Bile-duct. — This  state  rarely  arises  as  a  sequence 
of  the  acute  type  just  described.  More  commonly  it  is  due  to  obstruction  of  the 
common  duct  caused  by  the  presence  of  gallstones,  growths,  or  stricture.  Two 
results  ensue  from  such  a  state,  depending  upon  the  degree  of  obstruction.  When 
the  duct  is  totally  blocked,  we  find  on  opening  it  that  it  is  not  filled  with  bile,  but 
with  clear  or  slightly  tinged  mucus  which  is  devoid  of  bile,  and  that  the  mucous 
membrane  is  not  much  affected,  for  it  remains  smooth.  Such  patients  present 
marked  and  -persistent  jaundice,  the  skin  often  being  olive-green  in  hue.  When  the 
duct  is  not  cjuite  occluded,  the  retained  mucus  is  bile-stained;  it  is  cloudy,  not 
clear,  and  it  may  contain  micro-organisms  from  the  bowel.  Because  of  the  infection 
of  this  mucus  from  the  bowel  marked  fever  may  be  present,  characterized  b\'  sharp 
intermittency,  and  associated  \v\t\\  fever  and  sweats,  just  like  those  met  with  in  the 
suppurative  type  about  to  be  described. 

Treatment. — Chronic  catarrh  of  the  bile-ducts  cannot  be  materially  modified 
by  medicinal  measures.  Prolonged  counter-irritation  in  the  form  of  tincture  of 
iodine  over  the  liver  may  be  tried,  but  it  must  be  continued  for  long  periods  of 
time  before  any  possible  influence  can  be  expected  from  it.  If  constipation  exists, 
the  bowels  should  be  relieved,  preferably  by  saline  purgatives,  of  which  the  ])hos- 
phate  of  sodium,  Ilunyadi  water,  or  some  similar  mild  purgative,  are  considered 
the  best. 

The  diet  should  be  composed  of  easily  digested  meats  and  easily  digested  starches, 
the  digestion  of  which  should  be  aided  by  the  use  of  pancreatin  and  taka-diastase. 
Milk  and  fatty  foods  are  usually  not  well  digested  by  such  patients,  and  are  prone 


OCCLUSION  AND  CONSTRICTIONS  OF  THE  BILE-DUCTS  G19 

to  cause  fermentation  and  distention  of  the  bowels  by  gas.  Tfie  best  treatment 
for  these  patients  is  operative  interference,  for  the  presence  of  fever  indicates  infec- 
tion and  hints  at  the  existence  of  pus. 

3.  Suppurative  Inflammation  of  the  Bile-ducts. — When  infection  of  the  mucous 
membrane  results  from  the  growth  of  the  Baclllvs  coli  communis,  or  more  rarely 
the  Streptococcus  pyogenes  or  other  pyogenic  organisms,  suppuration  occurs.  It 
is  sometimes  called  "suppurative  cholangitis."  The  solution  of  continuity  in  the 
mucous  membrane  which  permits  infection  may  be  due  to  gallstones.  In  some 
cases  typhoid  fever,  pneumonia,  typhus  fever,  or  pyemia  may  be  the  cause. 

This  form  of  inflammation  extends  much  farther  into  the  smaller  biliary  passages 
than  the  acute  catarrhal  form,  and  by  this  means  the  liver  may  become  generally 
infected,  the  ducts  containing  pus  and  the  gallbladder  also  being  filled  with  the 
same  material.  In  some  cases  the  suppurating  ducts  may  cause  small  abscesses 
in  the  liver  substance  outside  their  walls,  and  these  again  may  grow  large  enough 
to  communicate,  and  so  abscesses  of  considerable  size  develop.  When  the  process 
is  severe  the  ducts  may  be  perforated,  and  the  pus  and  bile  escape  into  the  peritoneal 
cavity,  causing  peritonitis,  or  fistulous  tracts  may  communicate  with  the  bowel 
or  the  exterior  of  the  body. 

Symptoms. — The  symptoms  are  usually  so  sharply  developed  that  there  is  little 
difficulty  in  deciding  that  pus  is  present  in  the  liver.  The  jever  ranges  from  high 
to  low,  as  in  sepsis;  the  liver  is  enlarged  and  very  tender;  the  gallbladder  may  be 
palpable,  and  jaundice  is  also  well  marked  in  some  cases,  but  slight  in  others.  The 
presence  of  pus  in  so  vascular  and  important  an  organ  causes  profuse  sweats  and 
rapid  loss  offiesh,  but  pain  is  usually  not  severe. 

Diagnosis. — Suppurative  cholangitis  is  to  be  differentiated  from  abscess  of  the 
liver,  if  possible,  and,  more  important  than  all,  from  severe  catarrhal  cholangitis 
without  the  formation  of  pus. 

In  hepatic  abscess  there  will  be  found,  on  careful  examination  of  the  patient's 
history,  that  at  some  time  in  the  near  or  remote  past  there  has  been  an  attack 
of  dysentery  or  of  an  infection  in  some  part  of  the  body  from  which  pyogenic 
micro-organisms  have  been  carried  to  the  liver.  Very  rarely  there  may  be  a  history 
of  trauma.  While  such  a  history  may  be  found  in  a  case  of  suppurative  cholangitis 
it  is  much  more  indicative  of  abscess.  A  history  of  gallstone  colic  is  indicative 
of  cholangitis,  and  it  must  be  recalled  that  only  moderate  attacks  of  pain  in  the 
hepatic  or  gastric  region  may  be  present  in  cases  of  gallstones.  In  other  words, 
every  person  that  has  passed  a  gallstone  does  not  give  a  history  of  severe  colic. 
Finally,  the  presence  of  jaundice  is  a  sign  of  cholangitis,  for  this  sjTnptom  is 
usually  absent  in  abscess.  In  both  cases  the  liver  is  enlarged  and  there  is  a  distinct 
leukocytosis. 

From  severe  catarrhal  cholangitis  suppurative  cholangitis  is  separated  by  the 
facts  that  in  the  former  state  the  leukocytosis  is  not  so  marked  as  in  the  suppiu-ative 
type,  there  are  no  marked  chills,  sharp  fevers,  or  sweats,  nor  is  there  so  much 
tenderness  and  enlargement  of  the  liver. 

Treatment. — There  is  no  medicinal  treatment  for  this  condition.  The  same 
rule  holds  good  in  regard  to  pus  here  as  for  pus  elsewhere;  whenever  it  is  present, 
the  safety  of  the  patient  demands  that  it  should  be  given  an  exit,  but  if  the  suppu- 
rative process  is  diffuse  this,  of  course,  cannot  be  done. 

4.  Occlusion  and  Constrictions  of  the  Bile-ducts. — Occlusion  of  the  bile-ducts 
sometimes  takes  place  by  the  entrance  of  an  intestinal  worm,  by  the  impaction 
of  a  gallstone,  or  by  the  pressure  produced  by  an  aneurysm,  a  carcinoma,  or  other 
growth,  such  as  enlargement  of  the  lymph  nodes,  enlargements  or  tumors  of  the 
head  of  the  pancreas,  inflammation  and  fibroid  changes  around  the  ducts,  and 
twisting  or  angulation,  caused  by  hepatoptosis  or  other  changes  in  the  visceral 
relations.      If  the  cystic  duct  is  obstructed  the  gallbladder  is  greatly  enlarged. 


620  DISEASES  OP  THE  BILIARY  TRACT 

hut  no  jaundice  is  present,  but  if  the  common  or  biliary  ducts  are  closed,  intense 
jaundice  is  developed.     (See  Tumors  of  the  Gallbladder.) 

Congenital  occlusion  of  the  ducts  sometimes  is  met  with.  When  it  is  complete 
death  occurs  within  a  few  weeks  after  birth.  Hemorrhages  from  the  navel  and 
other  parts  of  the  body  are  usually  present  in  these  cases. 

Symptoms. — The  symptoms  are  those  met  with  in  chronic  catarrh  of  the  bile- 
ducts  and  vary  as  these  vary  with  the  degree  of  obstruction  and  the  degree  of 
infection.  Cases  occur,  however,  in  which  life  is  prolonged  for  long  periods  if 
the  ducts  are  not  completely  closed  and  infection  does  not  take  place.  A  remark- 
able instance  of  this  character  has  been  reported  by  Cocking,  of  Sheffield,  in  which 
a  woman  was  jaundiced  for  fifty  years  from  her  third  week  of  life,  yet  was  in  perfect 
health  otherwise. 

Treatment. — The  treatment  is  surgical. 

ACUTE  CHOLECYSTITIS. 

Definition. — This  is  a  state  in  which  the  gallbladder  suffers  from  an  acute  inflam- 
matory process,  which  varies  from  catarrh  of  the  mucous  membrane  to  suppuration, 
and  even  to  phlegmonous  change  in  the  walls  of  the  viscus.  The  process  may  be 
catarrhal,  pseudomembranous,  gangrenous,  or  suppurative.  It  may  be  restricted 
to  the  lining  mucosa  and  submucosa,  or  extend  to  all  the  coats.  When  the  over- 
lying serosa  is  affected  the  process. is  called  pericholecystitis  or  paracholecystitis. 

Etiology. — Cholecystitis  arises  from  the  presence  of  gallstones,  which,  by  injuring 
the  gallbladder,  permit  infection  to  occur,  and  by  the  entrance  of  pathogenic 
organisms,  which,  by  reason  of  lowered  vitality  of  the  patient,  or  other  causes, 
are  able  to  produce  more  or  less  severe  inflammatory  changes  by  their  presence. 
The  time  at  which  the  micro-organism  enters  the  gallbladder  and  that  at  which  it 
makes  its  presence  felt  may  be  widely  separated;  for  while  it  is  true  that  bile  is 
antiseptic  in  its  influence  under  certain  conditions,  the  germ  may  remain  alive  but 
quiescent  for  months  or  even  for  years,  and  produce  its  effects  only  when  .some 
illness  or  other  cause  offers  an  opportunity  for  it  to  develop.  This  period  of  inac- 
tivity, so  far  as  inflammatory  action  is  concerned,  may  be  utilized  in  the  formation 
of  gallstones  about  the  nucleus  formed  by  those  bacilli  which  have  become  agglu- 
tinated. (See  Cholelithiasis.)  The  organisms  found  in  the  gallbladder  are  very 
numerous  as  to  kind.  The  typhoid  bacillus,  the  tubercle  bacillus,  the  Bacillus 
suhtllin,  the  streptococcus,  the  staphylococcus,  and  the  colon  bacillus  ha^•e  all 
been  found  here,  although  it  is  probable  that  the  latter  does  not  remain  active, 
except  for  a  short  time. 

Morbid  Anatomy. — The  gallbladder  is  found  to  be  filled  with  dark,  mucopurulent 
material,  in  which,  if  the  wall  of  the  gallbladder  is  seriously  involved,  there  may 
be  traces  of  blood.  Occasionally  the  distention  of  the  gallbladder  is  due  not  only 
to  blocking  of  the  cystic  duct  by  a  stone,  but  the  canal  is  closed  by  the  intense 
inflammatory  process.  Perforation  of  the  gallbladder  or  gangrene  of  its  walls 
may  develop  if  the  inflammation  is  very  severe,  and  it  not  rarely  happens  that 
adhesions  form  between  it  and  the  nearby  tissues. 

Riedel  states  that  such  adhesions  develop  in  no  less  than  75  per  cent,  of  cases 
of  cholecystitis.  These  adhesions  are  of  imjjortance  because  as  a  result  of  their 
formation  a  gallstone  perforating  the  gallbladder  may  find  its  way  into  adjacent 
organs.  (See  below.)  Riedel  also  states  that  the  atlhesions  depend  as  to  their 
location  to  a  large  extent  upon  the  position  at  which  the  stone  exists.  Thus,  if 
it  be  in  the  gallbladder  the  adhesions  are  between  this  viscus  and  the  colon  or  the 
omentum.  If  it  be  in  the  cystic  or  common  duct  the  adhesion  is  to  the  stomach, 
in  the  region  of  the  pylorus.  These  adhesions  are  also  of  importance  because  they 
may  cause  pain  or  obstruction  of  the  pylorus  or  duodenum. 


CHOLELITHIASIS  621 

Symptoms  and  Diagnosis. — The  symptoms  arc  tliose  of  acute  inflammation  in 
the  hepatic  area,  varying  in  severity  from  a  slight  discomfort  and  .soreness  to  violent 
and  alarming  pain  and  collapse.  There  is  tenderness,  particularly  about  the  region 
of  the  gallbladder,  and  this  speedily  may  amount  to  exquisite  pain  on  pressure. 
The  point  at  which  the  greatest  tenderness  is  felt  is  where  the  lower  third  of  a  line 
drawn  from  the  navel  to  the  ninth  rib  joins  the  middle  third.  With  these  symptoms 
there  is  fever,  often  ushered  in  by  a  chill.  When  the  development  of  the  condition 
is  sudden,  as  it  very  frequently  is,  the  patient  may  be  seized  with  nausea  and 
vomiting,  threatened  collapse,  and  other  symptoms  of  fulminant  abdominal  disease. 

The  pulse  is  rapid;  the  belli/  is  distended  and  its  walls  rigid. 

Diagnosis. — Unless  the  pain  is  so  localized  as  to  aid  materially  in  diagnosis, 
and  unless  the  physician  is  provided  with  a  history  of  gallstone  colic,  or  of  an  inflam- 
mation in  the  gallbladder  after  one  of  the  acute  fevers,  as  typhoid  fever,  the  symp- 
toms may  mislead  him  into  a  diagnosis  of  intestinal  obstruction  or  acute  appendici- 
tis; for  paralysis  of  the  bowel  may  be  present,  on  the  one  hand,  and  in  appendicitis 
the  pain  is  often  referred  to  the  region  of  the  epigastrium  or  liver.  In  certain 
cases  of  appendicitis,  with  a  history  of  recurrent  attacks  or  of  a  recent  attack,  the 
physician  must  also  recall  the  fact  that  pain  in  the  hypochondrium  may  arise 
from  a  septic  focus,  carried  there  from  the  appendix  by  the  lymphatics.  So,  too, 
a  gastric  ulcer  with  perforation  and  subdiaphragmatic  abscess  may  simulate 
acute  cholecystitis.  When  palpation  reveals  an  elongated  gallbladder  projecting 
below  the  edge  of  the  liver,  which  is  very  tender  on  palpation,  the  diagnosis  is 
readily  made.  Jaundice  may  or  may  not  be  present.  It  is  often  absent.  It  is 
important  to  bear  in  mind  the  fact  that  attacks  of  hepatic  colic  may  occur  in  cases 
of  cholecystitis  without  any  gallstones  being  present. 

But  in  hepatic  colic  an  examination  of  the  blood  will  not  reveal  leukocytosis 
of  polymorphonuclear  cells,  which  will  be  notably  increased  by  the  presence  of 
an  acute  inflammatory  process  in  or  about  the  gallbladder.  In  questioning  the 
patient  as  to  the  possible  presence  of  gallstones  it  should  be  remembered  that 
mild  attacks  of  pain  in  this  region  may  be  as  indicative  of  the  passage  of  these 
bodies  as  a  history  of  typical  gallstone  colic.  Acute  cholecystitis  is  rarely  character- 
ized by  the  suddenness  of  onset  of  pain  and  abdominal  tenderness  which  are  met 
with  in  acute  pancreatitis  or  perforation  of  the  stomach  due  to  ulcer.  If  these 
symptoms  are  present  they  may,  however,  be  due  to  perforation  of  the  gallbladder 
due  to  chronic  cholecystitis  arising  from  gallstones.  (See  Cholelithiasis.)  Some- 
times when  there  is  an  infection  of  the  gallbladder,  as  in  the  third  or  fourth  week 
of  tj'phoid  fe^"e^,  the  onset  of  cholecystitis  may  be  as  severe  as  that  of  perforation. 
Occasionally  during  the  course  of  acute  ulcerative  endocarditis  with  secondary 
cardiac  failure  the  liver  becomes  enlarged  and  tender  and  chills  and  fever  are  met 
with.     Pyopericardium  must  also  be  excluded  if  possible. 

Treatment. — The  treatment  in  all  cases  in  which  the  symptoms  are  severe  is 
prompt  operative  interference.  Temporizing  measures  consist  in  the  use  of  rest 
in  bed,  counter-irritation  over  the  region  of  the  gallbladder,  and  the  use  of  gentle 
saline  purges  to  unload  the  bowels. 

CHOLELITfflASIS. 

Definition. — The  term  cholelithiasis  is  applied  to  a  condition  in  which  the  gall- 
bladder or  the  other  parts  of  the  biliary  passages  contain  one  or  more  gallstones. 

Etiology  and  Pathology. — The  predisposing  causes  of  gallstone  formation  are 
all  conditions  which  produce  catarrh  of  the  stomach  and  duodenum  and  biliary 
passages.  A  sedentary  life  with  high  living  is  a  factor.  So,  too,  enteroptosis 
may  aid  in  its  development.  The  condition  is  commonly  met  with  after  forty 
years  of  age.  but  cases  have  been  seen  in  childhood  and  even  in  the  newborn.    INIore 


622  DISEASES  OF  THE  BILIARY  TRACT 

than  75  per  cent,  of  all  cases  occur  in  women,  and  90  per  cent,  of  these  women  have 
been  ]:)regnant  one  or  more  times. 

Biliary  calculi  are  formed  as  the  result  of  the  deposit  of  certain  of  the  ingredients 
of  the  bile,  chiefly  cholesterin,  about  a  nidus,  which  we  now  know  is  often,  if  not 
always,  an  accumulation  of  micro-organisms.  The  presence  of  these  infecting 
agents  has  already  been  discussed  in  the  article  on  Cholecystitis,  but  it  is  particu- 
larly important  to  bear  in  mind  the  fact  that  typhoid  bacilli  are  freciuently  the 
origin  of  stone,  probably  because  they  often  remain  in  the  gallbladder  for  years, 
and  because,  when  they  agglutinate,  they  form  with  epithelial  cells  a  good  nidus 
for  the  deposition  of  biliary  materials.  That  micro-organisms  play  this  part 
is  now  proved  not  only  by  many  observations  on  man,  but  by  experiments  on 
animals.  As  Moynihan  has  cleverly  expressed  it,  every  gallstone  is  a  tombstone 
erected  to  the  memory  of  the  germs  that  lie  dead  within  it. 

The  mere  presence  of  micro-organisms,  however,  is  not  sufficient  for  the  formation 
of  stone.  It  is  necessary  that  a  catarrhal  state  of  the  mucous  membrane  be  present, 
since  in  this  condition  three  ingredients  of  the  stone  are  excreted  by  the  walls  of 
the  gallbladder,  nameh%  mucus,  cholesterin,  and  a  substance  called  "  bilirubin  cal- 
cium." Healthy  bile  prevents  the  deposition  of  bilirubin  calcium,  but  if  albumin 
is  present  this  action  is  arrested  and  the  deposit  is  made.  When  inflammation 
is  present  enough  albumin  enters  the  bile  from  the  diseased  mucous  membrane 
to  permit  of  this  effect,  and  the  small  quantity  of  cholesterin  present  in  normal 
bile  is  also  much  increased.  It  is  evident,  then,  that  for  the  deposit  of  the  materials 
forming  a  gallstone  an  unhealthy  mucous  membrane  is  primarily  essential. 

The  view  that  inflammation  of  the  biliary  mucous  membrane  is  essential  to 
gallstone  formation  is  combated  by  Aschoft'  and  Bacmeister  who  believe  that 
obstruction  to  the  flow  of  bile  is  the  chief  factor.  They  also  insist  that  the  choles- 
terin is  derived  from  the  bile  and  not  from  the  mucous  membrane.  As  a  matter 
of  fact  stones  are  developed  in  both  ways. 

The  stones  are  single  or  few  in  number  and  have  a  radially  arrayed  centre  with 
a  laminated  exterior  rich  in  calcium  when  non-inflammatory  in  origin.  The  in- 
flammatory stones  are  not  radially  centred  and  are  usually  faceted  and  numerous. 

Gallstones  when  composed  chiefly  of  cholesterin  are  transparent  or  slightly 
tinged  b}^  bile.  If  broken,  such  a  stone  appears  crystalline,  with  radiating  lines. 
In  other  cases  the  stone  is  composed  not  only  of  cholesterin,  but  of  biliary  pigment 
and  salts  of  magnesium  and  calcium.  Such  stones  are  usually  dark  in  color,  brown 
or  green.  They  may  be  round  or  marked  by  facets,  due  to  attrition,  where  they 
have  rubbed  against  other  stones.  In  these  stones  also  a  radiating  crystalline 
formation  is  present  on  fracture.  These  dark-faceted  stones  are  the  ones  commonly 
found.  More  rarely  stones  of  small  size  are  found,  composed  almost  entirely  of 
bile  pigment.     Calcium  carbonate  stones  are  still  less  frequently  met  with. 

In  size  gallstones  vary  from  fine  gritty  sand  to  masses  as  large  as  a  small  banana. 

In  the  vast  majority  of  cases  of  cholelithiasis  biliary  calculi  are  formed  in  the 
gallbladder.  Very  rarely  small  particles  of  biliary  sand  form  in  the  bile-ducts 
of  the  liver  itself.  Tiie  large  stones  found  in  the  cystic  and  common  duct  have 
formed  in,  and  then  slipped  from,  the  gallbladder. 

The  number  of  stones  found  in  the  gallbladder  may  vary  from  one  or  two  to 
several  thousand,  if  the  tiny,  sand-like  pieces  are  counted.  "When  the  number  is 
large,  they  usually  show  signs  of  lateral  pressure,  but  sometimes  several  may 
exist  without  facets  being  developed. 

If  a  gallstone  lodges  in  the  common  gall-duct  so  as  to  completely  occlude  it, 
there  is  usually  found  at  autopsy  a  condition  of  dilatation  of  this  duct,  which  is 
filled  with  a  clear,  mucus-like  fluid.  (See  Occlusion  of  the  Bile-ducts.)  If  the 
obstruction  is  not  complete  and  infection  of  the  duct  takes  place,  the  state  is  one 
of  cholangitis,  already  described,  or  even  of  suppurative  angiocholitis. 


CHOLELITHIASIS  023 

When  the  cystic  duct  is  completely  obstructed  by  a  stone,  the  gallbladder 
may  be  greatly  enlarged  and  filled  with  clear  fluid  or  with  other  gallstones.  If  the 
gallbladder  is  infected  suppurative  cholecystitis  develops,  and  perforation  may 
occur.  (See  Symptoms.)  In  other  cases  the  gallbladder  undergoes  atrophy, 
and  may  be  so  shrunken  as  to  be  nothing  but  a  small  mass  of  fibrous  tissue  the 
size  of  a  large  nut,  hidden  in  the  hollow  naturally  occupied  by  the  gallbladder. 
Less  commonly  a  process  of  calcification  is  developed,  and  the  gallbladder  becomes 
coated  or  infiltrated  by  lime-salts. 

Symptoms. — It  is  important  to  bear  in  mind  the  fact  that  the  mere  presence  of 
gallstones  in  the  gallbladder  does  not  necessarily  cause  any  symptoms  whatever. 
The  records  of  autopsies  in  Germany,  in  particular,  show  that  a  very  large  propor- 
tion of  all  women  who  come  to  autopsy  in  the  later  years  of  life  have  gallstones, 
and  yet  there  has  been  no  suspicion  of  their  existence  prior  to  death.  Only  about 
5  per  cent,  suflfer  from  distinct  sj'mptoms  due  to  this  cause.  On  the  other  hand, 
if  the  biliary  tract  becomes  infected,  or  if  an  acute  congestion  of  its  mucous  mem- 
brane occurs,  more  or  less  severe  symptoms  may  be  at  once  produced  and  fever 
may  develop;  or  if  a  stone  becomes  dislodged  from  the  gallbladder  and  slips  into 
the  cystic  or  common  duct,  this  mechanical  difficulty  may  at  once  produce  biliary 
colic. 

The  symptoms  of  biliary  colic  may  consist  in  severe  pain,  which  amounts  to  an 
agony  in  many  instances.  Sometimes,  however,  the  pain  is  very  moderate,  and 
is  thought  to  be  due  to  indigestion.  The  patient  often  vomits  and  sweats  profusely 
during  the  pain.  The  pain  manifestly  originates  in  the  gallbladder,  but  is  radiated 
to  the  right  shoulder-blade  and  to  the  epigastrium.  The  facial  expression  is  one 
of  anguish  and  anxiety,  and  the  color  of  the  skin  is  pallid. 

After  the  attack  has  lasted  for  some  hours,  or  on  the  day  after  an  attack,  a 
moderate  degree  of  jaundice  may  appear,  but  it  is  rarely  well  marked  unless  the 
attack  lasts  for  several  days  or  the  obstruction  is  persistent.  If  the  stone  is  in 
the  cystic  duct,  no  jaundice  occurs  unless  the  neighboring  mucous  membrane 
in  the  common,  or  hepatic  duct,  becomes  swollen  and  inflamed,  or  unless  the  stone 
is  so  placed  in  the  cystic  duct  that  it  presses  upon  the  hepatic  duct.  The  presence 
of  jaundice  in  a  case  which  suffers  from  severe  pain  in  the  region  of  the  gallbladder 
is  a  positive  diagnostic  sign  of  much  value,  but  the  absence  of  jaundice  does  not 
in  the  slightest  degree  negative  the  view  that  gallstone  is  present.  Kehr  states  that  in 
720  cases  operated  on  for  gallstone,  80  per  cent,  showed  no  jaundice. 

The  urine,  if  the  stone  is  in  the  common  duct,  may  soon  show  the  presence  of 
bile,  and  not  rarely  albumin  is  found  in  it.  In  still  other  cases  red  blood  cells  may 
be  found  in  the  urine,  and  this  may  lead  us  into  the  belief  that  the  pain  is  due  to 
renal  colic. 

An  attack  of  biliary  colic  lasts,  as  a  rule,  for  but  a  few  hours,  but  occasionally 
the  patient  suflfers  from  a  prolonged  seizure  lasting  over  several  days  and  marked 
by  temporary  remissions,  which  are,  perhaps,  due  to  exhaustion  of  the  irritated 
gallbladder  or  to  temporary  restoration  of  biliary  flow. 

The  presence  of  a  stone  or  stones  in  the  common  or  cystic  duct  produces  not 
only  symptoms  of  biliary  colic  in  some  cases,  but  other  signs  as  well,  which  may 
be  of  use  in  diagnosis.  If  the  stone  blocks  the  common  duct  completely,  the  jaundice 
which  develops  is  persistent  and  well  marked,  and  further  attacks  of  colic  may 
never  occur,  or,  indeed,  there  may  not  be  a  single  attack  in  the  patient's  history. 
Febrile  movement  is  usually  absent,  because  the  complete  obstruction  of  the  duct 
prevents  infection  from  the  intestine.    The  gallbladder  is  usually  not  distended. 

When  the  common  duct  is  not  completely  closed,  and  in  the  majority  of  cases 
it  is  not  occluded,  the  attacks  of  biliary  colic  are  more  frequent,  and  the  degree  of 
jaundice  varies.  This  is  due  to  the  fact  that  at  times,  when  the  mucous  membrane 
surrounding  the  stone  is  not  acutely  inflamed  or  congested,  bile  is  permitted  to 


624  DISEASES  OF  THE  BILIARY  TRACT 

escape  into  the  bowel,  so  that  the  pressure  is  reheved  and  the  stools  Ijeconie  bile- 
stained.  Such  a  condition  of  repeated  attacks  of  coHc  with  varying;  degrees  of 
jaundice  may  also  be  due  to  the  stone  becoming  so  fixed  in  the  ampulla  of  Vater 
that  it  forms  a  ball-valve,  which  sometimes  permits  the  passage  of  bile  and  some- 
times prevents  it.  In  rarer  instances  the  stone  becomes  encysted  in  the  wall  of  the 
duct,  and  so  acts  as  a  valve,  and  in  still  other  cases  it  may  become  lodged  at  the 
junction  of  the  cystic  and  hepatic  duct,  and  by  ])ressure  cause  symptoms  character- 
istic of  obstruction  in  both  the  cystic  and  common  duct. 

These  cases  of  partial  obstruction  difi'er  from  those  of  complete  obstruction, 
in  the  fact  that  they  not  rarely  develop  fever,  owing  to  infection  of  the  common 
and  hepatic  duct  by  micro-organisms  from  the  bowel.  The  febrile  attacks  which 
ensue  may  be  so  irregular  or  so  intermittent  in  type  that  they  closely  resemble 
those  of  malarial  fever,  but  they  are  in  reality  septic  fever,  the  so-called  "  intermit- 
tent hepatic  fever  of  Charcot."  Such  attacks  may  persist  for  years  with  no  more 
serious  changes  in  the  ducts  than  a  chronic  catarrh  with  thickening  and  the  pro- 
liferation of  an  exudate  about  the  parts. 

In  some  cases,  however,  the  degree  of  infection  is  so  severe  that  supjjuration 
takes  place,  not  only  in  the  common  duct,  but  in  the  hepatic  duct  as  well,  and 
even  in  the  gallbladder,  producing  suppurative  cholecystitis  and  suppurative 
angiocholitis.  (See  Suppurative  Inflammation  of  the  Bile-ducts  and  Acute 
Cholecystitis.) 

The  additional  symptoms,  to  those  of  biliary  colic,  which  arise  when  the  cystic 
■  duct  becomes  the  lodging-place  for  a  stone  are  chiefly  enlargement  of  the  gall- 
bladder from  distention  and  the  negative,  but  nevertheless  valuable,  evidence  of 
absence  of  jaundice.  The  size  of  the  gallbladder  in  cases  in  which  the  obstruction 
is  complete  is  sometimes  marvellous.  Instances  have  been  recorded  in  which 
the  enlarged  gallbladder  has  been  mistaken  for  an  ovarian  tumor,  and  not  rarely 
the  enlarged,  pear-shaped  mass  can  be  felt  near  the  median  line  of  the  abdomen. 
(See  Diagnosis.)  On  the  other  hand,  the  facts  in  regard  to  atrophy  of  the  g.ill- 
bladder,  already  named  in  the  discussion  of  the  pathology  of  this  afiection,  should 
be  recalled;  in  other  words,  the  absence  of  a  large  gallbladder  does  not  exclude 
obstruction  to  the  cystic  duct. 

If  the  gallbladder,  which  is  distended  by  retained  bile  and  gallstones,  can  be 
palpated,  it  may  be  possible  to  produce  what  is  called  "gallstone  crepitus"  by  the 
ruljbing  of  the  stones  one  upon  the  other. 

Complications  and  Sequelae. — A  stone  may  perforate  the  gallbladder,  and,  by 
way  of  the  adhesion,  gain  the  cavity  of  the  duodenum  and  escape  with  the  feces. 
In  still  other  cases  the  perforation  takes  place  through  an  adhesion  to  the  colon, 
but  very  rarely  does  the  stone  escape  into  the  small  bowel  below  the  duodenum. 
In  other  instances  the  gallbladder  becomes  adherent,  by  an  inflammatory  exudate, 
to  the  abdominal  wall,  and  the  stones  finally  escape  from  the  fistulous  opening. 
I  had  a  case  in  my  clinic  at  the  Jeft'erson  Hospital  some  years  since  in  which  the 
patient  passed  almost  daily  a  little  pus  and  a  little  bile  with  one  or  more  stones 
through  such  an  opening,  yet  seemed  in  excellent  health,  probably  because  nature 
had  estal)lished  free  drainage.  More  commonly  the  perforation  takes  place  so 
that  the  stone  enters  the  peritoneal  cavity  and  then  the  associated  infectious  material 
causes  fatal  jjeritonitis.  When  the  gallbladder  becomes  adherent  to  the  diaphragm 
and  perforation  ensues,  the  stone  with  pus  and  bile  may  escape  into  the  pleura 
or  into  the  lung.  In  the  Transactions  of  the  Association  of  American.  Physicians 
for  1S97,  Graham,  of  Toronto,  reports  10  cases  of  cholelithiasis  perforating  into 
the  lung,  and  in  4  of  them  the  stone  passed  through  an  adhesion  which  existed 
between  the  gallbladder,  the  diaphragm,  and  the  pleura.  The  spitting  of  bile, 
with  a  distressing  cough,  and  dulness  on  percussion  in  the  area  just  above  the 
liver,  where  pulmonary  resonance  is  usually  present,  make  the  diagnosis  certain. 


CIIOLEUrillASIS  025 

Gallstones  have  been  carried  far  away  from  tlie  galll)la(liler  \>y  suppuration 
after  perforation,  and  have  even  been  found  in  tlie  urinary  bhidder  as  a  result  of 
this  process.  Perforation  of  the  gallbladder  with  fatal  syncope  has  been  reported 
during  an  attack  of  biliary  colic. 

Diagnosis. — When  the  symptoms  are  classical  a  diagnosis  is  easy,  but  they  are 
very  often  not  classical.  It  should  be  remembered  that  when  a  i)atient  has  repeated 
attacks  of  epigastric  pain  with  distention  and  vomiting  and  these  symptoms 
are  unrelieved,  or  only  temporarily  relieved,  by  medical  measures  and  if  these 
symptoms  develop  in  a  patient  who  has  had  typhoid  fever,  or  in  a  woman  wlio  has 
had  many  pregnancies,  the  presence  of  gallstones  is  to  be  susjiected,  even  if  palpa- 
tion reveals  no  enlargement  or  tenderness  of  the  gallbladder  and  even  if  there  is 
no  jaundice  but  there  is  hyperacidity.  The  conditions  to  be  differentiated  from 
cholelithiasis  are  appendicitis,  diaphragmatic  pleurisy,  gastric  ulcer,  gastralgia, 
the  gastric  crisis  of  ataxia,  acute  pancreatitis,  and  renal  stone.  Appendicitis 
is  detected  by  finding  even  greater  pain  on  palpation  in  the  appendicular  area; 
pleurisy  is  excluded  by  careful  auscultation  to  reveal  a  friction  sound.  In  gastric 
ulcer  there  is  a  history  of  pain  immediately  after  the  taking  of  food,  and  perhaps 
of  hematemesis;  and  the  patient  is  usually  a  young  woman,  whereas  gallstones  are 
usually  present  in  women  past  forty  years  of  age.  A  person  with  an  ulcer  is  usually 
poorly  nourished  and  anemic,  whereas  the  patient  with  gallstones  is  usually  plump 
and  possessed  of  a  thick  abdominal  wall.  Hyperchlorhydria  is  present  in  ulcer, 
and  may  be  present  in  cholelithiasis.  In  those  cases,  however,  in  which  there  are 
adhesions  between  the  gallbladder  or  its  duct  and  the  pylorus  or  duodenum,  these 
differential  signs  may  fail  because  pyloric  obstruction  causes  pain  after  taking  food 
and  produces  hyperchlorhydria.  An  attack  of  gastric  crisis  in  ataxia,  while  often 
associated  with  vomiting,  can  be  detected  by  the  history  of  an  ataxic  gait  and  by 
the  presence  of  an  Argyll-Robertson  pupil  or  other  signs  of  that  disease.  In  pan- 
creatitis the  swelling  and  centre  of  greatest  pain  is  usually  a  little  lower  and  nearer 
the  middle  line  than  in  gallbladder  disease  or  gastric  ulcer  and  the  condition  of 
the  patient  is  more  prone  to  be  that  of  collapse  and  shock.  Often,  of  course,  the 
pancreatitis  is  the  direct  result  of  the  cholelithiasis.  Renal  stone  causes  pain  to  be 
radiated  to  the  inside  of  the  thigh  and  to  the  testicle.  Movable  kidney  may,  by 
dragging  or  pressing  upon  the  common  biliary  duct,  cause  obstruction,  and  so 
produce  an  attack  of  biliary  colic  and  jaundice  not  due  to  stone.  Further,  the 
pain  due  to  twisting  of  the  ureter  in  such  a  case  may  simulate  hepatic  colic.  The 
finding  of  a  floating  kidney  clears  up  the  diagnosis.  A  new  growth  may  produce 
similar  symptoms,  and  it  may  be  impossible  to  differentiate  the  obstruction  from 
that  due  to  gallstones.  In  none  of  these  states  is  the  greatest  degree  of  pain  on 
pressure  over  the  gallbladder. 

It  is  essential  that  attention  be  paid  to  one  very  important  differential  point, 
which  must  always  be  borne  in  mind,  the  so-called  "  Courvoisier's  law,"  namely, 
that  an  enlarged  gallbladder  with  jaundice  is  a  sign  of  malignant  growth  of  the 
gallbladder  rather  than  that  of  obstruction  due  to  stone. 

In  a  certain  proportion  of  cases,  however,  a  correct  diagnosis  before  operation 
is  impossible  even  by  the  most  experienced  physician.  As  Lund  has  well  said: 
"Who  of  us  is  not  familiar  with  cases  in  which  we  have  made  a  diagnosis  of  gallstone 
disease,  on  a  basis  of  irregular  attacks  of  pain  in  the  right  hypochondrium,  with 
localized  spasm  and  tenderness,  the  pain  radiating  over  the  abdomen  and  perhaps 
into  the  right  shoulder,  only  to  find  on  operation  an  ulcer  of  the  pylorus,  requiring 
a  gastro-enterostomy  for  its  relief?  We  have  also  operated  for  relief  of  a  dilated 
stomach,  with  constant  vomiting  and  emaciation  expecting  to  find  a  cancer  or 
chronic  ulcer  of  the  pylorus,  and  found  a  gallbladder  full  of  pus  with  a  stone 
impacted  in  the  cystic  duct,  obstructing  the  pylorus  by  involving  it  in  a  mass  of 
adhesions  and  requiring  gastro-enterostomy  as  well  as  a  cholecystectomy."  The 
40 


0)26  DISEASES  OF  THE  lillJARY  TRACT 

proper  tiling  to  do  in  these  cases  is  to  explore  because  be  tlie  lesion  what  it  may  the 
condition  demands  surgical  interference.  On  the  other  hand  Richardson  has 
well  said  the  tendency  is  toward  hasty,  imperfect  and  inaccurate  diagnosis,  because 
operative  diagnosis  is  so  easy  and  unmistakable.  This  tendency  is  surely  a  per- 
nicious one,  and  one  to  be  resisted  with  all  our  might.  Wlienever  time  permits 
the  proposed  operation  should  be  based  uj^on  tiic  most  careful  and  exhaustive 
study  of  tlie  patient;  or,  still  better,  no  operation  should  be  performed  until  that 
operation,  by  a  positive  diagnosis,  has  been  found  necessary.  Every  lesion  should 
be  regarded  as  one  not  demanding  or  justifying  operation  until,  in  the  particular 
patient,  that  demand  has  been  completely  justified.  The  exploratory  laparotomy, 
for  example,  should  be  reserved  for  those  cases  in  which  security  of  the  patient 
demands  certainty  of  diagnosis,  and  those  in  which  there  is  everything  to  gain, 
and  little  to  loose  by  exploration. 

Treatment. — The  treatment  of  biliary  colic,  like  that  of  renal  colic,  consists  in 
the  administration  of  a  hypodermic  injection  of  J  of  a  grain  of  morphine,  with 
j-i-o  of  atropine,  and  y^nr  of  a  grain  of  nitroglycerin,  to  relieve  pain  and  to  relax 
spasm.  If  the  first  injection  does  not  give  relief  at  the  end  of  fifteen  or  twenty 
minutes  it  may  be  repeated,  the  atropine  being  left  out.  After  the  attack  is  over 
the  patient  should  rest  quietly  in  bed  for  two  or  three  days,  in  order  to  hasten  the 
disappearance  of  the  inflammation  of  the  mucous  membrane,  which  is  usually 
associated  with  the  attack,  and  thereby  decrease  the  danger  of  a  subacute  or  chronic 
inflammatory  process  developing  in  the  gallbladder  or  common  duct. 

No  medicines  have  any  effect  upon  the  gallstones  which  are  already  formed, 
but  a  number  of  remedies  may  be  given  to  patients  who  suffer  from  gallstones,  with 
the  object  of  preventing  the  formation  of  others,  and  with  the  hope  that  by  their 
use  catarrh  and  irritation  of  the  mucous  membrane  lining  the  gallbladder  and  the 
common  duct  may  be  materially  diminished.  These  remedies  consist  in  the  mild 
saline  purgatives,  such  as  the  various  imported  purgative  waters,  which  are  gentle 
in  their  action,  and  which  may  be  preferably  taken  hot  in  the  dose  of  one  or  two 
teacupfuls  before  breakfast.  Chloride  of  ammonium,  in  the  dose  of  5  to  10  grains 
three  times  a  day,  is  useful  for  its  effect  upon  mucous  membranes,  and  is,  perhaps, 
best  given  in  equal  parts  of  fluidextract  of  licorice  and  water. 

Until  within  recent  years  the  physician  was  content  when  a  case  of  cholelithiasis 
escaped  month  by  month  from  a  return  of  biliary  colic,  deeming  it  inexpedient 
that  any  radical  measure  of  relief  should  be  instituted.  With  our  present  knowl- 
edge, however,  it  cannot  he  doubted  that  the  question  of  operative  interference 
must  be  carefully  considered  in  every  case  in  which  a  positive  diagnosis  of  chole- 
lithiasis can  be  made.  The  time  for  operation  is,  of  course,  during  a  period  of 
quiescence,  since  at  the  time  of  an  attack  the  acute  inflammation  which  exists 
in  and  around  the  gallbladder  may  seriously  complicate  the  work  of  the  surgeon. 

The  question  as  to  how  frequently  the  patient  should  be  allowed  to  suffer  from 
gallstone  colic  before  operative  interference  is  urged  is  one  which  varies  with  each 
individual  case.  If  the  jaundice  which  is  present  with  the  first  attack  is  not  severe 
and  lasts  but  a  very  short  time,  and  if  the  temperature  of  the  patient  is  not  dis- 
turl)C(],  or  returns  to  normal  within  a  period  of  twenty-four  hours,  and  if,  again, 
palpation  in  the  neighborhood  of  the  gallbladder  some  days  after  the  attack 
fails  to  reveal  evidence  of  a  low-grade  inflammation,  as  manifested  by  tenderness 
or  pain,  it  is  then  permissible,  and,  indeed,  advisable,  that  the  patient  should  not 
be  operated  upon.  Even  when  as  many  as  two  or  three  such  mild  attacks  have 
occurred  at  long  intervals,  the  condition  may  not  be  such  as  to  require  that  the 
physician  should  strongly  recommend  surgical  aid.  When,  however,  the  attack 
of  biliary  colic  is  violent  or  repeated,  when  the  jaundice  persists  for  a  long  period, 
and  when  distinct  evidence  of  persistent  cholecystitis  continues,  then  operation 
should   be  resorted  to,  particularly  if  a  mass,  caused  by  the  gallbladder  being 


MALIGNANT  GROWTHS  OF  GALLBLADDER  AND  BILLiRY  PASSAGES     627 

distended  by  stones,  can  be  distinctly  felt.  To  delay  operation  in  a  case  of  this 
kind  until  frequent  attacks  have  resulted  in  the  formation  of  a  large  amount  of 
inflammatory  material  about  the  gallbladder  is  very  unwise.  By  this  means 
cases  which  would  offer  under  ordinary  circumstances  no  surgical  difficulties  may 
become  almost  inoperable,  and  what  should  be  an  easy  convalescence  may  be 
instead  a  difficult  and  prolonged  illness,  testing  the  skill  of  both  the  physician 
and  surgeon  to  the  utmost. 

The  Mayos  have  performed,  up  to  October  25,  1914,  848  operations  for  uncom- 
plicated gallstone,  with  a  mortality  of  only  0.7  per  cent.  Grouping  together  all 
cases  complicated  by  the  presence  of  stones  in  the  common  or  cystic  ducts,  cases  of 
cholelithiasis  in  which  infection  occurred,  cases  of  biliary  infection  and  malignant 
disease,  their  mortality  is  2.4  per  cent,  in  7014  cases  which  they  have  operated  on. 
They  believe  these  figures  to  be  a  strong  argument  in  favor  of  early  operation 
in  cases  of  cholelithiasis,  to  which  view  I  assent  provided  a  first-rate  abdominal 
surgeon  is  to  operate. 

MALIGNANT  GROWTHS  OF  THE  GALLBLADDER  AND  BILIARY 
PASSAGES. 

Etiology. — The  cause  of  the  development  of  morbid  growths  in  these  parts  is 
unknown,  and  only  some  of  the  predisposing  causes  are  recognized. 

In  the  case  of  carcinoma  of  the  biliary  ducts  and  the  gallbladder,  there  can  be 
no  doubt  that  age  has  a  very  distinct  influence.  The  growth  usually  develops  later 
in  life  than  does  carcinoma  in  any  other  part,  namely,  about  the  fifty-sixth  year; 
whereas,  the  period  of  greatest  frequency  of  cancer  of  the  mammary  gland  is, 
according  to  KeljTiack,  about  the  forteith  year.  It  would  also  seem  probable 
that  gallstones  verj'  distinctly  predispose  to  the  development  of  carcinoma  in 
these  parts,  for  they  are  found  present  in  from  90  to  95  per  cent,  of  all  cases;  whereas, 
the  frequency  of  gallstones  in  persons  dying  from  other  diseases  than  cancer  of 
these  parts  is  from  6  to  12  per  cent.  (Kelynack).  On  the  other  hand,  it  has  been 
claimed  that  the  presence  of  carcinoma  of  the  gallbladder  leads  to  the  rapid  forma- 
tion of  stone.  Probably  the  pathological  condition  of  the  mucous  membrane  which 
aids  in  the  formation  of  stone  (see  Cholelithiasis)  also  predisposes  to  the  develop- 
ment of  a  morbid  growth,  and  this  effect  may  be  increased  by  the  irritation  produced 
by  the  stones  after  they  are  formed. 

In  women  carcinoma  of  the  gallbladder  is  far  more  common  than  it  is  in  men. 
Musser,  in  his  classical  paper  upon  this  subject,  found  that  out  of  98  cases  75  were 
in  women  and  only  23  in  men,  and  other  clinicians  have  noted  an  even  greater 
percentage  among  women.  Curiously  enough,  this  is  not  the  case  when  the  gro'wth 
affects  the  biliary  passages  other  than  the  gallbladder,  for  in  such  instances  the 
number  of  men  and  women  affected  is  practically  the  same. 

Pathology  and  Morbid  Anatomy. — Carcinoma  of  the  gallbladder  is  usually  of  the 
type  of  cylindrical-cell  epithelioma,  but  in  statistics  there  is  much  contradiction 
as  to  this  point.  This  form  of  cancer  is  also  the  type  which  most  commonly  affects 
the  biliary  ducts.  AVhen  the  gallbladder  is  affected  the  fundus  is  the  part  that 
usually  suffers.  If  the  biliary  passages  are  involved,  the  common  duct  is  the 
part  that  is  usually  affected,  and  that  portion  of  it  where  it  enters  the  bowel  is 
the  favorite  site  of  the  growth.     (See  Fig.  110.) 

When  cancer  attacks  the  gallbladder,  as  already  pointed  out  in  the  article  on 
Cancer  of  the  Liver,  the  liver  is  affected  in  a  large  percentage  of  cases  by  secondary 
growths  (Musser  says  54  per  cent.).  The  pancreas  is  also  very  commonly  involved. 
When  the  growth  is  in  the  biliary  ducts,  metastasis  to  other  parts  is  rare. 

Carcinoma  of  the  gallbladder  may  also  result  in  the  formation  of  adhesions, 
by  which  it  becomes  attached  to  the  abdominal  wall,  the  colon,  and  even  the 


628 


DISEASES  OF  Till':  liffJARV   TUArr 


stomach  ami  small  intestines.  In  other  instances  a  sujjpnrative  cholecystitis  may 
develop. 

Symptoms. — The  symptoms  of  cancer  of  the  gallhladder  are  most  varied.  If 
the  growth  is  so  situated  that  it  interferes  with  biliary  How,  the  manifestations  of 
hepatic  disease  may  develop  while  it  is  still  a  very  small  mass;  whereas,  if  no  pressure 
is  ])roduced,  the  tumor  may  reach  a  very  considerable  size  before  its  presence  is 
suspected. 

As  soon  as  the  tumor  reaches  any  size  it  can  be  palpated  below  the  border  of  the 
last  rib  in  most  instances,  particularly  if  it  aft'ects  the  fundus  of  the  gallbladder, 
as  it  does  in  the  majority  of  cases.  Its  position  is  usually  along  the  outer  edge  of 
the  right  rectus  muscle  and  about  the  neighborhood  of  the  normal  gallbladder. 
It  may  extend  downward  toward  the  pelvis,  or  it  may  be  erect  and  protrude  through 
the  abdominal  wall,  as  an  aneurysm  protrudes  from  the  chest.  The  tumor  feels 
hard  and  is  usually  somewhat  pear-shaped.  It  varies  in  size  from  that  of  a  child's 
head  to  that  of  a  small  walnut. 


PiiiiKiry  cireinoma  of  the  diKidcnal  papilla  seen  at  the  upper  ciiil  of  tlio  lud  running  through 
the  duct.     (Kast  and  Rumpler.) 


If  the  growth  is  so  placed  near  the  neck  of  the  gallliladdcr  that  it  prevents 
the  cystic  duct  from  draining  that  viscus,  the  resulting  distention  of  the  gall- 
liladdcr may  cause  the  formation  of  a  greatly  distended  sac,  which  may  extend 
far  below  the  ribs,  and  by  its  pressure  upon  the  bowel  cause  intestinal  obstruction. 

Jaundice  and  pain  are  very  constant  symptoms  of  cancer  of  the  gallbladder. 
Musscr  found  jaundice  in  69  per  cent,  of  his  cases,  and  pain  in  62  per  cent.  \Yhen 
the  growth  invades  the  gallbladder  alone,  it  does  not  of  itself  cause  icterus,  but 
the  neighboring  glands  are  often  involved  very  early,  and  by  this  means,  or  by 
seconilary  growths  in  the  common  duct,  jaundice  is  produced.  In  this  connection 
"Courvoisier's  law"  is  to  be  recalled,  namely,  that  given  an  enlarged  gallbladder 
with  jaundice,  the  cause  is  carcinoma,  not  gallstone. 


MALIGNANT  GROWTHS  OF  GALLBLADDER  AND  BILIARY  PASSAGES     G29 

Wasting  is  usually  well  marked,  not  only  by  reason  of  the  malignant  growth, 
but  because  of  the  jaundice  and  gastroduodenal  catarrh  which  are  usually  present. 
Ascites  may  develop  (18  per  cent,  of  cases,  Musser).  Death  is  due  to  exhaustion, 
and  sometimes  to  cholemia. 

Diagnosis. — A  growth  in  the  gallbladder  can  usually  be  difi'erentiated  from  one 
in  the  bile-ducts  by  its  size,  the  readiness  with  which  it  can  be  palpated,  and  the 
absence  of  jaundice  until  it  is  of  some  size.  Given  a  case  in  which  jaundice  develops 
in  a  woman  well  along  in  years,  in  which  the  jaundice  remains  persistent  anil  in 
which  no  tumor  can  be  felt,  and  the  diagnosis  is  in  favor  of  growth  in  the  duct.  If 
metastatic  masses  can  be  found  in  the  liver,  the  primary  growth  is  probaljly  in 
the  gallbladder,  for  they  rarely  develop  from  a  growth  in  the  duct. 

An  even  more  important  differential  point  is  that  between  cancer  of  the  gall- 
bladder with  cystic  enlargement  and  enlargement  due  to  hydrops  of  the  gallbladder. 
In  the  latter  case  the  gallbladder  is  distended  with  a  clear  fluid  as  the  result  of  the 
presence  of  stone  or  other  cause,  completely  closing  the  cystic  duct.  As  Courvoisier 
found  this  state  of  hydrops  79  times  in  91  cases  of  impacted  gallstone,  it  is  not  a 
very  rare  condition.  The  differentiation  between  these  two  states  is  made  as 
follows:  In  hydrops  of  the  gallbladder  there  is  usually  no  jaundice,  and  the  tumor 
presents  a  smooth,  pear-shaped  surface,  and  there  may  be  a  history  of  gallstone 
colic.     Bile  is  present  in  the  stools  and  the  degree  of  wasting  is  not  marked. 

In  some  rare  cases  the  gallbladder  undergoes  thickening  and  presents  a  small, 
hard  mass,  which  may  be  palpated.  This  has  already  been  described  elsewhere 
as  calcification  of  the  gallbladder.  The  absence  of  metastasis  and  of  other  signs 
of  cancer  aids  us  in  excluding  the  morbid  growth  in  these  cases. 

Other  causes  of  tumor  in  the  region  of  the  gallbladder  are  aneurysm,  cancer 
of  the  pylorus,  cancer  of  the  head  of  the  pancreas,  and  tumor  of  the  kidney.  A 
fecal  mass  in  the  bowel  may  also  mislead  the  physician. 

Prognosis. — Life,  in  a  case  of  cancer  of  the  gallbladder,  usually  does  not  last 
beyond  a  year,  and  in  many  instances  death  comes  earlier  than  this. 

Death  usually  comes  much  earlier  in  cases  of  malignant  growth  in  the  duct 
than  of  malignant  growth  in  the  gallbladder. 

Treatment. — The  treatment  of  malignant  growth  of  the  gallbladder,  of  necessity, 
does  not  offer  much  promise  for  ultimate  and  complete  recovery,  for  medicinal 
measures  are,  of  course,  entirely  useless,  except  for  the  purpose  of  relieving  pain. 
Operative  procedures,  even  if  they  result  in  the  complete  removal  of  the  diseased 
gallbladder,  are  nearly  always  followed  by  the  development  of  secondary  growths 
in  neighboring  parts,  where  they  are  inoperable  and  where  they  straightway  proceed 
to  destroy  the  patient.  Nevertheless,  given  a  case  in  which  the  gallbladder  is 
greatly  enlarged,  and  in  which  evidence  of  the  presence  of  a  growth  in  nearby 
parts  is  not  marked,  it  is  certainly  permissible,  and,  indeed,  advisable,  that  opera- 
tion shall  be  performed,  with  the  hope  that  the  growth  can  be  removed,  or  that  the 
operation  will  reveal  the  fact  that  enlargement  of  the  gallbladder  is  not  cancerous 
in  origin,  but  dependent  upon  the  presence  of  gallstone,  or  other  cause,  or  obstruc- 
tion of  the  cystic  or  common  duct. 

In  all  of  these  cases  in  which  jaundice  is  present,  the  very  grave  influence  of  this 
complication  upon  operative  procedure  must  be  taken  into  consideration,  for 
while,  on  the  one  hand,  we  are  learning  every  year  that  operations  upon  the  gall- 
bladder can  be  performed  with  a  surprising  degree  of  impunity,  we  have  also  learned 
with  increasing  experience  that  jaundiced  persons  withstand  operations  badly, 
and  that  the  presence  of  bile  in  the  blood  predisposes  the  patient  to  obstinate 
and  persistent  capillary  hemorrhage  during  and  after  operation.  This  has  not 
infrequently  resulted  in  death,  although  the  mere  operative  procedure  itself  was  a 
success. 

When  the  growth  involves  the  bile-duct  the  outlook  is,  of  course,  even  more 


630  DISEASES  OF  THE  PANCREAS 

discouriigiiig,  for  the  hile-duct  cannot  be  excised,  and  the  jaundice  is  usually  so 
extreme  that  the  condition  of  the  patient  scarcely  justifies  operative  interference. 
The  most  that  can  be  done  for  a  patient  witli  a  mahgnant  growth  in  tlie  bile-duct 
is  to  operate  with  the  idea  of  providing  drainage  and  relieving  pressure. 

ICTERUS  NEONATORUM. 

Jaundice  of  the  newborn  is  a  very  common  condition,  and  usually  appears  about 
the  third  or  fourth  day  after  birth.  It  is  noticeable  in  the  skin  and  in  the  conjunc- 
tiva, but  it  is  never  intense,  and  in  many  cases  may  be  so  slight  as  to  be  overlooked. 
Holt  states  that  it  occurred  300  times  among  900  babies,  and  Kehrer  asserts  that 
in  his  statistics  it  was  present  in  75  per  cent.  The  last  of  these  estimates  is  much 
too  high  a  proportion  for  private  practice.  Hofmeier  and  others  believe  that  it  is 
hematogenous  in  origin,  and  results  from  the  destruction,  shortly  after  birth,  of  a 
large  number  of  red  blood  cells.  On  the  other  hand  it  not  rarely  happens  that  the 
urine  is  slightly  bile-stained,  and  the  stools  are  lacking  in  bile,  which  would  indicate 
disordered  hepatic  action.  In  some  instances  the  portal  vein  may  have  been 
overdistended  in  birth,  and  in  this  way  the  finer  bile-ducts  may  have  been  ob- 
structed. Whatever  the  cause,  in  its  simple  form  the  condition  possesses  no  evil 
import  whatever. 

A  severe  and  rare  form  of  icterus  of  the  newborn  may,  however,  develop  and 
cause  the  death  of  the  child.  It  is  due  to  sepsis  following  infection  of  the  umbilical 
vein,  with  phlebitis,  to  congenital  syphilis  of  the  liver,  or  to  congenital  atresia 
of  the  biliary  ducts,  so  that  the  bile  cannot  escape  into  the  bowel.  (See  also 
Congenital  Hemolytic  Icterus.) 


DISEASES  OF  THE  PANCREAS. 

PANCREATITIS. 

Definition. — Pancreatitis,  as  its  name  implies,  is  an  inflammation  of  the  pancreas. 
It  occurs  in  three  forms,  although  it  must  be  understood  that  no  hard-and-fast 
lines  separate  these  conditions  one  from  the  other.  These  three  forms  are  the 
acute,  the  subacute,  and  the  chronic. 

Acute  Pancreatitis. — History. — As  long  ago  as  1672  Tulpius  described  an 
acute  aljsccss  of  the  pancreas  due  to  pyemia.  In  1799  BaOlie  studied  what  was 
evidently  a  case  of  chronic  interstitial  pancreatitis.  In  1S04  Portal  recorded 
an  instance  of  acute  suppurative  pancreatitis,  as  did  Percival  in  ISIS.  In  1879 
Balzer  reported  a  case  of  acute  pancreatitis,  with  fat-necrosis  but  it  was  not  till 
the  epoch-making  paper  of  Fitz  appeared  in  1889  that  the  profession  recognized 
the  frequency  and  importance  of  lesions  of  this  gland,  although  in  1886  another 
American  jjractitioner,  Senn,  had  written  a  paper  upon  its  surgery.  Von  Mering 
and  Minkowski  made  valualjle  contributions  in  1S89  and  1890. 

Chronic  pancreatitis  was  not  recognized  till  Birch-IIirchfeld  described  it  in 
1895.  vSince  that  time  the  literature  on  pancreatitis  has  become  quite  voluminous, 
and  a  number  of  studies  have  appeared,  of  which  the  most  notable,  from  the  surgical 
standpoint,  have  been  those  of  Robson  and  ^Nloynihan,  of  Leeds,  and,  from  the 
pathological  standpoint,  one  by  Opie,  of  Baltimore,  who  has  done  more  than  anyone 
else  to  throw  light  on  diseases  of  this  organ. 

Etiology. — By  far  the  more  common  cause  of  pancreatitis  is  infection  of  the 
gland  by  way  of  its  duct.     This  results  usually  from  the  presence  of  a  gallstone  in 


PANCREArrns 


(;:!i 


the  ampulla  of  Vater,  which  prevents  the  flow  of  bile  into  the  bowel,  but  does  not 
occlude  the  opening  of  the  pancreatic  duct.  Again,  the  presence  of  a  gallstone 
is  prone  to  result  in  the  development  of  a  septic  process  in  the  surrounding  mucous 
membrane,  and  this  results  in  infection  of  the  bile,  which  fluid  passes  along  the 
duct  of  Wirsiing  and  so  enters  the  pancreas.  This  is  particularly  apt  to  occur  if 
the  gallbladder  is  so  shrunken  by  disease  that  it  cannot  readily  expand  when  the 
bile  is  dammed  back  into  the  duct.  Further  than  this,  bile  alone  entering  the 
pancreas,  even  if  it  be  free  from  micro-organisms,  may  cause  hemorrhagic  pancrea- 
titis and  fat-necrosis. 

It  has  been  argued  that  if  these  causes  are  active  in  the  production  of  pancreatitis, 
this  state  would  be  met  with  much  more  frequently.  The  explanation  of  the 
fact  that  so  many  cases  sufl:"er  from  gallstones  and  gallbladder  infections  without 
pancreatitis  lies  in  the  fact  that  in  a  certain  proportion  of  individuals  the  bile-duct 
and  pancreatic  duct  do  not  enter  the  bowel  by  one  opening,  but  through  separate 
openings.  In  a  few  cases  the  chief  secretion  of  the  pancreas  escapes  by  way  of 
the  duct  of  Santorini.     (See  Fig.  111.) 


Portion  of  human  pancreas  and  duodenum,  showing  a  condition  in  which  pancreatic  juice  may 
enter  the  intestine,  although  the  gall-duct  is  obstructed:  A,  duodenum  showing  the  projection  formed 
by  Brunner's  gland;  B,  B,  the  large  pancreatic  duct;  C,  C,  anastomoses  between  the  small  pancreatic 
duct  and  the  large  pancreatic  duct;  D,  opening  of  the  superior  pancreatic  duct  into  the  intestine;  E, 
opening  of  the  small  inferior  pancreatic  duct  into  the  bile-duct.     (Bernard.) 


Acute  pancreatitis  may  result  from  several  other  causes,  as  one  of  the  acute 
infectious  diseases,  such  as  mumps,  or,  again,  in  the  course  of  septicemia.  Another 
cause  is  infection  from  a  neighboring  lesion,  as  in  direct  extension  from  a  gastric 
ulcer  or  cancer,  or  a  subphrenic  abscess.  Still  another  cause  is  injury  by  blows 
or  by  surgical  procedure. 

Pathology  and  Morbid  Anatomy. — Acute  pancreatitis  is  characterized  not  only 
by  a  primary  hyperemia  of  the  gland,  but  in  some  cases  by  the  escape  of  its  ferments 
into  its  own  tissues,  and  adjacent  tissues  as  well.  As  a  result  of  this  accident, 
a  condition  of  "fat-necrosis"  develops  in  the  fatty  tissues  in  the  immediate  region 
of  the  pancreas,  and  often  in  other  parts  of  the  body  to  which  the  pancreatic  ferment 
may  escape  in  the  lymph.    The  fat  is  split  up  into  glycerin  and  fatty  acids.     The 


632  DISEASES  OF  THE  PAXCREAS 

glycerin  is  absorbed;  the  acids,  being  insoluble,  are  not  eliminated,  but  combine 
with  calcium  salts,  and  with  the  necrotic  fat  form  yellowish-wiiitc  patches  in  the 
retroperitoneal  fat,  and  in  the  fat  of  the  omentum,  mesentery,  abdominal  wall, 
and  it  may  be  in  otlier  parts. 

In  a  certain  number  of  cases  of  acute  pancreatitis,  but  not  in  all  cases,  hemorrhage 
into  the  body  of  the  gland  occurs,  forming  what  is  known  as  acute  hemorrhagic 
pancreatitis.  (See  also  Hemorrhage  into  the  Pancreas.)  Whether  this  hemorrhage 
is  the  result  of  the  action  of  the  ferment  of  the  gland  upon  its  own  vessels  is  not 
known. 

Acute  pancreatitis  may  proceed  to  suppuration  (suppurative  pancreatitis) 
or  to  gangrene  (gangrenous  pancreatitis).  The  suppurative  form  may  be  circum- 
scribed or  diffuse.  In  some  cases  the  pus  may  he  confined  to  the  pancreas  or 
peripancreatic  structures,  but  the  lesser  peritoneum,  or  even  the  general  peritoneum, 
may  be  involved. 

Symptoms. — In  acute  pancreatitis  the  patient  is  suddenly  seized  by  a  severe 
pain  in  the  epigastric  region,  which  is  associated  with  faintness,  or  even  collapse, 
and  it  may  be  active  vomiting.  Inquiry  reveals  the  fact  that  constipation  is  present, 
and  so  the  physician  may  bemisled  into  a  diagnosis  of  intestinal  obstruction,  but 
doubt  is  thrown  upon  this  belief  by  the  fact  that  gas  can  be  passed  by  the  anus. 
The  pain  may  be  paroxysmal  in  tj'pe,  and  there  is  great  tenderness  in  the  epigastrium 
upon  pressure.  This  area  becomes  swollen  and  tense,  and  as  the  case  progresses 
the  entire  abdomen  may  become  distended.  The  face  is  pinched  and  anxioiis- 
looking,  and  the  upper  lip  drawn  as  in  acute  peritonitis.  The  vomit  may  become 
black  and  tarr\'  from  the  presence  of  altered  blood. 

If  the  patient  survives  more  than  a  few  hours,  a  more  or  less  marked  jaundice 
develops,  provided  that  the  bile  is  prevented  from  escaping  into  the  bowel  by 
swelling  of  the  mucous  membrane  or  the  presence  of  a  stone.  Hiccough  may  be 
an  annoying  symptom,  and  the  jmlse  is  rapid  and  running.  The  temperature  may 
be  febrile,  Jiormal,  or  subnormal.  Tlie  urine  may  contain  casts  and  albumin. 
Death  in  collapse  with  profound  asthenia  usually  occurs  by  the  second  to  the  sixth 
day,  but  recovery  may  occur  in  mild  cases,  and  it  sometimes  happens  that  these 
acute  symptoms  gradually  merge  into  the  subacute  type  of  the  malady. 

Subacute  pancreatitis  cannot,  of  course,  be  sharply  separated  from  the  acute 
form,  yet  cases  occur  in  which  the  symptoms  are  sufficiently  modified  to  indicate 
that  another  form  of  pancreatitis  is  present.  The  malady  is  not  so  sudden  in  its 
onset,  the  pain  is  not  so  excruciating,  and  the  epigastric  swelling  is  neither  so 
great  nor  so  rapid  in  its  development.  The  pulse  is  less  rapid,  and  the  constipation 
is  more  prone  to  give  place  to  diarrhea,  the  stools  containing  pus,  tarry  blood,  and 
undigested  food.  Chills  also  occur,  and  after  a  few  days  a  swelling,  due  to  abscess, 
may  be  felt.  This  abscess  may  burrow  in  such  a  way  as  to  form  a  perirenal  abscess, 
a  psoas  abscess,  or  a  subphrenic  abscess,  or  it  may  burst  into  the  stomach  or  bowel. 
The  symptoms  of  sepsis  are,  of  course,  present  in  such  a  case,  and  if  surgical  relief 
is  not  given  death  is  due  to  this  cause  or  to  profound  asthenia.  Such  a  case  must 
be  separated  from  perforation  of  a  gastric  ulcer,  from  abscess  due  to  caries  of  the 
spine,  from  suppurating  cholecystitis,  and  from  perirenal  abscess. 

Diagnosis. — Fitz  gives  the  following  rule  for  the  diagnosis  of  this  state:  "Acute 
])ancreatitis  is  to  be  suspected  when  a  previously  healthy  person,  or  a  sufferer 
from  occasional  attacks  of  indigestion,  is  suddenly  seized  with  violent  pain  in  the 
epigastrium,  followed  by  \oniiting  and  collapse,  and  in  the  course  of  twenty-four 
hours  by  a  circumscribed  epigastric  swelling,  tympanitic  or  resistant,  with  slight 
rise  of  temperature."  These  symptoms  are  still  more  indicative  if  there  is  a  history 
of  gallstone  colic  or  cholecystitis. 

Acute  pancreatitis  must  be  separated  from  intestinal  obstruction,  perforation 
of  the  duodenum,  and  the  perforation  of  a  gastric  ulcer.     It  must  not  be  confused 


PANCREATITIS  633 

with  rupture  of  the  gallbladder,  suppurative  cholecystitis,  and  fulminating  appen- 
dicitis. The  differential  diagnosis  from  intestinal  obstruction  has  already  been 
touched  upon.  If  doubt  exists  an  operation  will  reveal  the  true  cause  of  the 
symptoms,  for  in  pancreatitis  fat-necrosis  may  be  evident  as  soon  as  the  belly  is 
opened.  The  operation  is  justified,  because  it  ought  to  be  performed  in  either 
instance  to  save  life.  When  perforation  of  the  stomach  or  duodeimm  is  considered, 
the  history  of  an  old  gastric  ulcer  or  of  hemorrhage  from  the  bowel,  in  which  dark, 
tarry  blood  is  passed,  will  be  of  importance,  and  here,  again,  an  operation  to  save 
life  is  necessary,  whether  the  condition  be  pancreatic  disease  or  perforation. 

When  suppurative  cholecystitis  is  suspected,  it  may  be  confirmed  by  the  discovery 
that  the  early  swelling  is  in  the  neighborhood  of  the  gallbladder,  and  a  history  of 
typhoid  fever  or  of  gallstones  will  be  presented.  However,  this  latter  history  may 
be  equally  suggestive  of  secondary  pancreatic  disease.  Here,  again,  an  operation 
primarily  for  diagnosis  and  secondarily  for  relief  is  indicated. 

Perhaps  the  most  important  differential  diagnosis  lies  between  acute  pancreatitis 
and  fulminating  appendicitis,  because  appendicitis  is  a  common  disease,  because 
the  pain  accompanying  it  is  often  referred  to  the  epigastrium,  and  because  an 
incision  in  the  pancreatic  region  is  far  removed  from  that  required  for  appen- 
dectomy. 

Palpation  of  the  appendix  will  usually  elicit  pain  over  its  site,  and,  perhaps, 
localized  swelling.  Examination  by  the  rectum  may  reveal  marked  iliac  tenderness 
and  a  history  of  repeated  attacks  of  appendicitis  may  be  found. 

A  very  large  number  of  tests,  of  the  urine,  the  feces,  and  the  duodenal  and  the 
stomach  contents  have  been  proposed  to  determine  pancreatic  disease.  No  one 
of  them  is  in  itself  satisfactory.  For  ordinary  clinical  purposes  the  test  of  Loewi 
is  perhaps  the  most  interesting.  This  depends  upon  the  fact  that  if  a  minute 
quantity  of  adrenalin  solution  (1 :  1000)  be  injected  under  the  conjunctiva  it  causes 
mydriasis  in  5  to  20  minutes  when  there  is  disturbed  equilibrium  of  the  internal 
secretions  of  the  tissues  of  the  chromaffine  system.  The  test  is  positive  in  diseases 
of  the  pancreas,  hyperthyroidism,  diabetes  mellitus,  diseases  of  the  peritoneum, 
stomach,  intestine,  and  in  certain  diseases  of  the  central  nervous  system  and 
meninges.  It  is  about  as  accurate  as  any  of  the  other  tests,  capable  of  being  used 
by  those  who  are  not  trained  physiological  chemists.  (For  valuable  articles  on 
'  the  chemistry  of  the  urine  in  disease  of  the  pancreas  see  Cammidge,  British  Medical 
Journal,  x\pril  2,  1904;  and  Sladden,  in  the  Quarterly  Journal  of  Medicine,  July, 
1914.) 

Prognosis. — Acute  pancreatitis  is  always  an  exceedingly  grave  state.  Death 
ensues  in  the  majority  of  cases.  Recovery  occurs  in  the  very  mild  cases,  as  has 
been  proved  by  instances  in  which  a  subsequent  operation  has  revealed  the  evidences 
of  the  disease. 

Treatment. — The  treatment  of  acute  pancreatitis  consists  in  the  prompt  institution 
of  surgical  proceedings  as  soon  as  the  shock  of  the  onset  of  the  disease  has  been 
overcome.  Robson  insists  that  the  surgeon  should  not  wait  until  collapse  passes 
off,  as  the  collapse  may  be  due  to  septic  absorption,  wliich  only  an  operation  can 
relieve.  By  the  relief  of  pressure,  the  providing  of  drainage,  and  the  removal  of 
the  cause  of  the  attack,  if  it  exists  in  the  gall-duct,  relief  may  be  given  the  patient 
and  the  process  arrested  before  it  has  proceeded  too  far.  Ebner's  statistics  reveal 
a  death  rate  of  90  per  cent,  in  cases  not  operated  upon  and  of  52.8  per  cent,  in 
those  operated  upon.  Moynihan  makes  the  seemingly  bold  but  really  guarded 
statement  that  when  there  is  a  timely  diagnosis  (Italics  mine)  the  recovery  of  the 
patient  can  generally  be  assured.  In  a  certain  proportion  of  cases,  however, 
the  state  of  the  patient  from  the  onset  is  too  grave  to  permit  of  surgical  intervention. 
Excessive  pain  is  to  be  relieved  by  morphine  given  hypodermically,  and  collapse 
is  to  be  treated  by  the  employment  of  strychnine  and  atropine. 


634  DISEASES  OF  THE  PANCREAS 

The  treatment  of  the  subacute  form  of  the  disease  consists  in  su])i)orting  the 
nutrition  of  the  patient  by  the  use  of  predigested  foods  and  stimulants,  and  by 
surgical  intervention  for  the  relief  of  tension  and  removal  of  pus  as  soon  as  the 
diagnosis  is  made  and  the  patient  is  strong  enough  to  stand  operative  procedures. 

Chronic  Pancreatitis. — This  form  of  pancreatitis  has  been  in  the  past  con- 
sidered (juite  rare,  but  it  would  seem  probable  that  it  exists  more  conimoidy  than 
is  generally  thought.  It  is  usually  developed  as  a  result  of  chronic  catarrh  of  the 
duct  of  Wirsiing,  which,  in  turn,  is  caused  by  chronic  gastroduodenal  catarrh  or  by 
cholelithiasis,  pancreatic  lithiasis,  or  by  gastric  ulcer. 

Of  chronic  pancreatitis,  Opie,  of  Baltimore,  thinks  there  are  two  types.  One 
is  an  interlobular  pancreatitis,  with  increase  in  the  connective  tissue  between  the 
lobules;  the  intralobular  tissues  being  unaffected  and  the  islands  of  Langerhans 
escaping  until  very  late  in  the  pathological  process.  This  is  the  type  of  chronic 
pancreatitis  which  follows  blocking  of  the  pancreatic  duct  by  a  morbitl  growth 
or  by  pancreatic  or  biliary  calculi.  Glycosuria  is  rarely  present,  because  the  islands 
escape.  This  the  common  form.  In  the  second  form  there  is  an  interacinar 
pancreatitis,  that  is,  new  connective-tissue  formation  in  the  lobules  themselves. 
The  islands  of  Langerhans  are  seriously  affected  in  this  type,  and  hence  glycosuria 
is  usually  present.     This  form  is  not  due  to  obstruction  of  the  ducts. 

These  pathological  facts  show  why  it  is  that  glycosuria  does  not  appear  as  a 
sign  of  pancreatic  disease  in  most  cases  in  which,  as  the  result  of  gallstone  disease 
or  other  sources  of  infection  or  obstruction,  we  suspect  the  presence  of  pancreatitis. 
For  a  recent  and  exhaustive  consideration  of  the  Relation  of  the  Islands  of  Langer- 
hans to  Morbid  Conditions  of  the  Pancreas  and  Diabetes  Mellitus  see  Finney's 
article  in  the  Medical  Chronicle  for  June,  1903. 

The  interstitial  type,  like  the  more  acute  forms,  may  be  diffuse  or  localized. 
When  localized  a  single  area  may  manifest  the  change.  A  some\yliat  subacute 
form  is  also  recognized,  and  in  some  of  these  cases  there  is  a  conspicuous  enlarge- 
ment of  the  area  involved,  so  that  the  head  of  the  pancreas  when  affected  may  be 
mistaken  for  a  neoplasm.  Presumably  this  enlargement  represents  a  cellular 
infiltration,  which  later  passes  on  to  a  fibrosis.  The  typical  fibroid  pancreas  is 
small,  dense,  resists  incision,  and  may  creak  when  under  the  knife.  Fatty  infiltra- 
tion is  usually  also  present,  and  evidences  of  a  primary  acute  process  may  be 
manifest.  On  microscopic  examination  there  is  a  notable  increase  in  the  fibrous 
tissue,  which,  as  already  stated,  may  be  perilobular  or  interlobular,  or  it  may  be 
interacinar.  In  the  latter  form  the  islands  of  Langerhans  show  hyaline  or  fibro- 
hyaline  transformation,  or  they  may  be  absent  from  certain  areas,  or,  perhaps, 
cannot  be  demonstrated  in  any  part  of  the  organ.  The  ducts  may  show  dilatation, 
and  in  some  instances  be  stained  with  bile. 

Symptoms. — Chronic  pancreatitis  may  be  divided  into  those  cases  in  which  the 
symptoms  are  mild  and  those  in  which  they  are  seA'ere.  In  one  case  there  may  be 
little  if  any  pain,  but  there  is  present  persistent  loss  officsh,  and  in  the  epigastrium, 
near  the  gallbladder,  may  be  found  a  hard  mass  which  may  be  mistaken  for  a 
malignant  growth  in  the  stomach  or  gallbladder.  The  patient  complains  of 
epigastric  distress,  such  as  that  which  follows  taking  food  which  is  difficult  of  diges- 
tion, and  attacks  of  vomiting  may  occur.  Somtimes  jaundice  appears.  Fever 
may  be  present  if  the  infection  of  the  ducts  is  marked. 

In  the  most  severe  form  of  chronic  pancreatitis,  the  symptoms  are  in  close 
accord  with  those  of  the  subacute  form,  in  tliat  the  symptoms  may  begin  with 
severe  pain  in  the  epigastrimn,  as  if  the  patient  had  gallstone  colic.  There  is 
tenderness  in  the  midepigastrium.     Chills  and  fever  may  be  well  developed. 

Diagnosis. — Chronic  pancreatitis  is  to  be  separated  from  gallstones  in  the  ductus 
commimis  choledochus,  from  cancer  of  the  head  of  the  pancreas,  from  cancer  of 
the  gallbladder  and  of  the  liver,  and  from  subphrenic  abscess.     From  impacted 


PANCREATITIS  635 

gallstones  in  the  common  duct  the  ditt'erentiation  is  practically  impossible.  Tender- 
ness on  deep  pressure  will  usually  be  found  over  the  gallbladder  in  the  case  of 
gallstones  and  over  the  epigastrium  in  pancreatic  disease,  and  etherization  may 
permit  sufficiently  deep  palpation  to  feel  the  enlarged  head  of  the  pancreas  if 
chronic  pancreatitis  is  present.  The  distribution  of  the  pain  may  be  of  value  in 
the  differentiation.  In  gallstone  cases  the  pain  is  in  the  gall-bladder  area  and 
radiates  around  to  the  right  scapular  region;  whereas,  in  pancreatic  disease  it  is 
central  and  travels  directly  backward  to  a  space  between  the  ends  of  the  scapula. 

Cancer  of  the  head  of  the  pancreas  is  a  disease  of  advanced  life;  its  onset  is 
usually  painless,  and  the  jaundice  that  may  ensue  is  gradual  in  onset  and  persistent, 
because  the  growth  primarily,  or  secondarily,  presses  continually  on  the  gall-ducts. 
The  presence  of  great  swelling  of  the  gallbladder  in  association  with  jaundice  and 
with  the  other  symptoms  of  pancreatic  disease  already  named  indicates  cancer. 
Sometimes  in  these  cases  secondary  cancerous  nodules  are  to  be  found  in  the  liver 
and  in  other  organs.  The  liver  may  be  much  enlarged  from  the  damming  back 
of  bile  and  from  secondary  growths.  Robson  and  ^loynilian  lay  stress  on  the 
fact  that  the  absence  of  pancreatic  secretion  from  the  stools  causes  them  to  be 
clay-colored,  even  when  bile  is  present,  and  this  may  aid  in  diagnosis.  If  on  testing 
the  stools  bile  is  found,  and  the  feces  are,  nevertheless,  light  in  hue,  it  is  a  fair 
supposition  that  pancreatic  secretion  is  absent.  The  test  of  the  urine  for  leucin 
and  tyrosin  should  also  be  used. 

There  are  two  other  facts  which,  if  present,  will  decide  the  diagnosis  positively, 
namely,  fatty  stools  due  to  the  lack  of  pancreatic  juice  in  the  bowel  and  the  presence 
of  glycosuria  due  to  the  invasion  of  the  islands  of  Langerhans  in  the  pancreas 
by  the  pathological  process.  Both  of  these  signs  are  often  absent,  but  if  they  are 
associated  they  are  pathognomonic  of  pancreatic  disease.     (See  Diabetes  ^Nlellitus.) 

Prognosis. — Patients  suffering  from  chronic  pancreatitis  in  moderate  degree  may 
live  for  months  or  even  for  years.  If  glycosuria  develops  the  prognosis  becomes 
very  grave,  not  only  because  this  symptom  is  grave  in  itself,  but  because  the 
glycosuria  indicates  that  the  involvement  of  the  gland  in  the  disease  process  is 
well-nigh  universal,  for  as  long  as  but  a  few  islands  of  Langerhans  exist  glycosuria 
does  not  ensue.  Great  emaciation,  marked  jaundice,  and  the  development  of  a 
tendency  to  have  multiple  hemorrhages  are  evil  signs. 

It  is  in  this  form  of  pancreatitis  that  surgery  has  given  its  most  valuable  results, 
often  producing  perfect  recovery. 

Treatment. — The  treatment  of  the  mild  form  of  chronic  pancreatitis  depending 
upon  catarrh  of  the  biliary  and  pancreatic  ducts  may  be  medicinal  for  a  time  in  the 
hope  that  the  condition  may  be  relieved.  The  measures  instituted  are  practically 
identical  with  those  advised  in  cases  of  chronic  cholangitis  (which  see).  It  is, 
however,  a  vital  mistake  to  permit  these  cases  to  drift  along  in  a  state  of  chronic 
ill  health,  because  the  condition  is  one  which  will  eventually  lead  to  pancreatic 
cirrhosis,  and  this  in  turn  results  in  great  emaciation  and  the  development  of 
glycosuria,  which  causes  death.  In  other  words,  if  the  patient  does  not  improve 
surgical  measures  should  be  adopted  to  give  relief. 

The  treatment  of  chronic  pancreatitis  of  the  severe  tj-pe  is  wholly  surgical, 
for  it  is  cured  in  the  majority  of  instances  by  abdominal  section  and  drainage  of 
the  pancreatic  and  gall-ducts.  Robson  gives  the  mortality  of  operations  in  chronic 
pancreatitis  as  12.9  per  cent,  in  62  cases.  Operations  in  all  cases  of  jaundice  are 
of  a  grave  character,  because  persistent  oozing  hemorrhage  is  prone  to  follow. 
Robson  and  Moynihan  are  firmly  convinced  that  the  danger  from  oozing  hemorrhage 
after  operation  in  cases  of  jaundice  without  pancreatic  lesions  is  less  than  in  those 
cases  in  which  the  pancreas  is  affected.  They  strongly  advise  the  use  of  full  doses 
of  calcium  chloride  in  all  these  cases  prior  to  operation,  to  increase  coagulability 
of  the  blood.     They  advise  20  to  60  grain  doses  three  times  a  day  for  one  or  two 


63G  DISEASES  OF  THE  PAXCREAS 

days.  It  is  not  to  be  forgotten  that  the  persistent  use  of  this  salt  finally  decreases 
the  coagulability  of  the  blood.  Horse  scrum,  a  coagulosc,  is  ])r()bal)ly  better  than 
calcium  chloride. 

To  sum  up  the  subject  of  treatment,  it  may  be  said  that  all  forms  of  pancreatitis 
should  be  operated  upon  if  the  condition  is  such  that  an  oi)erativc  procedure  can 
be  supported.  While  in  acute  pancreatitis  the  operation  can  do  little  good  directly, 
it  permits  drainage  and  it  may  remove  some  provoking  cause,  and  so  lead  to  recov- 
ery. In  any  case  it  is  the  patient's  only  chance.  In  the  hemorrhagic  or  suppura- 
tive cases,  the  relief  of  pressure  or  of  pus  is,  of  course,  advantageous. 

PANCREATIC  CALCULUS. 

Pancreatic  calculus  is  an  exceedingly  rare  condition.  The  stones  arc  composed 
of  phosphates  and  carbonates.  They  vary  in  size  from  two  and  a  half  inches  in 
length  to  fine  sand,  and  they  may  be  single  or  multiple.  As  many  as  300  have  been 
reported  in  one  case. 

Symptoms. — There  are  no  pathognomonic  signs  of  the  presence  of  pancreatic 
calculus.  Pain  in  the  upper  zone  of  the  abdomen  near  the  middle  line  or,  as  in 
Minnich's  case,  near  the  left  costal  border  may  be  present.  It  is  often  colicky  in 
character,  and  with  the  pain  there  may  be  vomiting,  sweating,  and  collapse, 
as  in  gallstone  colic.  Fatty  stools  from  the  absence  of  pancreatic  juice  may  be 
present,  and  glycosuria  may  occur.  Occasionally  pieces  of  the  stone  or  small 
stones  can  be  found  in  the  stools. 

Treatment. — The  treatment  consists  in  removal  of  the  stones  from  the  duct  by 
operation.  Hypodermic  injections  of  pilocarpine  have  been  advised  to  increase 
the  flow  of  the  pancreatic  fluid,  but  this,  of  course,  cannot  remove  the  stone  if  it  is 
embedded.     I  would  expect  it  to  do  more  harm  than  good. 

PANCREATIC  CYSTS. 

These  occur  in  four  forms,  namely,  as  retention  cysts,  proliferation  cysts,  hydatid 
cysts,  and  pseudocysts.  Such  cysts  are,  however,  exceedingly  rare.  Hale  White 
states  that  in  6000  autopsies  at  Guy's  Hospital  cysts  of  the  pancreas  were  found 
only  four  times.  As  Jordan  Eloyd  has  shown,  cysts  in  the  epigastric  area  are  usually 
collections  of  fluid  in  the  lesser  sac  of  the  peritoneum  closed  at  the  foramen  of 
Winslow. 

Retention  cysts  arise  from  blocking  of  the  flow  of  secretion  by  calculi  or  by  a 
single  calculus,  by  the  formation  of  cicatricial  tissue,  which  narrows  the  duct,  and 
by  pressure  from  neighboring  morbid  growths.  If  no  infection  accompanies  the 
retention  of  the  fluid  a  cyst  results  instead  of  pancreatitis. 

Proliferation  cysts  occur  as  cystadenoma,  or  multilocular  tumors,  witli  a  lining 
of  cylindrical  epithelium,  and  as  cystic  epithelioma.  Hydatid  cysts  of  the  pancreas 
are  very  rare  indeed,  particularly  in  the  United  States  and  England;  Hale  White 
has  reported  one  in  England. 

Hemorrhagic  cyst  results  from  the  occurrence  of  a  hemorrhage  into  the  gland 
tissue.     Its  existence  is  doubted  by  many  pathologists. 

Pseudocysts  are  not  real  cysts  of  the  pancreas,  but  small  cystic  accumulations 
of  fluid  in  adjacent  tissues.  Sometimes  a  pancreatic  pseudocyst  is  due  to  ett'usion 
into  the  lesser  peritoneal  cavity.  They  are  thought  to  follow  some  injury  to  the 
epigastrium. 

Pancreatic  cysts  occur  at  all  ages  from  infancy  to  old  age,  and  are  met  with 
more  frequently  in  men  than  in  women,  but  the  dift'erence  in  the  two  sexes  is  very 
slight.  The  fluid  varies  very  greatly  in  appearance.  It  may  be  as  clear  as  water, 
or  it  may  be  opaque,  or  yellow,  or  coft'ee-colored,  and  even  green  or  black.     Its 


HEMORRHAGES  INTO  THE  PANCREAS  637 

specific  gravity  is  from  1.010  to  1.020,  and  it  contains  albumin.  Sometimes  it 
contains  all  the  digestive  ferments  of  the  pancreas.  The  presence  of  any  of  them 
is  of  value  in  diagnosis,  but  their  absence  does  not  negative  the  pancreatic  origin 
of  the  fluid.  Nor  does  their  presence  prove  that  the  cysts  arose  from  the  pancreas. 
Pressure  upon  the  pancreas  and  secondary  changes  in  a  cyst  wall  may  cause  com- 
munication with  the  pancreas  and  admit  its  secretion  to  the  cyst  cavity. 

Symptoms. — The  symptoms  of  pancreatic  cyst  are  dependent  upon  the  pressure 
which  is  produced,  and,  therefore,  more  or  less  discomfort  may  be  the  only  sign 
of  its  existence.  If  the  pressure  is  great  pain  is  present.  If  the  cyst  be  large 
enough  to  palpate  it  will  be  found  to  fluctuate,  to  be  flat  on  percussion,  and  to 
transmit  an  impulse  as  in  ordinary  hallotment.  Puncture  with  a  fine  aspirating 
needle  may  reveal  the  character  of  the  fluid. 

Diagnosis. — Pancreatic  cysts  must  be  separated  from  cystic  kidney,  horseshoe 
kidney,  ovarian  cysts,  cysts  of  the  liver,  hydrops  of  the  gallbladder,  and  cysts  of 
the  suprarenal  capsules.  It  must  also  be  separated  from  mesenteric  cysts,  omental 
cysts,  and  retroperitoneal  cysts. 

Prognosis. — Pancreatic  cyst  may  last  for  years  without  'causing  discomfort 
or  death.  On  the  other  hand,  cases  occur  in  which  the  cyst  ruptures  into  the 
peritoneal  cavity  or  into  the  bowel  or  stomach,  and  when  this  happens  death 
ensues,  preceded  by  vomiting  and  diarrhea.  Rarely  hemorrhage  takes  place  into 
the  cyst,  and  this  is  accompanied  by  sudden  increase  in  its  size,  and  by  faintness 
and  collapse. 

Treatment. — The  treatment  consists  in  aspiration,  evacuation  and  drainage 
or  complete  extirpation  of  the  cyst  wall.  The  second  procedure  is  usually  that  of 
election. 

PANCREATIC  TUMORS. 

These  growths  are  exceedingly  rare.  Park  states  that  in  53,000  autopsies  only 
226  showed  primary  malignant  disease  of  this  gland.  Tumors  of  the  pancreas 
consists  in  carcinoma,  sarcoma,  adenoma,  and  gumma.  The  infrequency  of  car- 
cinoma is  shown  by  the  fact  that  in  23,581  autopsies  made  in  various  parts  of  the 
world,  in  only  29  instances  was  pancreatic  carcinoma  present.  The  relative  fre- 
quency of  these  growths  is  scirrhus,  encephaloid  and  colloid. 

Carcinoma  is  the  most  frequent  primary  growth,  according  to  Osier,  and  sarcoma 
is  a  more  common  secondary  tumor  because  of  involvement  of  the  retroperitoneal 
glands  by  this  disease. 

As  nearly  all  cases  of  pancreatic  malignant  growth  are  secondary  to  disease  of 
the  gallbladder,  a  tumor  in  the  region  of  that  viscus  will  usually  be  found  to  confirm 
the  diagnosis. 

The  prognosis  in  the  case  of  malignant  tumors  is,  of  course,  hopeless.  In  benign 
tumors  the  outlook  depends  upon  the  pressure  symptoms.  If  a  gumma  is  present, 
antisyphilitic  treatment  is,  of  course,  indicated. 

HEMORRHAGES  INTO  THE  PANCREAS. 

This  condition  is  to  be  distinctly  separated  in  the  physician's  mind  from  "acute 
hemorrhagic  pancreatitis."  Local -hemorrhages  may  take  place  into  the  pancreas 
without  any  injury  being  received  and  without  the  patient  being  a  sufl^erer  from 
hemorrhages  elsewhere.  The  hemorrhage  may  occur  in  a  person  who  has  seemingly 
been  in  excellent  health  without  any  other  symptoms  than  collapse,  with  a  feeble 
pulse  and  evidences  of  shock.  Sometimes  hemorrhage  into  the  pancreas  occurs  as 
the  result  of  aneurysm  of  nearby  vessels,  or  of  cancer  of  the  head  of  the  gland. 
When  hemorrhage  into  the  pancreas  occurs,  it  may  be  a  limited  extravasation  of 
blood  into  the  gland,  from  which  the  patient  may  recover,  or  it  may  be  so  profuse 


638  DISEASES  OF  THE  KIDNEYS 

as  to  flood  the  rctro])eritoiieal  s])acc,  cxtcndini,'  Imck  to  tlic  kidneys  and  u])  to  tlie 
posterior  insertion  of  the  diaphragm. 

The  differentiation  between  the  symptoms  produced  by  liemorrliage  into  the 
pancreas  and  acute  pancreatitis  is  practically  impossible  if  there  is  no  previous 
history  of  hepatic  and  duodenal  disorder.  If  the  condition  is  due  to  hemorrhage, 
an  operation  to  relieve  local  tension  is  indicated,  as  death  is  due  rather  to  this 
cause  than  to  the  loss  of  blood. 


DISEASES  OF  THE  KIDNEYS. 

MALFORMATIONS  OF  THE  KIDNEY. 

It  happens  not  very  rarely  that  one  kidney  is  absent,  its  place  being  occupied 
by  a  little  fibrous  tissue  or  by  atrophied  renal  tissue  and  fat.  In  order  that  the 
blood  may  be  relieved  of  effete  materials  the  other  kidney  is  often  very  large,  and, 
as  it  is  usually  lower  down  in  the  loin  for  this  reason,  it  may  be  mistaken  for  a 
dislocated  or  cystic  kidney,  and  removed,  which  means  death  to  the  patient. 
Not  uncommonly  one  kidney  is  larger  than  the  other,  even  if  both  are  functionally 
active.  In  other  cases  one  kidney  has  two  pelves  and  two  ureters.  Perhaps  the 
most  common  of  these  malformations  is  the  so-called  "horseshoe  kidney,"  in 
which  the  two  kidneys  are  joined  across  the  vertebral  column  by  a  mass  of  renal 
or  connective  tissue.  Sometimes  this  horseshoe  kidney  is  displaced  into  the  pelvis, 
or  it  may  be  altogether  on  one  side  of  the  vertebral  colimin. 

Again,  the  kidneys  may  be  fused  into  a  single  mass,  usually  occupying  a  median 
position  much  below  the  normal  le^^el,  or  even  in  the  pelvis. 

MOVABLE  KIDNEY. 

Definition. — Aside  from  the  renal  malpositions  incident  to  malformation,  and, 
therefore,  essentially  of  congenital  origin,  the  kidney  may  wander  from  its  normal 
position.     Several  forms  of  such  displacement  are  recognized. 

The  movable  kidney  lies  behind  the  peritoneum,  and  usually  can  be  made  to 
assume  its  normal  position,  but  descends  during  the  erect  posture;  its  malposition 
may  be  parallel  to  the  axis  of  the  body,  or  it  may  show  a  lateral  mo\"ement,  or 
the  two  may  be  combined — the  "cinder-sifting"  kidney.  The  organ  may  be 
pushed  from  its  place  and  anchored  in  its  new  position — the  "incarcerated  kidney." 

When  the  kidney  falls  forward  and  develops  a  pedicle,  consisting  of  the  ureter, 
vessels,  and  peritoneum,  the  last  also  covering  the  organ,  it  then  becomes  a  "floating 
kidnei/,"  the  pedicle  forming  the  so-called  mesonephron. 

Kidneys  enlarged  from  any  cause  are  prone  to  displacement,  and  displaced 
kidneys,  on  account  of  obstruction  of  the  ureters  and  veins,  are  frequently  subject 
to  enlargement. 

Movable  kidney  is  far  more  frequent  in  women  than  in  men,  in  the  proportion 
of  about  7  to  1.  Again,  the  right  kidney  is  the  one  at  fault  in  the  majority  of 
cases,  or  in  the  proportion  of  about  7  to  1.     Sometimes  both  kidneys  are  movable. 

Etiology. — The  mo.st  important  etiological  factor  is  undoubtedly  bodily  configvra- 
tion.  Women  of  the  lean,  lank  type  with  floating  ribs  that  slope  markedly  down- 
ward and  who  are  hollow  in  the  flank,  like  a  hunting  dog  in  training,  are  the  most 
frequent  subjects.  Their  muscles  are  usually  poorly  developed,  and,  if  they  have 
been  pregnant,  as  a  rule,  the  abdominal  wall  is  relaxed.  If  to  the  natural  configura- 
tion and  these  other  causes  is  added  the  effect  of  a  tight  corset  and  a  sudden  effort 


MOVABLE  KIDNEY  fi39 

or  fall,  the  needful  etiological  factors  are  all  present,  and  a  sharp  pn'm  in  the  side 
may  be  the  sign  that  the  kidney  has  made  its  maiden  movement  from  its  natural 
site.  In  one  case  the  woman  says  she  had  a  fall  and  has  wrenched  her  side  in 
falling;  in  another  she  has  reached  high  above  her  head,  as  in  playing  tennis;  and 
in  a  third  case  a  blow  or  jar  in  a  railway  accident  may  have  been  the  needed  trauma. 

Symptoms. — Many  patients  have  no  symptoms  of  this  condition  for  years. 
If  on  examining  the  belly  in  the  region  of  the  gallbladder  a  floating  kidney  is 
found  in  a  person  ignorant  of  its  existence,  and  anything  is  said  of  it,  the  patient 
not  rarely  becomes  a  hypochondriac  on  this  subject,  and  goes  from  physician  to 
surgeon,  insisting  on  relief  of  symptoms  which  are  often  not  really  in  existence. 
As  the  condition  is,  to  a  large  extent,  harmless,  it  should  be  ignored,  unless  it  is 
causing  symptoms. 

When  symptoms  are  present  they  vary  over  a  wide  degree  of  severity.  In 
some  they  consist  of  a  sensation  of  draqging  in  the  back  and  side,  in  others  they 
amount  to  keen  suffering,  and  in  still  others  they  may  consist  in  attacks  of  agony 
due  to  twisting  or  angulation  of  the  ureter  by  the  kidney  becoming  rotated  on 
its  axis  or  bent  by  great  displacement.  These  paroxysms  of  pain  have  been  called 
"Dietl's  crises."  Nausea,  vomiting,  chiUs,  and  collapse  are  present,  and  after 
the  attack  the  urine  is  found  loaded  with  urates  and  perhaps  pus  and  blood  cells. 
Sometimes  even  free  hematuria  may  be  present.  When  by  postural  change  or 
manipulation  the  kidney  assumes  its  normal  position,  a  distinct  renal  pelvis  may 
suddenly  be  emptied  and  a  gush  of  urine  o^'erdistends  the  bladder  and  escapes 
by  the  urethra. 

Diagnosis. — There  are  several  states  that  resemble  the  pain  of  floating  kidney. 
Violent  pain  in  the  epigastrium  may  be  due  to  this  cause  or  to  appendicitis,  or 
gastric  ulcer.  I  have  seen  a  "  Dietl's  crisis"  closely  resemble  a  severe  attack  of 
acute  appendicitis.  It  also  may  resemble  gallstone  or  renal  colic,  or  the  symptoms 
produced  by  abdominal  aneurysm.  The  presence  of  the  mass  in  the  abdominal 
cavity  may  lead  to  a  diagnosis  of  malignant  growth  or  of  impacted  feces. 

The  dislocated  kidney  may  be  felt  on  careful  palpation  in  thin  women  just 
below  the  border  of  the  ribs  and  back  of  the  area  in  which  the  tip  of  the  gallbladder 
can  be  felt  when  that  viscus  is  enlarged,  but  gentle  pressure  often  causes  it  to  dis- 
appear. A  floating  kidney  may,  however,  be  found  almost  anywhere  in  the  abdomi- 
nal cavity,  and  has  even  been  discovered  in  the  pelvis.  When  found  in  the  belly 
it  is  usually  so  movable  as  to  be  easily  pushed  about,  and  it  is  so  free  and  slippery 
that  it  is  often  elusive,  being  found  one  moment  and  lost  the  next.  Not  rarely 
some  movement  of  the  patient  may  cause  it  to  sHp  into  its  normal  position.  This 
fact  often  leads  the  physician  to  overlook  its  presence,  and  only  when  the  patient 
is  repeatedly  examined  is  the  kidney  found  "away  from  home."  In  other  words, 
inability  to  find  a  floating  kidney  at  one  examination  does  not  prove  that  the  patient 
is  not  a  sufl^erer  from  this  state. 

Pressure  upon  the  kidney  gives  rise  to  a  sickening  sensation,  which  causes  the 
patient  to- wince. 

To  examine  the  patient  properly  the  woman  should  be  placed  on  her  back  with 
the  knees  drawn  up  so  that  the  belly  wall  is  relaxed.  If  the  right  side  is  being 
examined  the  left  hand  of  the  physician  is  so  placed  that  the  tissues  of  the  right 
side  can  be  grasped  close  to  the  last  rib,  between  the  thumb  in  front  and  the  fingers 
behind.  The  patient  is  then  told  to  take  a  deep  breath,  when  the  kidney  may  be 
felt  to  slip  out  between  the  fingers  and  thumb,  as  a  watermelon  seed  slips  when 
pressed  upon  in  this  way.  The  left  hand  reniaining  in  situ  to  block  the  pathway 
of  return,  the  fingers  of  the  right  hand  can  now  feel  the  smooth,  rounded  surface 
of  the  organ  below  the  area  grasped  by  the  left  hand.  If  the  pressure  by  the  left 
hand  be  relaxed  and  pressure  upward  is  produced  by  the  right  hand,  the  kidney 
may  be  felt  to  slip  back  into  its  place.    While  the  kidney  is  wandering  deep  palpa- 


640  DISEASES  OF  THE  KIDXEYS 

tion  in  the  flank  may  reveal  a  lack  of  resistance  due  to  absence  of  the  kidney. 
When  the  left  kidney  is  examined  the  same  process  is  followed,  save  that  the  right 
liand  takes  the  place  of  the  left. 

Treatment. — No  treatment  is  needed  unless  the  kidney  really  causes  ])ain.  If 
it  does  it  can  usually  be  kept  in  place  by  the  avoidance  of  ti^lit  lacing  and  of  severe 
exercise,  or  by  wearing  a  properly  adjusted  pad  and  banflage  to  suj)port  the  tissues 
just  below  the  floating  ribs.  Operative  interference,  with  the  object  of  stitching  the 
kidney  in  place,  is  needed  in  bad  cases,  but  the  difficulty  is  that  the  relief  obtained 
by  operation  is  not  permanent  in  all  cases,  the  kidney  wanderirg  away  from  where 
it  is  sutured.  Further  than  this,  the  operation  is  not  entirely  ilcvoid  of  danger. 
My  colleague,  Dr.  Keen,  has  placed  the  mortality  at  2  to  3  per  cent.  Out  of  137 
cases  which  were  operated  upon  and  collected  by  Watson  there  were  5  deaths, 
but  4  were  not  the  result  of  the  operation.  In  neurasthenic  patients  operation 
should  be  avoided,  at  least  until  a  rest  cure  is  instituted,  when  not  rarely  all  signs 
of  renal  tenderness  may  diappear.  Even  in  those  cases  which  have  had  one  attack 
of  severe  pain  (Dietl's  crisis)  the  kidney  may  give  no  further  troutile  if  a  belt  and 
pad  are  worn. 

CIRCULATORY  DISTURBANCES  IN  THE  KIDNEY. 

Changes  in  the  circulation  in  the  kidneys  produce  very  great  alterations  in  the 
urinary  flow,  both  as  to  its  quantity  and  quality.  If  the  vessels  of  the  kidney,  and 
particularly  those  of  the  Malpighian  tufts,  are  poorly  supplied  with  blood,  the 
urinary  secretion  is  scanty,  even  though  the  amount  of  solids  in  the  urine  may  be 
fairly  large.  On  the  other  hand,  any  cause  which  sends  a  large  amount  of  rapidly 
flowing  blood  to  the  kidneys  results  in  free  diuresis.  Thus,  chilling  the  surface 
of  the  body  often  causes  a  profuse  urinary  flow,  and  nitroglycerin,  by  dilating  the 
renal  vessels,  may  do  likewise. 

Any  substance  which  acts  deleteriously  upon  the  delicate  cells  of  the  ^dalpighian 
tufts  causes  them  to  permit  not  only  the  transudation  of  fluid,  but  of  albumin  as  well. 

Acute  Hyperemia. — An  acute  hyperemia  of  the  kidneys  may  follow  exposure 
to  cold,  or  the  attempted  elimination  of  irritating  substances,  such  as  cantharides, 
turpentine,  and  a  host  of  other  drugs  capable  of  damaging  the  kidney  epithelium. 
It  is  also  generally  accepted  that  a  similar  state  of  these  organs  may  exist  in  the 
course  of  acute  infectious  diseases,  like  scarlet  fever,  but  it  is  exceedingly  doubtful 
if  this  is  true  even  in  a  modified  form. 

Treatment. — The  treatment  of  this  state  consists  in  the  use  of  a  few  dry  cups 
on  the  back  over  the  kidneys  and  in  the  liberal  administration  of  some  water, 
like  Poland  water,  to  flush  these  organs.  Rest  in  bed  is,  of  course,  essential.  An 
old-fashioned  and  useful  remedy  is  watermelon-seed  tea  or  the  infusion  of  flaxseed. 
Often  the  use  of  an  alkaline  diuretic,  such  as  2  drachms  of  liquor  potassii  citratis, 
with  1  drachm  of  sweet  spirit  of  nitre,  is  valuable,  if  given  every  three  hours. 

Chronic  Hyperemia. — Chronic  hyperemia  is  a  very  much  more  common  con- 
dition, and  occurs  in  nearly  every  case  in  which  the  circulation  becomes  sluggish 
by  reason  of  cardiac  weakness,  as  in  valvular  disease  with  rupture  of  compensa- 
tion, in  cases  of  ascites  with  pressure  on  the  kidneys,  and  when  tumors  produce  a 
mechanical  interference  with  the  flow  of  blood  in  these  organs. 

Symptoms. — All)uminuria  is  a  prominent  symptom  of  this  state,  and  hyaline 
casts  and  tube  casts  containing  blood  cells  may  be  found.  The  amount  of  urine 
passed  in  each  twenty-four  hours  is  often  very  scanty.  If  such  kidneys  are  seen 
at  autopsy,  they  will  be  found  to  be  cyanotic  in  the  early  stages,  somewhat  enlarged 
and  heavier  than  normal,  but  the  capsule  is  not  adherent  and  the  surface  of  the 
kidney  is  not  roughened.  When  this  condition  has  persisted  a  long  time  the  con- 
nective tissue  increases,  and  when  the  kidnev  is  incised  it  is  found  to  be  firm  and 


ACUTE  NEPHRITIS  Ml 

tough,  due  to  this  overgrowth  of  interstitial  tissue.  The  pyramids  are  dark  and 
purple  in  appearance.  A  more  minute  examination  will  reveal  the  fact  that  the 
capillaries  forming  the  Malpighian  tufts  are  greatly  engorged,  their  walls  thickened, 
and  that  the  vasa  recta,  the  interlobular  veins,  and  the  stellate  veins  of  the  cortex 
are  also  in  a  similar  state. 

Diagnosis. — Such  kidneys  may  lead  the  physician  to  a  diagnosis  of  nephritis 
complicating  cardiac  disease,  hut  the  renal  symptoms  often  disappear  entirely 
under  rest  and  proper  cardiac  treatment,  although  developed  fibroid  changes  in 
the  organ  are,  of  course,  irremediable. 

Treatment. — The  treatment  consists  in  giving  the  patient  digitalis  in  full  doses 
if  the  heart  is  feeble,  and  in  applying  a  hot  compress  over  the  kidneys;  or  in  the 
use  of  dry  cups  over  these  organs,  and  in  the  employment  of  gin  and  digitalis  as 
stimulants  to  the  heart  and  kidneys.  Rest  in  bed  for  the  tired  heart  and  for  the 
congested  kidneys  is  essential.  Another  very  useful  remedy  is  fluid  extract  of 
apocynum  cannabinum  in  the  dose  of  5  to  10  minims  twice  or  thrice  a  day.  (See 
Valvular  Disease  of  the  Heart.) 

ACUTE  NEPHRITIS. 

Definition. — By  acute  nephritis  is  meant  a  state  in  which  the  tissues  of  the 
kidney  are  involved  in  an  acute  inflammatory  process,  that  is  to  say,  it  is  an 
acute  diffuse  nephritis.  The  condition  is  not  far  removed  from  that  of  acute 
hyperemia  already  described. 

Etiology. — The  causes  of  acute  diffuse  nephritis  are  the  acute  infectious  diseases, 
particularly  scarlet  fever,  and  also  diphtheria,  croupous  pneumonia,  and  septicemia. 
Sometimes  typhoid  fever  or  malaria  act  as  exciting  causes.  In  other  cases  an 
acute  infection  gains  access  to  the  body  through  the  tonsils,  and  it  is  remarkable 
how  often  evidences  of  renal  irritation  follow  the  onset  of  tonsillitis.  Still  another 
cause  is  exposure  to  cold,  particularly  if  the  circulation  is  disturbed  by  violent 
exercise,  and  if  the  kidneys  are  irritated  by  the  process  of  eliminating  alcohol  and 
other  waste  products  after  a  Bacchanalian  revel.  So,  too,  the  ingestion  and 
elimination  of  irritant  poisons  may  cause  it.  Severe  burns  or  scalds  may  also 
produce  acute  nephritis. 

Acute  and  subacute  nephritis  are  not  rare  in  children,  and  are  produced  by 
one  of  the  acute  infections.  By  this  term  is  included  not  only  the  eruptive 
fevers,  but  infections  such  as  bronchopneumonia  and  the  various  forms  of  severe 
summer  diarrhea,  in  all  of  which  nephritis  is  by  no  means  unusual.  Thus,  in  70 
cases  of  gastro-intestinal  disorder  Morse  found  signs  of  renal  inflammation  in  no 
less  than  15  per  cent.,  and  Holt  states  that  in  every  case  in  which  tliese  conditions 
become  severe  the  kidneys  suffer. 

Pathology  and  Morbid  Anatomy. — As  with  all  acute  inflammatory  processes, 
great  variations  as  to  the  severity  of  the  alterations  in  the  kidney  are  met  with  in 
different  cases.  In  mild  cases  the  organ  may  show  no  gross  changes.  The  essential 
point  to  be  remembered  is  that  the  texture  of  the  kidney  is  inflamed  through  and 
through,  although  not  uniformly  so.  The  glomeruli,  the  tubules,  the  connective 
tissue,  and  the  bloodvessels  all  share  in  the  process.  In  typical  cases,  for  this 
reason,  the  kidney  is  more  or  less  congested,  enlarged  and  edematous,  pitting  on 
pressure,  and  if  it  is  cut  it  oozes  free  blood  in  excess.  The  capsule  strips  readily 
and  is  often  less  firmly  attached  than  normal.  As  a  rule,  the  more  edematous 
the  organ  the  less  adherent  is  the  capsule.  Often  the  pyramids  are  red  and  en- 
gorged, while  the  broadened  cortex  is  comparatively  pallid. 

In  some  instances  (glomerular  nephritis)  the  glomeruli  appear  to  bear  the  brunt 
of  the  process.  Under  the  microscope  the  vessels  forming  the  tuft  are  seen  to  be 
distended  and  contain  leukocytes  and  larger  cells  having  large  nuclei,  which  are 
41 


642  DISEASES  OF  Till-    KIDXEYS 

probably  endothelial  in  origin.  Degeneration  of  these  cells  ensues,  and  as  this 
change  progresses  they  are  shed  into  Bowman's  capsule  with  large  mononuclear 
leukocytes,  which  fill  it  so  completely  that  the  vessels  of  the  tuft  arc  compressed. 
The  epithelium  lining  the  capsule  may  escape,  although  it  usually  undergoes 
proliferation,  degeneration,  and  exfoliation.  Added  to  these  different  sets  of 
cells  we  find  an  albuminous  exudate,  due  to  the  acute  inflammatory  state  of  the 
surrounding  tissues,  mixed  with  both  red  and  white  blood  cells. 

In  the  tubules  there  is  also  degeneration  and  necrosis  of  the  epithelium  lining 
their  walls,  so  that  the  cells  become  albuminous  or  fatty,  and  desquamate.  In  this 
way  the  tubules  are  more  or  less  distended,  not  only  with  these  cells,  but  with 
red  and  white  cells  and  granular  detritus.  Fusion  of  these  materials  results  in 
the  formation  of  casts  of  the  tubules,  which  appear  in  the  urine  as  blood  casts,  and 
as  casts  of  desquamated  epithelium. 

As  with  inflammations  elsewhere,  there  is  an  extravasation  of  fluid  into  the 
tissues,  and  when  this  occurs  the  interstitial  portions  of  the  kidney  become  edema- 
tous, filled  with  outwandering  leukocytes,  and,  in  addition,  a  considerable  number 
of  small  spheroidal  cells,  many  of  which,  in  some  cases,  as  shown  by  Councilman, 
are  of  the  plasma-cell  type.  If  the  inflammation  is  very  severe,  there  is  an  actual 
hemorrhage  into  the  tissues — "hemorrhagic  nephritis."  When  the  extravasation 
of  serum  and  leukocytes  is  particularly  copious,  Delafield  calls  the  condition 
"  exudative  nephritis."     This  is  the  form  prone  to  occur  during  or  after  scarlet  fever. 

Sjrmptoms. — The  symptoms  of  acute  diffuse  nephritis  are  usually  rather  sudden 
in  onset.  A  child  convalescing  from  scarlet  fever,  or  a  man  suffering  from  an  acute 
infection,  or  after  exposure,  suddenly  suft'ers  from  scanty  urinary  flow,  and  almost 
before  the  scantiness  is  noticed  the /ace  may  be  seen  to  be  edematous  and  the  ankles 
swollen.  The  patient  may  go  to  sleep  with  a  normal  visage  and  awaken  with  a 
puffy  one,  the  puffiness  being  particularly  marked  on  the  pendent  side.  In  children, 
if  the  nephritic  irritation  be  severe,  a  convulsion  may  develop  as  one  of  the  early 
signs.     Fever  may  or  may  not  be  present. 

It  is  an  interesting  fact  that  severe  anemia  develops  with  extraordinary  speed, 
so  that  the  swollen  face  becomes  pallid  and  white  in  appearance  as  soon  as  it  is 
puffy.  Natisea  and  vomiting  are  often  early  symptoms,  and  are  to  be  regarded 
with  some  alarm,  as  they  are  indicative  of  toxemia. 

The  scanty  urine  is  heavily  loaded  with  solids,  and  if  examined  microscopically 
it  shows  red  blood  cells,  epithelial  cells  from  the  uriniferous  tubules,  and  tube 
casts  composed  of  blood  cells,  epithelial  cells,  and  hyaline  material.  When  the 
heat  and  nitric  acid  test  is  applied  to  the  urine,  the  amount  of  albumin  present  is 
found  to  be  very  large,  forming  a  thick  and  heavy,  curd-like  mass,  which,  in  the 
heat  test,  gradually  settles  to  the  bottom  of  the  tube.  The  indsc  is  usually  hard 
and  the  tension  high,  but  sometimes  the  high  tension  is  more  apparent  than  real, 
the  pulse  being  full,  but  gaseous  in  resistance. 

Auscultation  will  reveal,  in  the  cases  which  have  a  high  arterial  tension,  an 
accentuated  aortic  second  sound,  and  a  comparatively  feeble  first  sound  at  the 
apex.  Sometimes  acute  cardiac  dilatation  develops,  and  secondary  pulmonary 
congestion  aids  in  the  destruction  of  the  patient.  In  other  cases  in  which  edema  is 
particularly  marked  a  rapid  effusion  of  fluid  takes  place  into  the  pleural  spaces 
and  into  the  peritoneal  cavity,  and  pulmonary  edema  develops  with  remarkable 
rapidity.  The  only  vessels  which  do  not  leak  freely  are  those  of  the  skin,  the 
kidneys,  and  the  bowels.  The  .s7iin.  is  dry  and  harsh,  the  iirine  scanty  or  suppressed, 
and  the  bowels  are  usually  constipated. 

These  are  the  symptoms  of  what  may  be  called  a  severe  attack  of  the  disease, 
but  it  is  important  to  bear  in  mind  that  very  often  no  edema  is  present,  and  that 
in  others  the  urinary  flow  is  not  greatly  diminished.  Often  anemia  and  pallor 
may  be  the  first  sign  during  convalescence  from  an  acute  infectious  malady,  to 


CHRONIC  NEPHRITIS  643 

show  that  all  is  not  well  with  the  kidneys.  In  other  cases  some  giddiness  may 
be  present,  and,  if  the  patient  is  an  adult,  uremic  symptoms  are  more  prone  to 
develop  than  if  he  is  a  child. 

The  urine  of  persons  suffering  from  the  infectious  diseases  should  be  examined 
repeatedly,  in  order  that  the  earliest  signs  of  renal  involvement  may  be  recognized. 
There  is  no  excuse  for  letting  the  condition  run  on  unrecognized  until  it  is  forced 
upon  the  physician  by  marked  objective  sjTnptoms. 

Diagnosis. — It  is  evident  that  this  state  does  not  present  signs  or  symptoms  which 
are  often  presented  by  other  maladies,  but,  on  the  other  hand,  it  is  important 
for  the  physician  to  recall  the  fact  that  certain  prominent  symptoms  may  be  absent 
without  casting  doubt  on  the  diagnosis.  Thus  the  amount  of  albumin  in  the  urine 
may  be  small,  the  degree  of  edema  slight,  and  the  urinary  flow  may  not  be  greatly 
decreased.  Again,  the  mere  presence  of  large  amounts  of  albumin  is  not  alone 
indicative,  because,  as  already  pointed  out  in  the  article  on  circulatory  disorders 
of  the  kidneys,  it  often  happens  that  scanty  urine  and  a  large  amount  of  albumin 
are  present  in  renal  congestion.  Casts  made  up  of  degenerated  cells  and  blood 
corpuscles  are  pathognomonic. 

Prognosis. — The  outlook  in  cases  of  acute  diffuse  nephritis,  if  the  patient  has 
previously  had  healthy  kidneys,  is  fairly  favorable,  particularly  if  his  habits  of  life 
have  been  satisfactory.  This  statement  holds  true  of  the  acute  condition  following 
exposure  in  young  adults  rather  than  in  children  and  in  young  adults  who  have 
nephritis  from  acute  infectious  maladies,  particularly  scarlet  fever.  The  younger 
the  child  the  more  grave  the  danger  in  scarlet  fever.  (See  Scarlet  Fever.)  Evil 
sjTnptoms  are  drowsiness  from  toxemia,  a  tendency  to  pulmonary  edema,  a  feeble 
heart,  and  a  free  transudation  into  the  subcutaneous  tissues.  Suppression  of 
urine  is,  of  course,  a  most  serious  symptom. 

The  renal  lesions  in  those  who  su^vi^•e  the  acute  stage  of  the  inflammation  vary 
greatly  in  their  persistency.  In  some  cases  all  signs  of  renal  trouble  clear  up  in  a 
fortnight,  but  in  others  albuminuria  in  some  degree  persists  for  months  and  returns 
whenever  the  patient  is  chilled  or  takes  excessive  exercise.  'When  anemia  is 
persistent  and  resists  fresh  air  and  tonics,  even  if  the  albuminuria  is  scanty,  sus- 
picion of  subacute  or  chronic  lesions  following  the  acute  stage  is  aroused.  In 
other  cases  the  acute  nephritis  is  but  an  exacerbation  of  a  hitherto  unrecognized 
chronic  parenchymatous  nephritis,  in  which  case  the  outlook  is  most  grave.  Some- 
times, just  as  the  most  encouraging  progress  is  being  made,  a  terminal  pneumonia 
occurs,  and  death  ensues. 

Treatment. — The  treatment  of  acute  diffuse  nephritis  consists  in  putting  the 
patient  to  bed  at  once  and  in  the  ordering  of  a  liquid  diet  containing  nothing  which 
can  irritate  the  kidneys,  such  as  condiments  like  pepper  or  mustard.  Coimter- 
irritation  over  the  kidneys  in  the  shape  of  frequently  renewed  hot  compresses  are 
of  value,  but,  as  a  rule,  it  is  un'^'ise  to  add  any  irritating  drug  to  these  compresses, 
for  it  may  be  absorbed  and  cause  renal  irritation.  If  the  pulse  is  quick,  small  doses 
of  tincture  of  aconite  (1  minim  every  one  or  two  hours)  may  be  given,  with  a  tea- 
spoonful  of  sweet  spirit  of  nitre  in  cool  water. 

During  convalescence  tincture  of  the  chloride  of  iron  and  tincture  of  nux  vomica 
may  be  used  as  tonics  and  to  combat  anemia.  Great  care  should  be  taken  that  the 
patient  is  not  exposed  to  cold  and  dampness,  and  that  woollen  garments  are  worn 
next  the  skin  to  protect  it  from  being  chilled,  since  chilling  of  the  surface  may  pro- 
duce secondary  renal  congestion. 

CHRONIC  NEPHRITIS. 

Definition. — The  term  "chronic  Bright's  disease"  is  apphed  to  several  types 
of  slow,  persistent,  inflammatory  process  in  the  kidney  which  result  in  very  definite 


644  DISEASES  OF  TIIK  KIDSKYS 

alterations  from  the  normal  in  these  organs.  Each  type  is  also  so  distinct  from  the 
other  in  its  rapidity  of  progress  and  results  that  it  is  difficult  to  regard  them  as 
related  in  any  way,  yet  in  each  instance  we  find  inliaiiiiiiiition  and  degeneration 
forming  the  chief  pathological  change. 

The  two  chief  forms  of  chronic  Bright's  disease  are  called  "chronic  parmchymakni.'i 
nephritis"  and  "chronic  interstitial  nephritis,"  because  in  the  first  the  jjathological 
process  is  chiefly  concerned  with  the  parenchyma  of  the  organ,  and  in  tlie  second 
form  the  conspicuous  changes  are  in  the  connecti\T  tissue. 

There  are  also  cases  in  which  these  two  forms  of  nephritis  exist  simultaneously, 
that  is,  the  kidneys  present  the  changes  fovuid  in  both  types.  Indeed,  these  cases 
are  much  more  numerous  than  is  generally  thought,  because  physicians,  having 
been  taught  in  student  days  that  nephritis  is  capable  of  being  divided  into  two 
forms,  are  continually  trying  to  force  cases  that  come  to  them  into  one  of  these 
categories,  it  being  forgotten  that  while  classification  and  division  are  artificial 
methods  devised  for  teaching  purposes,  nature  does  not  adhere  to  any  such  bound- 
aries, but  presents  cases  which  may  partake  of  more  than  one  type  at  the  same 
time.  It  is  perhaps  well,  then,  to  consider  that  chronic  Bright's  disease  is  a  chronic 
diffuse  nephritis,  although  sometimes  the  parenchyma  and  sometimes  the  interstitial 
tissues  suffer  chiefly. 

On  the  other  hand,  the  clinical  pictures  afforded  by  the  two  classes  of  cases 
constitute  adequate  grounds  for  recognizing  chronic  parenchymatous  nephritis 
as  different  from  the  chronic  interstitial  form.  There  can  be  no  doubt  that  we 
have  been  laying  too  much  stress  on  the  results  obtained  from  an  examination  of 
the  urine  in  differentiating  the  two  conditions.  Sometimes  a  urinary  examination 
at  once  settles  the  diagnosis,  but  Cabot  is  clearly  right  in  his  contention  that  the 
urine,  in  many  cases,  offers  no  information  as  to  the  exact  type  of  change  going 
on  in  the  renal  cortex.  Differentiation,  when  possible,  must  rest  upon  symptoms 
considered  with  the  results  of  urinary  examination. 

Etiology. — Chronic  nephritis  may  follow  acute  nephritis,  but  this  is  very  rarely 
the  case.  Its  most  common  causes  are  alcoholism  and  exposure,  and  in  the  upper 
classes  alcoholism  and  overfeeding,  with  lack  of  exercise.  Gout  and  syphilis, 
chronic  lead  poisoning,  and  chronic  digestive  disorders  are  also  causes,  in  all  prob- 
ability. While  the  latter  are  not  as  yet  proved  to  be  definite  causes,  there  is  good 
reason  to  believe  that  the  continued  absorption  of  toxic  materials  from  the  bowels 
for  long  periods  of  time  may  cause  renal  lesions  in  the  effort  of  these  organs  to 
eliminate  the  noxious  substances.  A  very  important  cause,  in  all  probability 
very  closely  allied  to  those  just  named,  is  arteriosclerosis,  it  being  considered  that 
the  changes  in  the  bloodvessels  are  responsible  for  renal  changes,  although,  on 
the  other  hand,  the  renal  lesions  are  often  the  cause  of  the  vascular  degeneration. 
In  many  cases  it  is  probable  that  the  same  causes  produce  both  the  arterial  and 
the  renal  changes  simultaneously.  In  some  cases,  indeed  it  may  be  said  in  the 
majority,  the  exciting  cause  of  the  renal  changes  is  undiscovcrable,  and  perhaps 
may  depend  upon  some  congenital  defect,  which  as  yet  we  do  not  understand. 
This  defect  may  be  localized  in  the  kidneys,  or  lie  in  other  organs  whose  imperfectly 
performed  labor  results  indirectly  in  renal  disease. 

Chronic  parenchymatous  nephritis  is  a  disease  of  early  and  middle  life,  while 
chronic  interstitial  nephritis  is  observed  in  patients  of  more  advanced  years,  but 
exce])tions  to  this  rule,  of  course,  occur. 

Frequency. — Ciironic  renal  disease  is  one  of  the  most  common  maladies  affecting 
man,  a  large  i)roi)ortion  of  the  deaths  of  all  persons  over  thirty  years  of  age  being 
due  to  this  cause.  Not  only  do  the  UKirtality  statistics  prove  the  correctness  of 
this  statement,  but  it  is  now  becoming  a  well-recognized  fact  that  many  cases  which 
die  of  acute  pneumonia  are  in  reality  cases  of  chronic  nephritis,  in  which  the  pneu- 
monia acts  as  a  terminal  infection  and  destroys  the  patient  when  liis  powers  of 


CHRONIC  NEPHRITIS  645 

resistance  have  diminished  as  a  result  of  his  renal  state.  The  United  States  census 
shows  that  disease  of  the  kidneys  stands  sixth  in  the  Hst  of  diseases  causing  death, 
pneumonia,  tuberculosis,  heart  disease,  diarrheal  afl'ections,  and  unknown  causes 
only  leading  it. 

Of  41,924  medical  cases  treated  in  five  large  Philadelphia  hospitals,  1395,  or 
3.32  per  cent.,  were  affected  with  nephritis,  and  of  24,624  medical  cases  treated  in 
four  large  Philadelphia  hospitals  in  which  the  form  of  the  lesion  was  stated,  797, 
or  3.23  per  cent.,  were  affected  with  chronic  nephritis.  On  the  other  hand,  of 
228,232  cases  treated  in  the  medical  dispensaries  of  four  large  Philadelphia  hospitals, 
only  1902,  or  0.9  per  cent.,  were  affected  with  some  form  of  nephritis.  This  remark- 
able difference  in  frequency  in  the  wards  and  in  the  out-patient  departments  is 
probably  due  chiefly  to  the  fact  that  most  of  the  cases  of  renal  disease  presenting 
themselves  for  treatment  were  so  ill  that  they  became  in-patients,  and  are  so 
recorded. 

From  this  point  on  it  will  be  best  to  consider  the  two  chief  forms  of  chronic 
renal  disease  separately. 

Chronic  Parenchymatous  Nephritis. — Chronic  parenchymatous  nephritis  is 
sometimes  called  "chronic  desquamative  nephritis,"  because  of  the  desquamation 
of  the  epithelial  cells  lining  the  tubules;  "chronic  tubular  nephritis,"  because 
the  uriniferous  tubules  are  involved,  or  in  certain  cases,  "chronic  glomeruloneph- 
ritis," because  the  glomeruli  of  the  kidney  are  chiefly  affected  in  this  malady.  It 
is  also  called  "chronic  diff'use  nephritis,"  because  all  parts  of  the  secreting  epithe- 
lium are  affected  and  the  intervening  connective  tissue  usually  shows  marked 
changes. 

Pathology  and  Morbid  Anatomy. — In  typical  cases  the  kidney  is  found  to  be 
large,  pale,  its  subcapsular  veins  conspicuous,  and  the  capsule  easily  detached. 
The  organ  offers  little  resistance  to  incision,  and  inspection  of  the  incised  surfaces 
shows  that  the  marked  enlargement  of  the  organ  is  due  to  broadening  of  the  cortex. 
The  medullary  pyramids,  while  often  lighter  in  color  than  normal,  never  attain 
the  pale  yellowish  hue  of  the  cortex,  and  may  be  dark  from  associated  congestion. 
In  this  form  the  microscope  shows  the  epithelium,  especially  that  of  the  convoluted 
tubules,  granular  or  even  fatty,  desquamating,  and  coalescing  to  form  casts,  which 
may  readily  be  recognized  in  position,  or,  having  been  passed,  these  casts  leave 
tubules  which  are  imperfectly  lined  by  epithelial  cells.  There  is  a  less  conspicuous, 
but  fairly  constant,  change  of  a  similar  character  involving  the  glomerular  epithe- 
lium, and  also  the  epithelial  cells  of  some  of  the  pyramidal  tubes.  Hemorrhages 
in  the  interstitial  tissue  are  sometimes  present.  This  is  the  form  called  "large 
white  kidney." 

In  some  cases  the  interstitial  tissue  is  but  slightly  involved,  but  in  others  it 
is  notably  increased  and  irregularly  distributed,  with  unequal  contractions,  giving 
rise  to  a  more  or  less  bossed  or  granular  surface,  not  unlike  that  seen  in  typical 
interstitial  nephritis.  In  this  form  (small  white  kidney)  the  organ  may  not  be 
enlarged,  and  may  be  even  smaller  than  normal.  It  resists  incision,  due  to  the 
increase  in  fibrous  tissue,  which,  with  the  unaided  eye,  may  be  seen  as  grayish 
patches  in  the  yellow  cortex.  Hemorrhages  may  be  present,  mottling  the  incised 
surface  with  reddish  or  reddish-brown  areas. 

Microscopically,  the  changes  in  the  epithelium  are  similar  to  those  seen  in  the 
large  white  kidney,  but  the  increase  in  fibrous  tissues  constitutes  a  conspicuous 
difference.  It  has  not  been  definitely  decided  whether  the  small  white  kidney 
is  a  later  stage  of  large  white  kidney,  an  independent  affection,  or  a  form  of  nephritis 
which  having  been  primarily  interstitial  has  had  parenchymatous  disease  super- 
imposed. 

The  cardiovascular  changes  of  chronic  parenchymatous  nephritis  are  similar 
in  kind,  but  do  not  approach  in  degree  those  found  in  chronic  intersitial  nephritis. 


646  DISEASES  OF  THE  KIDNEYS 

With  the  small  white  kidney,  cardiac  hjqDertrophy  and  slight  arteriosclerotic  changes 
are  not  of  infrequent  occurrence.  There  is  usually  an  excess  of  fluid  in  the  serous 
cavities,  a  varying  quantity  of  edema  in  the  subcutaneous  fat,  and  also  in  the  lungs 
and  meninges.     Uetinal  hemorrhages  are  occasionally  observed. 

Symptoms. — When  chronic  diffuse  nephritis  of  the  "large  white  type"  is  well 
developed  there  are  few  clinical  i)ictures  which  are  so  typical.  The  more  or  less 
swollen  visiujc;  the  greasy,  pallid  skin;  the  stupid  fades,  and  the  dysjmca  on  exertion 
strike  the  eye  at  once.  Not  rarely  the  partly  buttoned  wiastcoat  and  the  loosely 
laced  shoes  show  that  sufficient  anasarca  exists  to  cause  the  patient  some  discomfort. 

If  the  pretibial  tissues  are  pressed  upon,  they  j^ii  on  pressure.  Percussion  may 
show  the  presence  of  fluid  in  the  pleural  and  peritoneal  cavities,  although  large 
effusions  are  not  commonly  met  with  in  these  cases. 

If  the  heart  is  examined,  its  sounds  are  found  to  be  altered,  so  that  t\ie  first  sound 
lacks  good  quality,  and  the  second  sound  is  usually  accentuated.  The  pulse  is  rapid, 
and  the  arterial  tension  higher  than  normal.  The  patient  is  prone  to  be  sleepy 
during  the  day  and  restless  at  night,  and  may  be  dyspneic  on  lying  down.  The  urine 
is  scanty  and  heavily  laden  with  solids,  and  under  the  microscope  shows  a  large 
number  of  fatty,  granular,  hyaline,  and  epithelial  casts,  leukocytes,  and  even  red 
blood  corpuscles.  Occasionally  the  granular  casts  are  particularly  opaque  to 
light,  forming  the  "big  black,  granular  casts,"  which  are  so  significant  of  severe 
parenchymatous  nephritis.  Tested  with  heat  or  nitric  acid,  the  urine  is  found  to 
contain  an  excessive  amount  of  albumin,  so  that  the  coagulum  may  equal  half  the 
urine.  The  specific  gravity  of  the  urine  is  high — about  1.025.  AYith  the  advent 
of  marked  interstitial  fibrosis,  the  quantity  of  urine  increases  and  may  equal  or 
even  exceed  the  normal  amount.  At  this  time  the  albumin  diminishes,  the  casts 
often  lessen  in  number,  and  cardiovascular  changes  occur,  the  chief  sign  of  which 
is  increased  arterial  tension. 

When  the  function  of  the  kidneys  is  seriously  distm^bed,  apathy,  stupor,  and 
finally  coma  may  ensue  from  uremia,  and  in  some  cases  convulsions  occur.  These 
may  vary  from  a  slight  twitch  followed  by  stupor  to  a  severe  general  convulsion, 
in  which  all  the  voluntary  muscles  are  involved.  Sometimes  a  fleeting  monoplegia, 
aphasia,  or  hemiplegia  comes  on  as  the  result  of  the  uremic  poisoning  and  without 
any  connection  with  an  actual  apoplexy.  (See  Uremia.)  Occasionally  very 
definite  forms  of  mental  disturbance  occur  so  that  the  disease  may  first  be  discovered 
when  the  patient  is  committed  to  an  asylum  for  the  insane.  The  Folic  Brigldique 
of  the  French  often  possesses  great  medicolegal  importance. 

Patients  suft'ering  from  chronic  parenchymatous  nephritis  are  sometimes  seized 
by  a  severe  serous  diarrhea,  which  is  an  effort  at  elimination  on  the  part  of  the 
economy,  and  should" be  cautiously  checked  only  when  it  becomes  severe  enough 
to  be  dangerous  in  itself. 

Comparatively  rarely  in  the  course  of  chronic  parenchymatous  nephritis  an 
albuminuric  retinitis  develops,  but  when  the  nephritis  complicates  pregnancy 
this  ocular  symptom  is  very  common. 

The  combinations  of  symptoms  just  recited  are  met  with  in  the  well-developed 
cases  which  present  characteristic  manifestations  of  the  disease.  It  is  to  be  dis- 
tinctly recollected  that  in  many  cases  few  or  none  of  these  signs  develop  until  the 
patient  is  suddenly  overwhelmed  b>-  the  climax  of  his  malady,  and  that  of  all  the 
chronic  and  grave  maladies  which  affect  man  none  other  advances  and  develops  as 
insidiously  as  does  chronic  parenchymatous  nephritis  in  many  cases.  In  one  in- 
stance a  persistent  indigestion  which  fails  to  yield  to  appropriate  digestive  remedies  is 
found  to  be  due  to  renal  disease;  in  another  anemia  fails  to  yield  to  ordinary  chaly- 
beates  and  is  found  to  be  renal  in  origin;  in  still  another  a  persistent  failure  of 
health  without  apparent  cause  has  its  origin  in  bad  kidneys.  In  yet  another 
group  of  cases  a  persistent  bronchitis  is  founded  on  this  cause.    If  consulting 


CHRONIC  NEPHRITIS  647 

physicians  could  be  polled,  I  feel  confident  that  they  would  universally  state  that 
the  average  case  of  grave  ill-health  seen  by  them  in  consultation,  when  the  diagnosis 
is  obscure,  is  not  really  difficult  of  diagnosis  if  the  state  of  the  kidneys  is  care- 
fully studied.  It  is  not  sufficient  to  examine  the  urine  once.  It  should  be  done 
repeatedly  before  deciding  that  it  throws  no  light  on  the  case. 

An  important  clinical  fact  to  bear  in  mind  is  that  a  latent  chronic  parenchymatous 
nephritis  may  exist  for  a  long  time,  and  finally  be  recognized  by  the  sudden  develop- 
ment of  uremia  due  to  an  acute  congestive  nephritis  coming  on  as  a  complication. 

Diagnosis. — The  diagnosis  of  chronic  parenchymatous  nephritis  is  reached  by 
the  following  symptoms  and  tests:  The  face  is  puffy  and  pallid;  there  is  often 
dyspnea,  even  without  exertion,  and  the  second  sound  of  the  heart  is  usually 
accentuated.  If  the  case  is  well  developed,  general  anasarca  may  be  manifest. 
The  chief  diagnostic  factor,  however,  is  the  state  of  the  urine.  It  is  less  than 
normal  in  quantity,  of  high  specific  gravity,  and  contains  very  considerable  quan- 
tities of  albumin.  (See  Albuminuria.)  A  microscopic  examination  of  its  sediment 
reveals  fatty,  granular,  and  hyaline  casts,  red  blood  cells,  and  large  amounts  of 
desquamated  epithelium  from  the  uriniferous  tubules.  The  gravity  of  the  disease 
is  usually  in  direct  proportion  to  the  quantity  and  quality  of  the  casts,  the  large, 
dark,  granular  casts  being  indicative  of  grave  disease.  Quantitative  analysis 
reveals  marked  decrease  in  the  total  elimination  of  urea  in  each  twenty-four  hours. 

Rowntree  and  Geraghty  have  introduced  the  phenolsulphonephthalein  test  to 
determine  the  functional  ability  of  the  kidney.  It  consists  in  injecting  into  a 
muscle,  or  hypodermically,  0.006  of  phenolsulphonephthalein  preceding  it  by  a 
draught  of  water  by  half  an  hour.  The  patient  must  also  have  an  empty  bladder. 
The  dye  begins  to  be  excreted  in  from  five  to  ten  minutes.  If  there  is  any  retention, 
or  obstruction,  a  catheter  must  be  used  to  empty  the  bladder,  and  allowed  to  remain 
in  place.  Its  external  end  is  placed  in  a  test-tube  containing  a  drop  of  25  per  cent, 
sodium  hydroxide  and  the  tube  watched  for  the  first  sign  of  a  pinkish  tinge.  In 
other  cases  the  patient  may  pass  water  every  little  while,  voluntarily.  If  the  urine 
is  acid  and  not  neutralized  it  appears  orange  colored  when  free  elimination  is 
established  and  becomes  light,  purple-red  when  made  alkaline.  The  urine  is 
now  diluted  with  distilled  water  to  make  one  litre  and  a  small  filtered  portion 
placed  in  a  small  test-tube.  The  contents  of  this  tube  is  compared  with  the 
contents  of  tubes  containing  different  standard  solutions  of  a  colorimeter.  By 
this  means  the  percentage  of  the  drug  eliminated  in  a  given  time  is  estimated. 
Normal  kidneys  excrete  the  greater  part  of  the  dose  in  two  hours  and  trace  for 
two  hours  more,  moderately  diseased  kidneys  eliminate  only  50  per  cent,  in  the 
fi^rst  two  hours.  Any  delay  in  the  time  of  the  first  appearance  of  the  dye  in  the 
urine  is  of  little  value  as  a  test,  as  it  may  be  due  to  slow  absorption,  but  much 
importance  is  to  be  attached  to  the  rapidity  of  elimination  after  it  once  begins. 

Prognosis. — The  prognosis  of  chronic  parenchymatous  nephritis  is  inevitably 
fatal,  and  the  patient's  life  is  often  ended  in  a  few  months,  when  once  the  disease 
is  well  developed.  In  those  cases  of  chronic  parenchymatous  nephritis  char- 
acterized by  early  dropsy  which  rapidly  develops  into  general  anasarca.  Senator 
states  that  the  duration  of  life  varies  from  a  few  months  to  a  year.  In  those  cases 
in  which  the  development  of  dropsy  is  gradual  and  irregular,  varying  in  degree 
from  time  to  time,  he  says  that  death  ensues  in  from  one  to  two  years  after  the 
beginning  of  the  malady.  Striimpell  gives  the  average  duration  of  life  in  chronic 
parenchymatous  nephritis  as  from  one-half  to  one  and  one-half  years.  Every 
clinician  of  experience  will,  however,  agree  with  Senator  in  recognizing  another 
class  of  cases  which  extend  over  several  years,  and  which  are  characterized  by 
mildness  of  symptoms.  In  these  cases  there  is  not  much  albumin  in  the  urine, 
but  slight  headache,  and  little  swelling  of  the  lower  extremities  or  of  the  face. 
Gradually  these  patients  become  worse,  until  they  finally  fall  into  one  of  the  well- 


MR  DISEASI'JS  OF  THE  KIDXEYf! 

defined  classes  already  described.  They  are  probably  representative  of  that  form 
of  the  disease  characterized  by  moderate  changes  in  the  parenchyma  of  the  kidney 
with  associated  interstitial  disease. 

Treatment. — It  lias  been  generally  held  that  diet  is  a  very  important  factor 
in  the  treatment  of  this  form  of  renal  disease.  While  it  is  somewhat  inconoclastie 
to  say  that  this  general  belief  is  untrue,  it  is,  nevertheless,  a  fact  that  a  generous 
diet  which  does  not  strain  the  digestion  and  the  eliminating  organs  can  usually 
be  allowed  in  most  cases.  We  have  before  us  a  patient  who  is  bound  to  die  within 
a  few  months,  and  the  question  arises  as  to  whether  we  can  so  regulate  the  diet 
that  we  will  ol)tain  results  which  compensate  for  the  discomforts  and  unhappiness 
of  the  rigid  milk  diet,  which  is  usually  ordered,  or  one  which  causes  the  patient 
to  regard  his  food  with  loathing  and  which  is  a  constant  reminder  that  he  is  ill. 

Although  skimmed  milk  is  theoretically  capable  of  maintaining  nutrition,  it  is 
practically  incapable,  because  such  enormous  cjuantities  must  be  consumed,  to 
provide  an  adult  with  a  sufficient  amount  of  nutriment.  Again,  milk  lacks  the 
quantity  of  iron  which  ordinary  food  contains.  It  presents  to  the  patient  the  same 
quantities  of  calcium,  magnesium,  potassium,  and  phosphorus  as  is  found  in  the 
ash  of  newborn  animals,  but  it  contains  only  one  sixth  iron;  this  lack  of  iron  being 
made  up  in  the  young  by  the  storage  of  this  metal  in  the  li\er,  and  possibly  in  other 
organs  during  intra-uterine  life.  Again,  the  quantity  of  proteid  which  is  present 
in  milk  is  excessive.  A  normal  adult  requires  approximately  .3000  calories  a  day 
to  maintain  full  nutrition.  One  quart  of  milk  has  a  caloric  value  of  about  700,  and 
therefore  it  takes  about  four  to  four  and  a  half  quarts  of  cows'  milk  to  present 
sufficient  nourishment.  This  large  quantity  of  milk  contains  nearly  170  grams  of 
proteid,  whereas  the  normal  average  quantity  of  proteid  ingested  by  a  healthy 
adult  does  not  exceed  100  grams  a  day.  A  milk  diet,  if  taken  in  the  quantities 
which  are  necessary  for  the  maintenance  of  nutrition,  forces  the  kidneys  to  eliminate 
enormous  quantities  of  liquid,  which  they  are  illy  prepared  to  do  when  suft'ering 
from  disease,  and  if  the  patient  does  not  take  these  quantities  his  vitality  is  impaired 
by  nephritis  and  starvation  combined.  Again,  such  a  diet  causes  the  kidneys  to 
eliminate  large  cjuantities  of  urea  and  much  phosphates,  and  so,  again,  kidneys 
which  are  impaired  in  function  because  of  disease  are  forced  to  perform  an  excessive 
amount  of  work. 

It  is  entirely  possible  to  arrange  a  suitable  diet  for  cases  of  nephritis  without 
in  any  way  throwing  undue  stress  on  any  of  the  organs  of  digestion  or  elimination, 
and  at  the  same  time  maintain  the  nutrition  of  the  body.  Unskimmed  milk — 
that  is,  milk  containing  cream — is  useful,  since  the  fats  add  a  very  considerable 
number  of  calories  to  the  milk,  and  by  the  use  of  starchy  food  an  additional  number 
of  calories  can  be  provided  the  patient,  who,  at  the  same  time,  does  not  receive  an 
e.Kcess  of  fluid.  As  Crofton  well  says,  one  litre  and  a  half  of  milk,  plus  a  quarter 
of  a  litre  of  cream,  for  instance,  contains  approximately  .50  grams  of  ])r(itei(ls  (equal 
to  22.5  calories),  75  grams  of  carbohydrates  (equal  to  337  calories),  and  150  grams 
of  fat  (equal  to  1350  calories),  or  a  sum  total  of  about  1912  calories.  In  order 
to  make  up  the  difference  of  1088  calorics,  a  little  meat,  eggs,  sugar,  butter,  toast, 
zweiback,  rice,  fresh  vegetables,  etc.,  may  be  allowed  with  impunity,  care  being 
taken  that  the  caloric  value  of  3000  is  not  greatly  exceeded,  and  that  all  articles 
of  diet  that  lead  to  the  formation  of  irritating  urinary  end-products,  and  spices, 
condiments  etc.,  are  avoided.  These  views  are  in  accord  with  opinions  expressed 
by  Robin,  of  Paris,  Bradford,  and  Hale  White,  of  London,  and  other  clinicians 
of  experience. 

The  fact  having  been  established  by  several  investigators  that  in  many  cases  of 
parenchymatous  nephritis  with  edema  there  is  a  retention  of  sodium  chloride  in 
the  tissues,  it  has  been  suggested  that  this  salt  be  temporarily  remoxed  from  the 
diet.    The  ground  for  this  is  that  the  excess  of  salt  in  the  tissues  requires  an  excess 


CHRONIC  NEPHRITIS  649 

of  fluid  to  keep  it  in  the  normal  molecular  concentration.  When  the  patient  is 
deprived  of  salt  increased  diuresis  takes  place  and  the  dropsy  often  diminishes. 
However  plausible  this  may  be  as  a  theory  it  accomplishes  little  in  its  practice  in 
5iost  cases. 

Much  discussion  has  occurred  among  physicians  as  to  the  quantity  of  water 
which  should  be  allowed  patients  suffering  from  Bright's  disease.  Some  believe 
that  the  amount  should  be  as  small  as  possible,  on  the  ground  that  copious  draughts 
of  water  engorge  the  vessels  and  increase  the  labor  of  the  heart.  That  this  cardiac 
influence  is  an  important  one  I  doubt,  but  as  Edsall  and  others  have  shown  that 
excessive  water-drinking  increases  nitrogenous  metabolism,  and  as  the  kidneys 
in  Bright's  disease  are  unable  to  fully  deal  with  the  products  of  normal  metabolism, 
it  would  seem  evident  that  excessive  quantities  of  water  must  be  harmful.  On 
the  other  hand,  there  can  certainly  be  no  good  results  from  depriving  the  patient 
of  water  to  the  extent  of  making  him  suffer. 

The  remedial  measures  other  than  diet  consist  in  the  use  on  each  alternate 
day,  if  the  heart  is  strong  enough,  of  an  electric  cabinet  bath,  in  order  that  the 
skin  may  aid  the  kidneys  in  eliminating  fluids  and  solids  from  the  body.  Fresh 
air  and  sunlight  are  essential,  and  severe  exercise  is  to  be  prohibited. 

Drugs  are  of  little  value,  except  to  relieve  symptoms  which  may  be  annoying. 
It  has  been  the  custom  of  physicians  for  many  years  to  prescribe  iron,  usually 
in  the  form  of  Basham's  mixture,  for  the  purpose  of  combating  the  anemia  of 
chronic  parenchymatous  nephritis.  This  method  of  treatment  does  not  possess 
the  advantages  with  which  it  has  been  credited.  The  anemia  depends  upon  the 
toxemia  of  the  disease,  and  this,  of  course,  is  not  removed  by  the  administration 
of  iron.  Further  than  this,  iron  has  a  tendency  to  produce  constipation,  and  con- 
stipation is  prone  to  increase  anemia,  and,  again,  constipation  is  a  particularly 
undesirable  condition  in  Bright's  disease,  since  it  prevents  the  bowels  from  aiding 
the  kidneys  in  eliminating  impurities. 

The  administration  of  very  large  doses  of  Basham's  mixture  is,  therefore,  unwise. 
It  should  be  borne  in  mind  that  iron  has  no  curative  effect  upon  the  renal  condition, 
and  therefore  it  is  useless  to  administer  more  than  the  system  can  utilize  for  the 
relief  of  the  secondary  anemia  in  the  blood.  Small  doses  of  Basham's  mixture  are, 
therefore,  as  useful  as  large  ones,  so  far  as  the  anemia  is  concerned.  If  the  effect 
of  Basham's  mixture  as  a  diuretic  is  desired,  the  liquor  ammonii  acetatis  of  the 
United  States  Pharmacopoeia  may  be  added  to  a  teaspoonful  of  Basham's  mixture 
and  given  three  or  four  times  a  day,  as  in  this  way  the  diuretic  effect  is  obtained 
without  an  excess  of  iron  being  given. 

Should  evidence  of  cardiac  dilatation  develop  digitalis  is  indicated,  and  may  be 
given  in  the  dose  of  5  or  10  minims  of  the  tincture  three  times  a  day  until  some 
evidence  of  its  physiological  effect  is  obtained,  when  the  dose  should  be  cut  down 
one-half.  While  the  infusion  of  digitalis  has  the  reputation  of  being  more  diuretic 
than  the  tincture,  it  is  so  much  more  prone  to  disorder  the  stomach  that  the  tincture 
is  usually  preferable. 

A  useful  formula  in  place  of  digitalis  will  be  found  on  page  486. 

If  uremic  symptoms  develop,  the  patient  should  be  given  a  hot  pack,  and  if 
there  is  any  reason  to  believe  that  pulmonary  edema  is  threatened,  or  that  the  heart 
is  too  feeble  to  endure  the  hot  pack,  a  hypodermic  injection  of  strychnine,  yi>  oi  a. 
grain,  should  be  given  before  the  pack  is  begun.  Sometimes  a  cup  of  strong  black 
coffee  is  also  useful  at  this  time.  Pilocarpine  should  not  be  employed,  as  it  is  too 
depressant  and  prone  to  produce  pulmonary  edema. 

In  regard  to  the  treatment  of  uremic  convulsions,  it  is  commonly  held  that  the 
administration  of  morphine  hypodermically  for  this  purpose  is  dangerous,  although 
there  are  some  active  practitioners  who  believe  that  it  is  a  useful  drug.  It  is 
probably  more  dangerous  in  the  parenchymatous  than  in  the  interstitial  form  of  the 


650  DISEASES  OF  THE  KIDNEYS 

disease.  If  the  convulsion  is  severe  cliloroform  or  nitrite  of  aniyl  should  be  given 
by  inhalation.  (See  Uremia.)  If  the  veins  are  turgescent  free  venesection  should 
be  practised. 

The  question  as  to  wlietlier  the  bowels  sliould  lie  thoroughly  purged  by  one 
of  the  hydragogue  cathartics  is  debatable.  On  the  one  liand,  it  is  claimed  that 
by  this  means  the  intestines  are  unloaded  and  a  large  quantity  of  liquid  and  toxic 
material  is  removed  from  the  body,  and,  on  the  other,  that  the  purging  may  cause 
concentration  of  the  blood,  and  so  increase  toxemia.  Probably  the  best  rule  to 
follow  is  to  administer  a  hydragogue  cathartic  only  when  there  is  reason  to  believe 
that  the  bowels  are  confined  and  are  consequently  loaded  with  fecal  matter.  Hypo- 
dermoclysis,  which  is  sometimes  useful  in  the  uremia  of  chronic  contracted  kidney, 
is  .worse  than  useless  in  chronic  parenchymatous  nepliritis,  owing  to  the  presence 
of  edema. 

A  valuable  drug  for  the  purpose  of  diminishing  arterial  tension  and  so  decreasing 
the  work  of  the  heart  and  also  because  it  diminishes  the  loss  of  albumin  through 
the  kidneys,  is  nitroglycerin,  which  should  be  given  in  the  dose  of  x^nr  of  a  grain 
three  or  four  times  a  day.  This  drug  often  increases  the  urinary  flow  when  it  is 
scanty. 

Comparatively  recently  it  has  been  suggested  that  cases  of  chronic  renal  disease 
should  be  treated  by  decapsulation  of  the  kidney.  This  plan  of  treatment  is  more 
indicative  of  surgical  enthusiasm  than  of  a  clear  conception  of  the  pathology  of  the 
disease.  A  knowledge  of  the  pathology  and  the  results  of  experiments  on  animals 
show  its  futility,  if  not  its  danger.  These  views  will  be  found  in  detail  in  the  editorial 
columns  of  the  Therapeutic  Gazette  for  January,  1904,  and  June  15,  1904. 

Chronic  Interstitial  Nephritis. — To  this  form  of  chronic  renal  disease  the  terms 
"contracted  kidney,"  "granular  kidney,"  "cirrhosis  of  the  kidney,"  and  "sclerotic 
kidney"  are  applied. 

Pathology. — Chronic  interstitial  nephritis  is  usually  a  primary  process,  although 
the  small  white  kidney  is  really  a  combination  of  the  fibroid  and  the  chronic  par- 
enchymatous form.  In  this  type  the  overgrowth  of  the  connective  tissue  of  the 
kidney  is  the  dominant  part  of  the  pathological  process,  and  the  degeneration  of 
the  parenchyma,  as  represented  by  the  glomeruli  and  the  tubules,  plays  a  secondary 
role. 

When  kidneys  affected  by  this  state  are  examined,  it  is  found  that  they  contain 
large  masses  of  fibrous  tissue  extending  through  the  organ,  which  bj^  contraction 
cause  a  shrinkage  in  size  and  a  puckering  of  the  surface.  The  capsule  becomes 
thickened  and  exceedingly  adherent,  and  the  tissues  beneath  it  are  torn  if  it  is 
stripped  off.  The  surface  of  the  cortex  is  roughened  by  rounded  granules  of  varying 
size  and  cysts  may  appear  at  various  points  on  its  surface  (Fig.  112).  ^Yhen  an 
attempt  is  made  to  cut  through  the  kidney,  it  is  found  to  be  tough  and  difficult 
to  incise.  x\fter  the  organs  split  open  it  is  seen  that  the  cortical  portion  is  very 
much  wasted. 

When  the  renal  tissues  are  placed  under  the  microscope,  they  show  an  irregularly 
distril)uted  increase  in  the  connective  tissue,  involving  in  particular  the  cortex 
and  tlie  interlobular  vessels.  There  is  also  an  associated  atrophy  of  the  epithelium 
lining  the  uriniferous  tubules.  Casts  are  seen  in  the  tubules,  but  not  to  the  degree 
in  which  they  are  met  with  in  the  parenchymatous  form  of  nephritis.  The  glo- 
meruli in  advanced  cases  may  be  converted  into  thick,  fibrous  bulbs;  the  walls  of 
the  bloodvessels  forming  the  tuft  may  be  thickened,  and  the  capsule  is  seen  to  be 
dense  and  fibrous.  Nor  does  the  fibroid  process  affect  the  finer  bloodvessels  and  the 
connective  tissue  alone.  It  extends  to  the  large  bloodvessels,  and  even  to  the 
renal  arteries  and  veins. 

It  is  also  a  noteworthy  fact  that  while  cardiac  hy])ertrophy  and  arteriosclerosis 
arc  often  met  with  to  some  degree  in  parenchymatous  nephritis,  they  are  constantly 


CHRONIC  NEPHRITIS  651 

found  in  a  well-developed  degree  in  the  interstitial  type  of  the  disease.  This 
cardiac  hypertrophy  is  not  limited  to  the  left  ventricle,  as  it  is  in  the  parenchymatous 
form.  It  affects  the  whole  heart  and  it  is  often  very  great.  The  cause  for  the 
hypertrophy  has  been  the  subject  of  much  debate,  but  the  conditions  present  in 
the  bloodvessels  seem  to  offer  an  adequate  explanation  of  the  state.  These  vessels 
are  always  fibroid  and  lacking  in  normal  elasticity,  and  this,  of  course,  offers  greater 
resistance  to  the  flow  of  blood  through  them  and  into  the  capillary  networks. 
As  the  process  is  a  gradual  one,  there  is  a  gradual  increase  in  the  demands  made 
upon  the  heart,  and  this  is  met  by  an  increasing  hypertrophy.  The  difficulty 
in  forcing  the  blood  through  the  renal  vessels  also  aids  in  producing  this  effect, 
but  such  influence  has  no  doubt  been  overestimated. 


Kidney  of  chronic  interstitial  nephritis.    The  surface  is  granulated  and  irregular  and  contains  numerous 
cysts.    The  contraction  is  quite  marked,  the  organ  being  but  little  more  than  half  the  normal  size. 

This  is  not  the  place  to  dilate  upon  the  relationship  of  these  vascular  changes 
to  the  renal  lesions.  Many  persons  think  that  the  renal  changes  are  the  cause 
of  the  vascular  lesions,  and  others  hold  that  the  vascular  degeneration  causes 
the  renal  state.  A  most  striking  illustration  of  the  relation  between  arterial  disease 
and  contracted  kidney  was  shown  by  Welch  at  the  meeting  of  the  American  Medical 
Association  in  1904.  He  presented  a  specimen  which  consisted  of  a  kidney  supplied 
by  two  renal  arteries,  one  of  which  was  sclerotic.  The  area  of  the  kidney  supplied 
by  this  vessel  was  typically  fibroid,  while  the  other  pole  of  the  organ  nourished 
by  the  uninvolved  trunk  was  but  slightly  changed. 

Again,  it  is  held  by  many  that  the  overgrowth  of  connective  tissue  takes  place 
to  fill  gaps  made  by  the  atrophy  of  the  parenchyma,  and  by  others  the  view  is 
taken  that  the  overgrowth  of  the  connecti\-e  tissue  destroys  the  parenchyma  by 
pressure.     The  latter  view  seems  the  more  probable,  but  the  former  opinion  is 


652  DiSEASEfi  OF  THE  KIDNEY.^ 

adhered  to  bj'  many  pathologists,  who  believe  the  primary  change  is  in  the 
parenchyma. 

Symptoms. — This  is  the  type  of  renal  disease  which  is  found  in  the  iron-master 
or  stock  broker  who  boasts  that  he  has  never  had  a  sick  day  in  his  life,  and  who 
begins  to  find  himself,  at  forty  or  fifty,  lacking  in  initiative,  and  who  suffers  from 
vertigo  or  dizziness,  which  he  thinks  due  to  a  club  dimier  or  a  strong  cigar. 
This  is  the  disease  of  the  hard-working,  "high-nervous-tcnsion"  indi\i(iual  who 
has  lived  hurriedly,  and  perhaps  cjuieted  himself  between  periods  of  great  exertion 
by  a  drink  or  two  of  whiskey,  repeated  it  may  be  many  times.  Often  it  develops 
in  those  who  have  not  used  alcohol,  but  given  a  man  who  takes  little  exercise, 
some  whiskey,  and  who  is  managing  one  or  more  large  business  interests,  and  he  is 
the  individual  who  is  paving  the  way  for  or  has  already  developed  chronic  contracted 
kidney.  Very  rarely,  indeed,  the  disease  develops  in  early  life,  but  cases  have  been 
reported  by  a  number  of  clinicians  in  children  as  young  as  from  two  to  seven  years. 
Most  of  these  cases  have  occurred  about  puberty.  Sutherland  and  AYalker  have 
reported  2  patients,  aged  eight  and  sixteen  months,  respectively,  who  had  con- 
tracted kidney  due  to  congenital  syphilis. 

The  symptoms  of  contracted  kidney  are,  in  a  large  proportion  of  cases,  absent 
until  the  disease  progresses  so  far  that  grave  secondary  changes  take  place.  In- 
deed, it  not  rarelj'  happens  that  the  patient  continues  in  what  he  considers  good 
health  until  an  acute  attack  of  uremia  or  cardiac  failure  sends  him  to  the  hands  of 
the  physician,  who  may  be  misled  into  the  diagnosis  of  acute  syncope,  due  to 
overexertion,  by  the  fact  that  the  heart  seems  to  be  feeble,  and  because  the  urine 
shows  little  or  no  albumin.  The  number  of  diagnoses  that  have  been  wrecked 
upon  the  shoal  of  "no  albumin"  is  a  multitude,  because  it  is  a  peculiarity  of  chronic 
contracted  kidney  that  albumin  is  often  absent  for  brief  periods,  or  present  in 
such  minute  amounts  that  it  is  overlooked.  It  is  only  when  the  heart  begins  to 
fail  so  that  some  congestion  of  the  kidney  develops  that  the  albumin  becomes 
more  copious.  The  albuminuria  of  contracted  kidney  is,  as  a  rule,  as  scanty  as 
it  is  profuse  in  the  parenchymatous  form.  Again,  the  scanty  urine  of  the  parenchy- 
matous type  is  replaced  by  a  inojuse  jioio  in  the  contracted  t>pe,  and  the  patient 
in  consequence  is  disturbed  in  his  sleep  by  having  to  get  up  at  night  to  empty 
the  bladder.  The  specific  gravity  of  the  urine  is  low,  about  1.005  to  1.012,  and 
it  is  clear  and  lacks  color.  If  the  urea  is  estimated  this  ingredient  is  usually  much 
reduced,  not  only  relatively,  but  actually,  so  that  the  patient  in  many  cases  does 
not  excrete  half  the  normal  output  per  day.  Casts  may  not  be  found  and  rarely 
are  abundant,  and  often  the  centrifuge  has  to  be  employed  to  reveal  them.  Further, 
these  casts  are  readily  overlooked,  for  they  are  chiefly  hyaline  and  so  trans])arent 
that  if  careful  focusing  and  illumination  are  not  resorted  to  they  are  not  seen. 
In  some  cases  granular  casts  are  only  periodically  demonstrable.  Occasionally 
hematuria  of  a  persistent  and  fairly  free  type  arises  in  the  course  of  chronic  nephritis 
of  this  character  and  it  must  be  separated  from  that  due  to  renal  calculus. 

The  circulatory  sympioms  of  contracted  kidney  are  as  important  in  reaching 
a  diagnosis  as  the  renal  signs.  Indeed  it  may  be  said  that  a  man  in  middle  life 
who  presents  a  blood  pressure  above  1.50  or  IGO  constantly  is  probably  developing 
contracted  kidney  even  if  no  casts  or  albumin  are  to  be  found  in  his  urine. 

Occasionally  hematuria  of  a  persistent  and  fairly  free  type  arises  in  the  course 
of  chronic  nephritis  of  this  character — it  must  be  separated  from  that  due  to  renal 
calculus.  But  sudden  pulmonary  edema  is  more  common.  The  indse  is  hard 
and  tense,  and  so  ///r/A  is  the  blood  -pressure  that  it  may  be  almost  impossible  to 
occlude  the  vessel  by  pressing  upon  it.  A  blood  pressure  of  260  is  not  uncommonly 
met  with.  If  the  radial  artery  is  rolled  under  the  fingers,  it  feels  like  a  piece  of 
thick  rubber  tubing,  and  it  is  easily  recognized  as  being  distinctly  fibrous  when  it 
is  palpated  carefully.     In  other  words,  the  blood  tension  is  high  and  the  vessel 


CHRONIC  NEFHRiriS  653 

is  thick.  If  the  heart  is  examined,  there  is  found,  as  a  very  constant  symptom, 
a  sharyly  accentuated  aortic  second  sound  at  the  second  right  costal  cartilage,  which 
is  due  to  the  high  arterial  tension.  On  inspection  the  ape.r  of  the  heart  is  found  to 
be  displaced  downward  and  outward  because  of  the  cardiac  hypertrophy.  At  the 
apex  a  more  or  less  distinct  systolic  murmur  is  heard  in  many  cases,  due,  as  a  rule, 
to  stretching  of  the  mitral  orifice  under  the  stress  of  high  pressure  in  the  ventricle, 
resulting  from  great  arterial  tension.  When  compensation  fails,  either  because 
the  heart  becomes  exhausted  or  because  of  fibroid  or  other  myocardial  degeneration, 
these  symptoms  may  be  replaced  by  weak  heart  sounds  and  by  a  feeble  pulse. 
It  is  only  while  the  heart  has  vigor  that  high  tension  can  exist. 

The  respiratory  system,  does  not  offer  much  that  is  characteristic,  but  complicating 
lesions  often  develop  in  these  parts.  One  of  the  most  common  is  jmevvumia, 
which  finds  a  fair  field  for  its  development  in  all  cases  of  renal  disease.  Indeed, 
in  every  case  of  acute  pneumonia  the  physician  should  study  the  renal  condition. 
Often  the  routine  examination  of  the  vessels  and  of  the  urine  in  a  case  of  pneumonia 
is  the  first  evidence  that  chronic  contracted  kidney  is  present.  Perhaps  the  most 
common  respiratory  manifestation  is  difficult  breathing  resembling  asthma,  which, 
coming  on  in  persons  not  previously  asthmatic,  should  always  raise  the  suspicion 
of  renal  disease.  Effusions  into  the  pleural  spaces  may  occur  with  suddenness  and 
cause  death,  but  sudden  pulmonary  edema  is  more  common.  When  the  toxemia 
is  well  marked,  Cheyne-Stokes  breathing  may  develop. 

The  cerebral  symptoms  consist  in  vertiginous  attacks,  miqraine-like  seizures,  and 
persistent,  dull,  or  throbbing  headache.  Apoplexy  due  to  the  degenerative  arterial 
changes  may  take  place. 

It  is  a  most  interesting  fact  that  edema  is  as  rare  in  contracted  kidney  as  it  is 
common  in  the  large  white  kidney.  When  it  occurs  it  is  not  renal  in  origin,  but 
due  to  the  failure  o£the  heart.     The  skin  in  this  type  of  renal  disease  is  usually  dry. 

Next  in  importance  to  the  examinations  of  the  urine  and  the  study  of  the  periph- 
eral circulation  in  these  cases  is  the  observation  of  the  state  of  the  retinal  vessels. 
They  very  commonly  reveal  the  renal  condition. 

Different  observers  give  varying  percentages  of  occurrence  of  retinal  lesions. 
Out  of  935  cases  of  renal  disease,  Groenouw  found  retinal  lesions  in  209,  or  22.4 
per  cent.  The  age  at  which  they  most  frequently  are  met  with  is  from  fifty  to 
sixty  years,  but  they  have  been  seen  in  adolescents. 

Five  types  of  these  lesions  are  recognized  by  ophthalmologists:  (a)  typical 
albuminuric  retinitis;  (b)  degenerative  albinninuric  retinitis;  (c)  hemorrhagic  albumin- 
uric retinitis;  (d)  albuminuric  neuroretinitis,  and  (e)  albuminuric  papillitis.  In 
the  first  form  irregularly  shaped  white  dots  or  spots  appear  in  and  around  the  macula, 
and  may  take  a  stellate  form.  When  the  condition  is  well  developed  a  zone  of 
whitish-yellow  may  surround  the  head  of  the  optic  nerve.  Flame-like  hemorrhages 
may  also  appear.  The  condition  is  at  first  one  of  hyperemia,  then  of  degeneration, 
and  finally  one  of  atrophy.  In  the  second  form  the  white  spots  are  small,  and 
hemorrhages  are  more  limited,  and  the  white  zone  about  the  nerve  head  is  not  well 
developed.  The  third  form,  as  its  name  indicates,  is  chiefly  hemorrhagic  in  type, 
and  the  hemorrhages  are  large  or  profuse,  while  the  other  changes  are  insignificant. 
Only  when  the  hemorrhages  are  absorbed  do  these  areas  become  whitish.  The 
fifth  form  shows  that  the  process  has  been  confined  to  the  optic  nerve,  so  that  a 
papillitis  or  choked  disk  is  present,  the  retina  being  but  little  involved. 

In  some  cases  detachment  of  the  retina  or  hemorrhagic  glaucoma  develop  as  com- 
plications. 

Of  even  greater  importance  than  the  states  just  described  in  the  early  diagnosis 
of  renal  and  cardiovascular  disease  is  the  tortuosity  of  the  retinal  veins  and  their 
narrowing  by  the  pressure  of  the  retinal  arteries  wherever  these  vessels  cross  the 
veins — the  so-called  "  Hirschberg's  vessels"  (Fig.  114). 


054 


DISEASES  OF   THE  KIDNEYS 


Albuminuric  retinitis.     Granular  kidney.     Note  hard-edged  "asterisk"  exudation  and  tlio  silver-wir 
condition  of  the  arteries,  and  the  punctate  and  linear  hemorrhages,     (de  Schweinitz.) 


Ketiiia  showing  compressed  veins.    The  high  teusion  in  the  arteries  can  be  seen  to  be  narrowing 
the  veins  by  pressure,    (de  Schweinitz.) 


CHRONIC  NEPHRITIS.  655 

Because  of  the  fact  tliat  the  symptoms  of  chronic  contracted  kidney  are  so  often 
insidious  in  their  development,  the  ophthalmologist  is  often  the  first  to  recognize 
the  existence  of  the  disease,  because  a  man  who  considers  himself  in  perfect  health 
asks  for  glasses  for  failing  vision  or  seeks  relief  for  blindness  in  one  eye.  Not 
rarely  these  patients  have  repeated  attacks  of  rupture  of  subconjunctival  vessels, 
as  well. as  hemorrhages  into  the  retina. 

Flexner  states  that  the  terminal  dysentery  of  Bright's  disease  is  often  due  to 
the  Bacillus  dysenteriw. 

■  Prognosis. — Here,  again,  chronic  contracted  kidney  presents  a  widely  different 
aspect  from  that  of  the  parenchymatous  form,  for,  while  in  the  latter  lesion  death, 
as  a  rule,  occurs  inside  of  eighteen  months  at  best,  these  cases  often  live  for  many 
years,  if  the  process  is  not  already  far  advanced  when  the  case  is  first  seen.  The 
points  governing  prognosis  are  the  state  of  the  heart  and  the  vessels,  the  ability 
of  the  kidneys  to  approximate  the  normal  daily  task,  and  the  life  which  the  patient 
can  or  will  lead.  It  is  manifest,  from  what  has  been  said  as  to  its  pathology,  that 
the  affection  is  incurable,  but  patients  often  live  as  long  as  ten  or  fifteen  years  after 
undoubted  signs  of  the  malady  are  present.  The  development  of  signs  of  uremia, 
of  feeble  heart,  or  of  pulmonary  congestion,  edema,  or  pneumonia  is,  of  course, 
alarming.  Nevertheless  I  have  seen  patients  develop  repeated  attacks  of  pulmonary 
edema  each  of  which  seemed  to  indicate  imminent  death  recover  from  such  attacks 
and  be  free  from  them  for  years. 

By  far  the  most  important  factor  in  determining  the  probable  duration  of  life 
is  the  state  of  the  retinal  vessels  already  named,  de  Schweinitz  has  studied  this 
matter  most  carefully  from  the  standpoint  of  the  ophthalmologist,  and  we  have 
followed  a  number  of  cases  together. 

These  facts  are  well  emphasized  by  the  following  figures,  which  illustrate  the 
duration  of  life  in  chronic  interstitial  nephritis  after  the  occurrence  of  retinal 
changes:  Belt  collected  419  cases,  of  which  72  per  cent,  died  within  one  year  and 
90  per  cent,  within  two  years.  The  cases  reported  from  Haab's  clinic  by  Possauer 
showed  that  none  of  the  men  applying  for  treatment  lived  more  than  two  years; 
of  the  women,  68  per  cent,  died  within  the  same  period  of  time.  Of  private  patients 
who  could  live  comfortably,  only  59  per  cent,  of  the  men  and  53  per  cent,  of  the 
women  had  died  at  the  end  "of  two  years.  Gruening  collected  100  cases,  none  of 
which  survived  more  than  two  years  after  retinal  changes  began,  and  Bull  found 
that  69  out  of  103  cases  died  within  two  years.  Of  the  remaining  34,  17  died 
after  a  longer  period,  and  17  were  alive  at  the  time  his  paper  was  published.  Harlan 
analyzed  40  cases  with  the  following  results:  33  ended  fatally  at  various  periods, 
averaging  four  months;  3  lived  a  year  after  the  discovery  of  retinal  changes;  3 
recovered,  and  1  regained  his  eyesight,  although  the  urine  was  albuminous  at  the 
end  of  two  years.  Miley  traced  45  cases,  and  found  the  average  duration  of  life 
to  be  less  than  four  months  from  the  time  eye  changes  were  first  observed.  One 
of  his  patients  lived  eighteen  months  and  two  fourteen  months,  but  all  the  others 
died  within  a  year.  Webster  mentions  the  case  of  a  clergyman  suffering  from 
chronic  interstitial  nephritis,  in  whom  retinal  changes  had  been  recognized  ten 
to  fifteen  years  before,  and  "who  is  still  living,"  and  Wert  had  a  woman  under 
observation  in  whom  retinal  changes  had  been  noticed  more  than  four  years  before 
he  reported  the  case.  Her  general  condition  was  much  the  same  as  when  she  came 
under  his  charge.  I  have  had  under  my  care  a  number  of  patients  who  have  lived 
from  six  to  eight  years,  during  which  retinal  hemorrhages  have  repeatedly  occurred, 
and  whose  arterial  tension  has  been  astonishingly  high.  Most  of  these  cases 
with  very  high  tension  and  retinal  changes  die  from  apoplexj''  or  an  acute  myo- 
cardial failure  soon  after  retinal  changes  develop,  the  patient  often  dropping 
dead  without  warning  symptoms. 

Treatment. — There  are  few  diseases  of  an  incurable  character  in  which  the  patient 
can  be  so  greatly  benefited  by  treatment. 


656  DISEASES  OF  THE  KIDXEYS 

Tlie  (luestion  of  diet  in  cases  of  chronic  contracted  kidney  is  to  be  decided  along 
pretty  much  the  same  Hnes  as  those  which  liave  been  drawn  in  tiie  article  upon 
the  treatment  of  chronic  parenchymatous  nephritis.  W.  Hale  White  has  expressed 
the  belief,  in  which  I  coincide,  that,  as  a  rule,  this  disease  is  treated  too  zealously, 
and  tliat  in  the  desire  to  spare  the  kidneys  the  patient  is  starved,  with  the  result 
that  the  only  means  by  which  the  degenerative  process  can  be  retarded,  namely, 
the  maintenance  of  general  good  health,  is  ini]«iired. 

As  we  do  not  know  of  any  articles  of  ordinary  diet  wliich  can  be  considered 
really  harmful  in  granular  kidney,  it  is  best  to  give  the  patient  ordinary  plain 
digestible  foofls  containing  the  normal  proportions  of  proteids,  fats,  carbohydrates, 
and  salts,  just  as  it  is  necessary  to  give  a  person  in  health  a  similar  mixed  diet. 
It  need  hardly  be  stated  that  highly  seasoned  foods,  or  foods  which  are  difiicult 
of  digestion,  should  be  interdicted.  Again,  I  am  glad  to  note  that  Hale  White 
is  in  accord  with  me  in  believing  that  the  limitation  of  these  patients  to  a  diet  of 
chicken  and  fish  without  any  red  meat  is  entirely  unnecessary.  Not  only  does  such  a 
limitation  do  no  good,  but  it  is  often  harmful  in  the  sense  that  it  makes  the  patient 
consider  himself  seriously  ill,  and  also  diminishes  his  appetite.  Patients  with 
interstitial  nephritis,  however,  should  especially  eschew  all  forms  of  alcohol,  since 
it  is  imperfectly  oxidized  in  these  cases,  and  tends  to  increase  arterial  tension.  Bj' 
far  the  best  treatment  of  these  cases  is  removal  from  business  cares,  avoidance 
of  alcohol  and  tobacco  in  excess  and  the  use  of  hot  electric  cabinet  baths,  care  being 
taken  that  there  is  no  exposure  to  cold  after  them  for  several  hours.  If  the  heart 
is  failing  rest  in  bed  all,  or  part  of  the  day  will  often  do  far  more  good  than  drugs. 
Massage,  if  not  given  too  severely,  is  valuable.  Often  several  nights  of  good  rest 
induced  by  morphine  or  medinal  will  work  wonders. 

High  tension  is  not  by  any  means  an  absolute  evil.  Indeed,  after  fibroid  changes 
in  the  vessels  have  developed  it  is  essential  to  the  existence  of  the  patient,  since 
by  this  means  blood  is  sent  in  adequate  amount  to  the  tissues  through  narrowed 
blood  paths.  In  the  early  stages  when  vascular  spasm  is  a  large  factor  in  producing 
high  tension  the  use  of  nitrites  is  wise  since  the  work  of  the  heart  is  thereby  decreased 
and  the  tissues  are  well  fed  with  blood  by  the  relaxing  of  the  arterioles.  When 
the  fibroid  process  is  marked  and  is  the  chief  or  sole  cause  of  high  pressure  the 
nitrites  cannot  aflFect  the  vessels,  and  in  large  doses  only  depress  the  heart. 

A  valuable  drug  in  chronic  contracted  kidney,  both  from  the  standpoint  of 
the  early  fibroid  changes  in  the  arteries  and  the  underlying  systemic  state,  is  the 
iodide  of  potassium.  There  can  be  no  doubt  that  if  any  remedy  exercises  an  influ- 
ence for  good  in  arresting  the  pathological  changes  in  the  kidneys  and  in  the  blood- 
vessels, that  remedy  is  certainly  one  of  the  iodides.  Usually  doses  of  from  10  to 
20  grains,  three  or  four  times  a  day,  are  cjuite  sufficient.  A  useful  substitute  for 
the  potassium  salt  is  the  sodium  or  strontium  salts  or  the  syrup  of  hydriodic  acid 
given  in  ascending  doses,  beginning  with  2  drachms  three  times  a  day. 

Digitalis  is  rarely  needed  in  chronic  interstitial  nephritis,  as  the  cardiac  hyper- 
trophy is  usually  adequate,  but  in  some  cases  there  comes  a  time  when  the  blood 
pressure  falls  largely  because  the  advancing  myocardial  degeneration  and  cardiac 
fatigue  prevent  the  heart  from  pumping  the  blood  with  normal  energy.  In  such 
cases  digitalis  and  strophanthus  may  do  good,  and  nitroglycerin  may  do  harm. 
(See  Arteriosclerosis.) 

Uremia  is  to  be  treated  by  the  use  of  the  hot  pack,  if  the  patient's  heart  is  strong; 
by  the  emi)loyment  of  hypodermoclysis,  and  if  the  patient  is  fairly  full-blooded 
by  venesection  as  well.  (See  Uremia.)  Cups  may  be  placed  o^■er  the  kidneys, 
if  there  is  any  condition  of  renal  congestion,  and  three  or  four  cups  should  be 
placed  over  the  base  of  each  lung,  if  any  signs  of  pulmonary  edema  develop.  When 
evidences  of  pulmonar\-  difficulty  arise,  full  hypodermic  doses  of  strychnine  and 
atropine  are  advisable. 


AMYLOID  DISEASE  OF  THE  KIDNEYS  657 

Many  practitioners  iiave  tliongiit  it  wise  to  enijiloy  fiiii  doses  of  morphine 
hypodermically  in  the  treatment  of  uremic  convulsions.  I  have  made  a  collec- 
tive investigation  in  regard  to  this  matter,  and  have  obtained  the  opinion  of 
physicians  of  experience  in  both  this  country  and  in  I'^ngland.  This  oj)inion  is 
almost  universally  adverse  to  this  use  of  morj^hine. 

The  convulsions  should  he  controlled  by  nitrite  of  amyl  and  by  chloroform  given 
by  inhalation.     (See  Uremia.) 

The  question  of  renal  decapsulation  has  already  been  discussed  under  Chronic 
Parenchymatous  Nephritis. 

If  the  progress  of  the  disease  is  slow,  it  is  advisable  to  send  the  patient  to  some 
warm  climate  during  the  winter  months,  if  his  home  is  in  a  northern  latitude. 
The  object  is  to  avoid  rapid  changes  in  temperature  in  the  atmosphere  and  con- 
sequent chilling  of  the  surface,  with  secondary  congestion  of  the  kidneys  and 
decrease  in  the  activity  of  the  skin. 

The  best  climate  is  to  be  found  in  the  neighborhood  of  San  Diego,  California,  or 
in  Egypt. 

AMYLOID  DISEASE  OF  THE  KIDNEYS. 

Defiaition. — Amyloid  disease  of  the  kidneys  is  part  of  a  general  process  affecting 
many  organs.  The  renal  manifestation  is  characterized  by  the  deposit  of  lardacein 
in  the  subintimal  stratum  of  the  bloodvessels,  in  the  glomeruli,  and,  to  a  lesser 
degree,  in  the  connective  tissue  of  the  tubules. 

Etiology. — Amyloid  disease  of  the  kidney  is  usually  the  result  of  a  prolonged 
suppurative  process,  such  as  hip-joint  disease,  chronic  pulmonary  tuberculosis 
with  cavity,  or  any  cause  whereby  the  system  is  simultaneously  sapped  by  suppura- 
tion and  poisoned  by  the  absorption  of  toxic  substances.  It  may  also  be  a  sequence 
of  one  of  the  prolonged  fevers  or  occur  as  an  associated  change  with  chronic  diffuse 
nephritis  of  the  parenchymatous  type.  Syphilis  is  a  common  cause,  and  malaria 
may  be  the  only  demonstrable  antecedent. 

Pathology. — The  kidneys  are  usually  enlarged,  and  when  incised  the  cut  surface 
is  shining  or  polished  in  appearance.  When  the  condition  is  combined  with  inter- 
stitial nephritis  these  organs  may  be  small.  The  surface  of  the  organ  is  paler 
than  normal,  particularly  in  the  cortex,  but  the  pyramids  are  deep  red  in  hue,  and 
the  glomeruli  are  readily  seen. 

If  an  aqueous  solution  of  iodine  is  painted  over  the  cut  surface  of  such  a  kidney, 
the  areas  most  affected  by  the  amyloid  change  stain  a  deep  mahogany  brown, 
and  if  to  these  areas  is  applied  a  dilute  aqueous  solution  of  sulphuric  acid,  the  brown 
hue  is  changed  to  blue. 

Microscopically  the  kidney  structure  when  examined  reveals  the  fact  that  the 
capillary  vessels  forming  the  tufts  in  the  capsules  are  the  parts  of  the  parenchyma 
most  affected,  the  tuft  being  transformed  into  a  waxy  mass.  The  disease  process 
also  involves  the  afferent  and  eft'erent  bloodvessels  of  the  tuft  and  the  straight  or 
direct  vessels  of  the  kidney.  In  marked  cases  the  connective  tissue  of  the  tubules 
is  infiltrated,  the  interstitial  tissue  increased,  and  the  epithelial  cells  may  be  granular 
or  fatty,  as  in  parenchymatous  nephritis.  In  some  instances  all  these  types  occur 
together. 

Symptoms. — There  are  no  symptoms  which,  taken  by  themselves,  may  be  con- 
sidered indicative  of  amyloid  disease  of  the  kidneys.  It  is  only  when  certain 
urinary  signs  develop  in  a  case  which  is  the  subject  of  those  maladies  which  predis- 
pose to  amyloid  change  that  we  can  say  that  a  diagnosis  is  assured.  The  patient 
is  usually  pallid,  may  be  well  covered  by  unhealthy  waxy  fat,  and  the  heart  is  not 
rarely  sbmewhat  enlarged,  although  no  less  an  authority  than  Dickinson  contradicts 
this  view.  The  urine  is  passed  more  freely  than  is  normal.  It  is  clear  and  has  a 
low  specific  gravity,  about  1 .005  to  1 .0 1 0.  The  quantity  of  album  in  which  it  contains 
42 


658  DISEASES  OF  THE  KIDNEYS 

varies,  hut  it  is  usually  present  in  cu nn id e ruble  quantiti/.  There  is  a  distinct  increase 
in  the  quantity  of  serum  globulin  in  the  urine.  I'nder  the  microscoiJC  the  tube 
casts  are  found  to  be  hyaline,  fatty,  or  waxy.  Occasionally  the  amyloid  reaction 
already  named  maj'  be  demonstrated  in  the  urine.  The  degree  of  edema  and 
the  state  of  the  bloodvessels  and  heart  depend  more  upon  the  presence  of  associated 
nephritis  than  upon  the  amyloid  change  itself.  If  nephritis  is  well  developed, 
anasarca  and  high  arterial  tension  may  be  present  as  an  associated  state. 

Prognosis. — The  prognosis  depends  upon  the  gra^•ity  of  the  causati\e  process 
and  the  degree  to  which  the  secondary  change  in  the  kidneys  has  progressed.  Then, 
too,  it  must  be  remembered  that  amyloid  disease  is  not  a  condition  limited  to  the 
kidneys,  but  affects  such  organs  as  the  liver,  spleen,  and  even  the  heart,  and, 
therefore,  the  patient  is  peculiarly  handicapped  in  his  struggle  for  liealth.  If  the 
casts  are  fatty  or  waxy,  and  are  present  in  large  numbers,  if  the  albuminuria  is 
copious,  and  if  anemia  is  marked,  the  outlook  is  bad.  Indeed,  in  every  case  it  is 
anything  but  good,  and  the  longer  the  suppurative  process  continues  the  worse 
the  outlook  becomes. 

Treatment. — This  consists  in  the  same  measures  as  have  been  recommended  for 
chronic  parenchymatous  nephritis,  such  as  iron,  arsenic,  cod-liver  oil,  and  fresh 
air  and  sunlight  -to  combat  the  underlying  cause.  If  possible,  the  suppurative 
process,  if  such  is  the  cause,  should  be  removed. 

UREMIA. 

Definition. — Uremia  is  a  condition  in  which  as  the  result  of  faulty  activity  of 
the  kidneys  a  patient  develops  a  series  of  symptoms  of  which  the  most  notable 
are  stupor,  coma,  convulsions,  or  paralysis,  or  in  other  instances  gastro-intestinal 
disorders. 

Etiology  and  Pathology. — The  causes  of  uremia  are  not  clearly  understood.  It 
is  well  known,  and  universally  recognized,  that  the  condition  is  due  to  perverted 
renal  activity,  both  as  to  the  elimination  of  the  ordinary  products  of  metabolism 
and  the  effects  of  renal  disease  upon  the  tissues  of  the  body,  but  beyond  this  the 
actual  cause  is  as  yet  undetermined. 

At  one  time,  under  the  leadership  of  Traube,  the  idea  prevailed  that  the  symptoms 
of  uremia  were  dependent  upon  changes  in  the  circulation  in  the  brain  produced 
by  the  constriction  of  its  arteries  by  the  vascular  changes  associated  with  nephritis 
or  by  cerebral  edema.  In  other  words,  that  cerebral  anemia  due  to  arterial  con- 
striction was  the  cause  of  the  symptoms.  This  view  has  been  cast  aside  because 
it  has  been  shown  that  ligature  of  the  carotid  arteries  does  not  cause  uremic  symp- 
toms, because  it  has  been  proved  that  the  high  arterial  tension  of  renal  disease 
results  in  dilatation  of  the  cerebral  vessels,  since  they  are  poorly  endowed  with 
muscular  fibres,  and  finally  because  it  is  impossible  to  cause  active  contraction  of 
the  cerebral  vessels  by  any  drug  or  measure  used  for  raising  arterial  tension. 

The  theory,  that  uremia  is  due  to  the  retention  of  the  ordinary  effete  materials 
of  the  bodj'  owing  to  renal  disease,  also  cannot  be  accepted  as  a  complete  explanation 
of  the  condition,  because  it  has  been  found  that  ligation  of  the  renal  arteries  in 
animals  and  ligation  of  the  ureters  fail  to  produce  uremia,  although  the  function 
of  the  kidney  is  by  these  means  completely  arrested.  Again,  suppression  of  urinary 
secretion  by  the  presence  of  stone  in  both  kidneys,  and  even  by  necrosis  of  the 
cortex  of  both  kidneys  in  man,  does  not  cause  typical  uremia.  Further  than  this 
the  injection  of  urea  and  even  of  healthy  urine  into  the  blood  does  not  cause  any 
symptoms  if  true  uremia.  Again,  in  certain  cases  of  renal  disease,  as  in  chronic 
contracted  kidney  of  the  aged,  when  the  renal  excretion  is  seriously  impaired, 
uremia  is  rare.     Al\  forms  of  deficient  renal  activity  do  not,  therefore,  cause  uremia. 

A  third  theory  is  that  as  a,  result  of  the  renal  disease  peculiar  poisons  are  made 


UREMIA  659 

in  the  body  which  when  they  accumulate  cause  uremia,  or  that  the  condition  of  the 
system  in  renal  disease  permits  certain  micro-organisms  to  grow  and  produce  a 
toxic  substance. 

A  fourth  opinion  is  that  the  kidney  secretes  when  in  health  an  "  internal  secretion" 
which  governs  metabolism  and  so  prevents  the  formation  of  certain  poisons.  The 
last  theorj'  falls  to  the  ground  because  ligation  of  the  renal  vessels  does  not  result 
in  uremia,  as  it  would  do  if  these  sj^mptoms  were  caused  by  the  lack  of  some  internal 
secretion. 

We  are  left,  therefore,  with  the  fact  that  uremia  is  due  to  the  presence  in  the 
body  of  peculiar  poisons  arising  in  Bright's  disease,  either  as  the  result  of  the 
growth  of  micro-organisms  or  perverted  metabolism,  and  with  the  knowledge  that 
the  kidneys  are  unable  by  reason  of  disease  to  be  active  in  the  elimination  of  any 
poisons.  It  would  seem  probable  that  this  combination  of  extra  poisons  and 
deficient  renal  activity  are  the  two  factors  necessary  to  the  development  of  uremia. 
This  is  further  supported  by  the  fact  that  if  the  labor  of  the  kidneys  is  increased 
by  gastro-intestinal  fermentation  or  putrefaction,  an  attack  of  uremia  is  very  prone 
to  occur.  Finally,  there  is  additional  proof  of  the  development  of  extra  poisons 
in  the  body  in  renal  disease.  This  is  found  in  the  marked  loss  of  weight  in  patients 
suffering  from  nephritis,  the  wasting  showing  that  nutrition  is  seriously  impaired 
and  that  tissue  breakdown  is  marked.  Manifest  loss  of  weight  may  not  be  present 
because  of  dropsy,  but,  if  this  is  removed  by  purging,  the  wasting  is  manifest. 
The  toxicity  of  the  urine  is  increased.  Golla  believes  there  is  sufficient  evidence 
of  a  specific  toxemia  of  the  nervous  system  to  make  imperative  a  search  for  a 
specific  uremic  poison  before  becoming  resigned  to  any  theory  of  multiple 
intoxication. 

Symptoms. — Uremia  occurs  in  several  forms.  The  most  common  manifestation 
of  uremia  is  that  in  which  the  patient  passes  into  coma,  which  may  be  preceded 
by  delirium  and  drowsiness.  In  certain  cases  there  is  associated  with  the  develop- 
ment of  the  comatose  state  twitchings  and  contractions  of  widely  separated  muscles, 
and  particularly  the  extensors  and  flexors  of  the  forearms. 

The  most  startling,  but  by  no  means  the  most  frequent,  form  is  the  convulsive 
type.  In  this  condition  the  patient,  with  or  without  any  preliminary  indications 
of  nervous  disturbance,  is  seized  with  a  more  or  less  severe  epileptoid  attack,  which 
usually  involves  the  muscles  of  the  face  and  hands,  and  then  spreads  rapidly  to 
the  whole  body.  No  sooner  is  one  seizure  over  than  another  comes  on,  and  with 
the  repetition  of  the  attacks,  or  it  may  be  with  the  development  of  the  first  fit, 
the  patient  becomes  unconscious,  or  has  very  distinct  mental  impairment.  The 
body  temperature  usually  falls  unless  the  convulsions  are  so  severe  as  to  temporarily 
cause  a  slight  rise.  The  knee-jerks  are  usually  markedly  exaggerated  and  the 
pupils  are  contracted.  Because  these  symptoms  are  so  extraordinary,  the  idea 
has  gained  ground  that  convulsive  seizures  in  uremia  are  commonly  met  with. 
This  is  incorrect,  as  they  are  not  common  except  in  that  peculiar  form  of  eclamptic 
convulsion  due  to  toxemia  which  is  encountered  in  pregnancy. 

A  third  form  is  that  in  which  there  is  marked  respiratory  disorder  of  a  dyspneic 
type.  The  patient  finds  it  exceedingly  difficult  to  breathe,  and  feels  as  if  suffocated. 
Not  only  is  the  respiration  wheezing,  as  it  is  in  asthma,  but  it  is  peculiar  in  that  it 
is  accompanied  by  a  hissing  sound,  the  patient  very  frequently  ending  each  expira- 
tion with  a  puffing  hiss.  Associated  with  these  symptoms  there  may  be  some 
duskiness  of  the  skin,  but  cj'anosis  is  not  marked.  The  patient's  mind  is  usually 
clear,  and  he  not  infrequently  complains  of  his  great  difficulty  in  getting  sufficient 
air.  As  this  condition  proceeds,  the  respirations  may  become  "  Cheyne-Stokes" 
in  type.  Although  it  is  generally  held  that  the  development  of  Cheyne-Stokes 
respirations  under  any  circumstances  is  indicative  of  a  fatal  result,  it  not  infre- 
quently happens  that  patients  with  this  symptom  arising  during  the  course  of 


660  DISEASES  OF  THE  K/DXEYS 

uremia  recover  from  that  particular  attack.  Sometimes  the  Ciieync-Stokes  breath- 
ing occurs  only  durinn;  sleep,  and  it  may  be  the  only  manifestation  of  uremia,  the 
mind  remaining  clear. 

There  is  still  a  fourth  form  in  which  the  jjatient  de\'elo])s  xuinia  or  acute  in.sanliy. 
He  is  restless,  very  excited,  and  may  be  extremely  violent.  As  a  rule,  after 
these  symptoms  have  lasted  for  a  short  time,  the  mental  excitation  is  followed  by 
gradually  increasing  drowsiness  which  finally  passes  into  coma. 

In  the  so-called  paralytic  form  of  uremia,  either  hemiplegia  or  monoplegia  may 
come  on  suddenly,  as  does  hemiplegia  in  cases  of  cerebral  hcmorriiage.  But  the 
paralysis  is  not  due  to  rupture  of  a  bloodvessel,  to  a  formation  of  a  thrombus, 
or  the  plugging  of  a  vessel  by  an  embolus.  So  far  as  is  known,  it  depends  upon 
intoxication  of  the  nervous  centres  controlling  the  parts  involved  in  the  paralysis. 
It  is  of  course  possible  for  cerebral  apoplexy  to  complicate  uremia,  and  for  this 
reason  it  may  be  difficult  to  immediately  make  a  differential  diagnosis  between 
the  hemiplegia  of  uremia  and  the  complicating  hemiplegia  of  cerebral  rupture. 

There  is  still  another  form  of  uremia  which  manifests  itself  in  persistent  insomnia 
with  muscular  irritability  or  cramps  and  hiccoughs. 

In  some  cases  of  uremia  violent  g astro-intestinal  disorders  suddenly  assert  them- 
selves, voiniting  may  be  persistent  and  severe,  and  nausea  intense.  Not  rarely 
profuse  serous  purging  comes  on,  which  may  be  an  effort  on  the  part  of  the  body 
at  elimination. 

In  some  cases  uremic  amaurosis  develops.  This  consists  in  sudden,  bilateral, 
and  complete  blindness.  Rarely  one  eye  suffers  before  the  other,  and  in  .some 
cases  the  perception  of  light  may  be  preserved,  although  ordinary  vision  is  destroyed. 
In  the  greater  number  of  these  cases  the  opthalmoscope  reveals  no  changes  in 
the  retina,  although  it  may  be  found  to  be  edematous  and  there  may  be  an  appear- 
ance of  the  optic  nerve  like  that  of  choked  disk.  This  condition  develops  more 
commonly  in  those  cases  of  acute  nephritis  associated  with  the  eruptive  fevers, 
as  scarlet  fever,  than  in  ordinary  chronic  nephritis.  The  amaurt)sis  lasts  for  a  few 
hours  to  a  day  or  even  longer  than  this,  and  vision  often  returns  as  suddenly  as 
it  was  lost.     The  prognosis  is  favorable  as  to  vision. 

All  of  these  forms  of  uremia  differ  very  materially  from  that  type  wliich  has  been 
called  "latent  uremia"  by  the  last  Sir  William  Roberts,  and  of  which  mention  may 
be  found  in  connection  with  the  article  upon  Nephrolithiasis.  In  these  patients 
life  is  maintained  for  periods  varying  from  one  to  two  weeks  in  the  presence  of 
total  urinary  suppression.  They  remain  conscious  almost  to  the  moment  of  death, 
and  the  uremic  symptoms  just  described  in  their  various  forms  are  never  present. 
There  may  be  some  headache  and  nausea  and  weakness  and  drowsiness.  The 
temperature  is  subnormal  and  the  pupils  are  contracted.  In  some  instances 
vomiting  is  a  prominent  symptom  in  this  type  of  uremia.  It  is  unfortunate  that 
the  term  "latent  uremia"  should  be  applied  to  this  condition,  as  the  condition  is 
really  not  one  of  latency  nor  of  uremia  as  that  term  is  generally  understood. 

A  very  important  symptom  of  uremia  is  the  peculiar  odor  about  the  patient, 
which  is  cjuite  characteristic  and  which  may  be  due  in  i)art  to  urea  which  is  being 
eliminated  by  the  skin  or  to  the  presence  of  some  toxic  substance  as  yet  not  isolated. 

Diagnosis. — The  presence  of  albuminuria  with  casts  of  the  uriniferous  tubules, 
of  somewhat  thickened  bloodvessels,  and  of  an  accentuatcil  aortic  second  sound 
in  association  with  the  develoi)ment  of  any  of  the  symptoms  which  ha\c  just  been 
described,  makes  the  diagnosis  of  uremia  jiractically  certain.  If  the  patient  is 
bled  for  the  purpose  of  relie\-ing  symptoms  of  venous  engorgement,  it  is  wise,  if 
opportmiity  offers,  to  make  a  determination  of  the  urea  in  the  blood  if  the  physician 
is  sufficiently  skilful  to  perform  the  necessary  manipulations.  The  most  difficult 
differentiation  lies  between  uremic  monoplegia  and  hemiplegia  due  to  rupture  of  a 
bloodvessel,  or  to  an  embolus,  or  thrombus.     In  some  cases  such  a  differentiation 


UREMIA  661 

is  impossible  because  these  vascular  lesions  may  be  present  as  a  complication  of  the 
uremic  state.  The  presence  of  the  urinary  changes  just  described  and  of  the  other 
signs  and  symptoms  mentioned  in  the  article  upon  Bright's  Disease  will  serve 
to  aid  in  the  differentiation  to  some  extent. 

At  times,  if  the  uremic  poisoning  is  not  of  such  a  character  as  to  produce  con- 
vulsions, but  merely  semiconsciousness,  the  patient  may  live  in  a  state  of  stupe- 
faction for  several  days  or  weeks,  and  because  of  the  mental  condition,  of  the  feeble 
pulse,  of  the  slight  fever,  and  of  the  coated  tongue,  be  considered  a  case  of  typhoid 
fever  or  general  tuberculosis.  Curschman  first  pointed  out,  and  my  experience 
is  confirmatory  of  his  statement,  that  a  Babinski  reflex  is  of  diagnostic  and  prog- 
nostic value  in  uremia.  Soper  and  Granat  have  shown  that  when  the  cerebrospinal 
fluid  contains  more  than  0.2  per  cent,  of  urea,  uremia  is  severe,  and  a  rapidly  fatal 
termination  is  likely.  Even  a  content  of  between  0.1  and  0.2  per  cent,  is  very 
grave.  A  content  of  0.05  to  0.1  per  cent,  suggests  distinct  impairment  of  proper 
renal  activity.    This  observation  I  have  confirmed  in  a  limited  number  of  cases. 

Opium  poisoning  is  to  be  separated  from  uremia  by  the  presence  of  an  odor 
of  laudanum  on  the  breath,  if  laudanum  has  been  used  instead  of  morphine,  by  the 
fact  that  the  pupils  are  contracted  to  a  pin-point,  and  by  the  examination  of  the 
urine.  From  alcoholism  uremia  is  separated  by  the  examination  of  the  urine, 
by  tlie  odor  of  alcoliol  in  the  breath,  and  by  tlie  history  of  the  patient.  But  it 
must  not  be  forgotten  that  many  alcoholics  have  chronic  renal  disease  and  that  the 
ingestion  of  considerable  quantities  of  alcohol  may  precipitate  an  attack  of  uremia, 
and  so  an  alcoliolic  liistory  may  be  present  which  will  mislead  the  physician. 

As  a  rule,  sudden  fulminating  uremic  symptoms  develop  in  patients  with  chronic 
interstitial  nephritis,  whereas  the  types  of  uremia  with  headache,  vertigo,  and  other 
warnings  of  toxemia  are  seen  most  frequently  in  tlie  parenchymatous  form. 

In  hot  weather,  when  men  are  exposed  to  great  heat  in  rolling  mills  and  furnaces, 
the  distinction  between  heatstroke  and  uremia  may  be  difficult,  since  in  both 
conditions  violent  convulsions  with  cyanosis  may  be  present.  In  lieartstroke, 
however,  tlie  temperature  is  usually  much  higher  than  in  uremia  and  the  cyanosis 
is  usually  more  intense.  It  is,  however,  quite  possible  for  heatstroke  to  complicate 
nephritis  and  to  cause  an  attack  of  uremia. 

Prognosis. — The  prognosis  is  always  grave,  but  not  necessarily  fatal  by  any 
means.  A  professor  in  one  of  the  medical  schools  of  Philadelphia  had  a  moderate 
uremic  seizure  after  nearly  every  lecture  for  a  whole  winter  course  of  lectures 
before  a  final  fatal  seizure  came  on.  In  uremia  due  to  acute  nepliritis  the  prognosis 
is  good  if  the  patient  can  but  survive  the  attacks  long  enough  for  tlie  kidneys  to 
regain  their  function.  In  tlie  cases  due  to  chronic  renal  disease  the  outlook  depends 
to  some  extent  upon  the  general  state  of  the  patient  and  particularly  the  condition 
of  the  lungs.  If  any  tendency  to  pulmonary  edema  or  congestion  is  present,  the 
outlook  is  much  more  serious. 

Treatment. — The  treatment  of  uremia  depends  to  some  extent  upon  the  variety 
of  nepliritis  which  has  produced  it  and  the  peculiarities  of  the  individual  wlio  is 
suffering  from  the  attack.  When  uremia  comes  on  as  a  complication  of  acute 
nephritis,  such  as  that  complicating  scarlet  fever,  the  patient  should  have  hot 
compresses  placed  across  the  small  of  the  back,  and,  if  diarrhea  is  not  already 
present,  one  of  the  saline  purgatives,  such  as  the  citrate  of  magnesium  or  the 
sulphate  of  magnesium,  should  be  given  in  sufficiently  concentrated  form  to  produce 
several  watery  movements.  After  this  5  to  10  grains  of  the  citrate  of  potassium 
dissolved  in  Poland  water  should  be  given  three  or  four  times  a  day.  If  the 
symptoms  of  uremia  persist,  it  will  be  necessary  to  place  the  patient  in  a  warm 
pack.  This  may  be  given  in  one  of  two  forms,  the  choice  of  the  form  depending 
upon  the  condition  of  the  patient's  skin  and  the  presence  of  an  eruption  resulting 
from  the  disease.     The  choice  also  depends  to  some  extent  upon  the  temperature 


662  Dlf^EASES  OF  THE  KIDNEY,'^ 

of  the  patient.  If  the  rash  has  to  some  extent  disappeared,  the  skin  is  dry  and 
hot,  and  the  temperature  high,  it  is  well  to  wrap  the  patient  in  a  sliect  wrung  out 
of  water  at  70°  or  S0°,  and  then  to  immediately  surround  him  witli  a  dry  blanket. 
The  primary  effect  of  this  cold  sheet  is  to  aid  in  the  dissipation  of  heat  over  the 
body,  but  it  very  rapidly  becomes  warmed  by  tlic  heat  of  the  body  so  that  the 
patient  at  first  is  under  the  influence  of  cold,  and  very  shortly  afterward  is  sur- 
rounded by  a  warm  pack.  The  jjrimary  cold  drives  the  blood  from  the  surface, 
and  the  secondary  heating  fills  the  peripheral  ca]>illaries  so  that  the  temperature 
is  lowered  by  an  improved  peripheral  circulation,  and  the  skin  is  thoroughly  supplied 
with  bloixl  so  that  it  has  a  better  opportunity  to  eliminate  poisons.  If  no  fever 
is  present,  and  the  rash  has  not  faded,  or  if  for  any  reason  it  is  considered  inadvisable 
to  use  cold  primarily,  the  hot  pack  may  be  given,  the  patient  being  quickly  wrapped 
up  in  a  l)lanket  which  has  been  wrung  out  of  water  as  hot  as  the  skin  can  bear. 
Outside  of  this  is  placed  a  dry  blanket  and  on  the  patient's  head  is  placed  an  ice-bag 
to  prevent  cerebral  congestion.  Every  few  moments  the  patient  is  given  a  few 
sips  of  cold  water  to  drive  the  blood  from  the  internal  portions  of  the  body  to  the 
skin,  the  object  being  to  flush  the  peripheral  circulation,  and  to  cause  a  sweat 
which  will  relieve  internal  congestion  and  eliminate  impurities  from  the  body. 
If  the  arterial  tension  is  high,  nitroglycerin  may  be  given  in  the  dose  of  ^Ju  of  a 
grain  to  a  child,  or  yott  to  a  man,  every  three  or  four  hours;  or,  in  its  place  for  a 
child  I  to  1  drachm  of  the  sweet  spirit  of  nitre  may  be  given. 

In  the  uremia  of  chronic  parenchymatous  nephritis  a  plan  of  treatment  identical 
with  that  which  has  just  been  described  for  that  of  acute  nephritis  may  be  carried 
out.  As  a  rule,  the  patient  is  already  too  anemic  to  permit  of  bleeding,  and  his 
tissues  are  so  edematous  that  hypodermoclysis  is  impossible. 

In  the  uremia  of  chronic  contracted  kidney  with  high  arterial  tension,  the  meas- 
ures already  indicated  for  the  uremia  of  acute  nephritis  may  be  instituted,  the 
nitroglycerin  being  particularly  useful,  and  being  given  hypodermically  in  order 
that  it  may  act  promptly.  It  also  has  a  beneficial  eft'ect  in  that  it  relaxes  any  spasm 
of  the  renal  bloodvessels  and  so  produces  diuresis.  If  there  is  much  engorgement 
of  the  venous  system,  venesection  is  exceedingly  useful,  particularly  if  it  is  accom- 
panied by  free  hypodermoclysis,  or,  in  urgent  cases,  by  an  intravenous  injection 
of  normal  saline  solution.  Sometimes  in  these  cases  if  the  heart  seems  strong, 
small  doses  of  pilocarpine,  I  of  a  grain,  may  be  given  hypodermically  to  aid  in 
producing  the  sweat  which  is  caused  by  the  hot  pack,  and,  with  the  object  of  pre- 
venting cardiac  depression,  it  is  usually  wise  to  combine  with  it  :|V  of  a  grain  of 
strychnine.  The  lungs  and  the  heart  should  lie  carefully  watched,  and  if  any 
signs  of  pulmonary  edema  or  cardiac  failure  develop,  strychnine  and  atropine 
should  be  given  freely,  and  1  or  2  drachms  of  Hoffmann's  anodyne  should  be 
administered  as  a  rapidly  acting  diffusible  stimulant.  In  some  cases  in  which 
there  is  a  tendency  to  suppression  of  urine,  not  only  nitroglycerin  but  cocaine 
in  the  dose  of  -|  to  \  of  a  grain  may  be  given  hypodermically  twice  or  thrice  a  day. 
Should  convulsions  occur,  they  should  be  controlled  by  chloroform,  if  they  are 
exceedingly  severe,  and  by  the  use  of  1  drachm  of  bromide  of  sodium  and  20  grains 
of  chloral  by  the  rectum.  Morpiiine,  which  has  been  largely  used  to  control 
uremic  convulsions,  is  not  regarded  with  favor  by  most  practitioners  at  the  present 
time.  If  the  arterial  tension  is  exceedingly  high,  full  doses  (.5  to  10  nnnims)  of 
the  tincture  of  veratrum  viride,  repeated  every  half-hour  until  some  evidences 
of  circulatory  depression  are  produced,  may  be  advantageous. 

PYELONEPHRITIS  AND  PYEUTIS. 

Definition. — Pyelonephritis  signifies  an  inflammatory  process  involving  both  the 
pelvis  of  the  kidney  and  the  kidney  texture  itself.     The  term  is  usually  applied 


PYELONEPHRITIS  AND  PYELITIS 


663 


to  that  form  in  which  the  condition  is  suppurative.  Hometimcs  it  is  called  suppura- 
tive pyelonephritis.  Pyelitis  is  an  inflammatory  state  of  the  pelvis  of  the  kidney 
without  involvement  of  the  kidney  proper.  As  synonyms  to  pyelonephritis  we 
may  use  the  terms  pyonephritis,  pyonephrosis,  and  caseative  nephritis. 

Etiology. — These  conditions  are  nearly  always  the  result  of  infection  from  below; 
that  is,  they  are  secondary  to  infection  of  the  lower  urinary  tract,  viz.,  the  bladder 
or  urethra.  Very  rarely  infection  of  the  kidney  may  take  place  through  the  blood, 
but  this  is  only  when  the  vital  resistance  of  all  the  tissues  is  greatly  impaired,  or 
when  the  infection  is  very  virulent,  for  the  healthy  kidney  quite  readily  eliminates 
micro-organisms  brought  to  it  by  the  blood  stream.  It  is  possible,  too,  in  cases  of 
floating  kidney,  in  which  the  ureter  becomes  twisted  or  obstructed  so  that  the 
vital  resistance  of  the  pelvis  is  impaired,  that  infection  through  the  blood  may 
ensue.  Although  stones  in  the  kidney  are  now  attributed  to  bacteria,  it  is  conceiv- 
able that  a  renal  calculus  by  damaging  the  pelvic  wall  may  prepare  the  way  for 
infection,  so  acting  as  a  direct  cause  of  pyelitis.  Infected  emboli  may  also  produce 
this  state. 

Fig.  115 


Brewis'  case  of  pyelonephritic  kidney.    Girth,  forty-eight  inches;  weight,  forty-five  pounds. 


The  micro-organisms  which  most  frequently  cause  pyelitis  and  pyelonephritis 
are  the  Bacillus  coli  communis,  the  Streptococcus  pyogenes,  the  Staphylococcus 
pyogenes  aureus,  the  tubercle  bacillus,  the  typhoid  bacillus,  the  gonococcus,  and 
the  Bacillus  proteus  vulgaris.  Brown  has  shown  that  the  Bacillus  coli  communis 
is  the  most  frequent  cause  in  women,  probably  because  of  the  near  relationship 


fi(i4  DfSKASKS  OF   THE   K I DX KYS 

of  tlic  aims  ami  the  meatus  urinarius.  IJmwn  also  asserts  tliat.  wlicrcas  smnc 
devitalizing-  eaiisc  is  usually  necessary  to  permit  infection,  a  eoiistantly  annnoniacal 
urine  is  sufficient  cause  in  many  cases  and  lirewer  and  others  have  re])(irted  instances 
in  which  an  acute  hematogenous  infection  of  one  kidney  occurred  with  \iolcnt 
pain  at  onset.     When  one  kidney  is  involved  it  is  usually  the  right. 

Pathology  and  Morbid  Anatomy. — Pyelonephritis  may  be  catarrhal,  pseudo- 
membranous, gangrenous,  or  suppurative.  The  first  two  forms  usually  depend 
upon,  and  are  overshadowed  by,  associated  diseases  such  as  typhoid  fever,  and 
rapidly  assume  the  suppurative  type.  In  pyelonephritis  the  mucous  membrane 
lining  the  pelvis  of  the  kidney  is  thickened  and  coated  with  pus.  A  fibrinous 
exudate  may  also  be  present.  The  kidney  structure  may  be  involved  in  two  ways: 
either  small  abscesses  are  scattered  through  the  parenchyma  o1  the  kidney  or  in  long 
white  streaks  which  project  themselves  along  the  tubules.  The  renal  tissue  in  and 
near  these  areas  is,  of  course,  necrotic.  If  the  suppurative  process  proceeds,  the 
calyces  of  the  kidney  become  enlarged,  the  renal  tissues  waste  and  suppurate, 
and  the  kidney  structure  is  largely  replaced  by  a  large  single  or  multiple  abscess. 
Finally,  if  the  patient  survives  so  long,  the  liciuid  drains  oft'  through  the  ureter, 
and  the  pus  becomes  inspissated  so  that  a  cheegy  mass  remains  which  may  f)ecome 
infiltrated  with  lime-salts.  This  process  may  extend  to  the  tissues  surrounding 
the  kidney  causing  paranephritis.  When  one  kidney  is  involved  the  cause  is 
nearly  always  primary  disease  in  the  bladder,  and  to  this  type  the  term  "  surgical 
kidney"  is  given. 

Symptoms. — The  symptoms  of  pyelitis  and  pyelonephritis  may  be  in  many 
cases  so  masked  by  the  conditions  which  produce  this  disorder  in  the  renal  jjclvis 
that  they  are  overlooked.  Thus  the  urinary  picture  is  commonly  obscured  by  an 
associated  cystitis,  which  may  either  precede  or  follow  the  renal  lesion.  The  most 
definite  symptoms  are  jyain  and  tenderness  in  the  back  over  the  kidneys,  with  or 
without  frequent  urination.  The  pain  is  increased  by  jarring  the  body  or  by  cough- 
ing, and  it  is  often  felt  in  the  testicle  or  inside  of  the  thigh  on  the  aft'ected  side. 
The  quantity  of  urine  passed  is  usually  scanty  in  acute  pyelitis  but  profuse  in  the 
chronic  form.  With  the  development  of  suppuration  septic  fever  develops,  vomiting 
may  come  on,  and  occasionally  a  profuse  septic  sweat  follows  a  chill  and  fcrer.  The 
urine  is  acid  and  contains  p?/.?,  blood  cells,  and  degenerated  epithelium.  At  times 
the  urine  may  appear  perfectly  normal,  but  soon  returns  to  its  earlier  state.  This 
variation  is  due  to  the  ureter  becoming  blocked  by  a  plug  of  putty-like  pus,  so 
that  for  several  hours  only  one  kidney,  anil  that  the  healthy  one,  drains  into  the 
bladder.  Such  a  variation  in  the  urine  therefore  proves  the  difficulty  to  be 
unilateral.  This  plugging  of  a  ureter  may  gi\'e  rise  to  attacks  of  pain,  somewhat 
like  those  due  to  a  renal  calculus  becoming  engaged  in  the  ureter,  but  the  pain  is 
rarely  so  severe. 

Diagnosis. — Pyelonephritis  is  sometimes  taken  for  malarial  fever,  as  are  other 
septic  processes,  because  of  the  chills,  fevers,  and  sweats.  An  examination  of  the 
l)atient  and  of  his  blood  and  urine  readily  excludes  malaria  and  reveals  the  renal 
disease. 

In  other  cases  the  dry  tongue,  loss  of  weight,  diarrhea,  and  alHloniiiial  tyinjiany 
may  mislead  one  into  a  diagnosis  of  tyjihoid  fever. 

From  suppurative  cystitis  the  condition  is  to  be  differentiated  by  the  fact  that 
the  i)ain  is  felt  ehiefiy  in  the  renal  region,  by  the  greater  quantity  of  jnis  in  the 
latter  state,  by  the  greater  alkalinity  of  the  urine  in  vesical  disease,  anil  finally 
by  the  use  of  the  cystoscope  and  the  ureteral  catheter. 

Usually  there  is  more  albumin  in  the  urine  in  pyelonephritis  than  in  cystitis, 
and  more  discomfort  in  the  suprapubic  area  in  the  latter  condition  than  in  the 
former. 

From  perinephric  abscess  jnelonepliritis  is  separated  l)y  the  greater  tenderness 


HYDRONEPHROSIS  665 

over  the  kidney  in  the  former  condition,  l)y  the  fact  that  this  area  is  not  hulfjinjj 
in  the  latter  state.  In  some  cases,  however,  of  pyelonephritis  very  distinct  bulging 
over  the  kidney  is  manifested.  A  vahiablc  sign  in  this  state  is  that  the  swelHng 
occasionally  diappears  or  diminishes  as  the  pus  and  urine  escapes  through  the 
ureter,  when  an  obstruction  is  removed.  A  bulging  or  swelling  in  the  renal  area 
may  also  be  due  to  hydronephrosis,  but  there  is  usually  no  fever  in  this  state. 

The  possibility  of  a  painful  swelling  in  the  region  of  the  kidney  being  due  to  an 
aneurysm  must  always  be  excluded  before  operation  is  resorted  to.  Most  impor- 
tant of  all  is  the  absence  of  pus  in  the  urine  in  the  first  condition  and  its  presence 
in  the  second. 

Prognosis. — Prognosis  depends  largely  upon  the  cause  of  the  malady  and  the 
state  of  the  kidney.  If  the  condition  is  one  of  simple  pyelitis,  occurring  during 
the  course  of  one  of  the  infectious  diseases,  the  outlook  is  not  necessarily  bad.  (See 
Typhoid  Fever.)  If  the  suppuration  is  marked  the  prognosis  is  not  good,  and  if 
the  kidney  structure  is  involved  to  the  extent  of  pyonephrosis  the  prognosis  is 
bad,  and  death  may  come  from  the  exiaaustion  of  prolonged  septic  fe^•er,  from 
the  extension  of  suppuration  to  other  parts,  or  because  of  amyloid  degeneration 
in  other  organs. 

Treatment. — The  treatment  of  pyelitis  in  its  milder  phases  consists  in  the  use 
of  mild  diuretics  if  the  urine  is  concentrated,  of  counter-irritation  by  cups  or  heat 
over  the  loins,  and  rest  in  bed.  When  bacteriological  examination  of  the  urine 
reveals  the  colon  bacillus  as  the  causative  factor,  excellent  results  often  follow 
the  use  of  colon  vaccine.  No  highly  seasoned  foods  are  permissible.  The  reaction 
of  the  urine  must  be  determined.  If  the  urine  is  acid,  alkaline  diuretics  and  salol 
are  useful.  If  it  is  alkahne,  then  we  may  give  10  grains  of  uritone  or  urotropin 
three  or  four  times  a  day  in  a  glass  of  sparkling  water,  preceding  it  by  one  or  two 
hours  with  full  doses  of  acid  sodium  phosphate  in  solution.  The  diet  should  be 
hearty  and  easily  digested.  Bitter  tonics  and  iron  are  useful,  but  quinine  is 
contra-indicated  because  of  the  state  of  the  bladder,  upon  which  it  acts  as  an 
irritant.  When  hectic  fever  is  developed  and  remains  persistent  the  patient 
should  be  subjected  to  nephrotomy  or  nephrectomy  before  he  becomes  exhausted 
by  sepsis.  Opium  or  morphine  may  be  needed  to  control  the  pain.  Several 
observers  have  reported  cases  in  which  benefit  was  derived  from  lavage  of 
the  renal  pelves,  by  means  of  ureteral  catheterization.     This  is  not  always  safe. 

HYDRONEPHROSIS. 

Definition. — Hydronephrosis  is  a  condition  in  which  because  of  obstruction 
in  the  ureter  there  takes  place  in  the  pelvis  of  the  kidney  an  accvmiulation  of  fluid 
which  is  not  purulent.  This  fluid  as  it  increases  in  quantity  stretches  and  dilates 
the  pelvis  and  the  calyces  until  very  large  amounts  of  fluids  are  retained  and  a 
good-sized  cyst  is  formed. 

Etiology  and  Pathology. — Hydronephrosis  may  be  acquired  or  congenital,  constant 
or  intermittent.  It  arises  from  permanent  or  intermittent  closure  of  the  ureter 
so  that  the  urine  cannot  escape  into  the  bladder.  When  congenital  the  ureter 
may  never  have  been  patulous  or  it  may  have  a  stricture  or  be  abnormally  inserted 
into  the  bladder  wall.  When  acquired  it  arises  from  stricture  of  the  ureter,  or 
from  plugging  by  a  clot  or  a  fragment  of  calculus.  It  may  result  from  twisting 
of  the  ureter  in  floating  kidney,  but  calculus  is  the  most  common  cause  of 
unilateral  hydronephrosis.  When  either  of  these  causes  is  responsible  for  the 
retention  of  fluid,  the  hydronephrosis  may  be  intermittent,  because,  when  the  twist 
is  undone,  or  when  the  calculus  slips,  the  fluid  can  escape.  The  patient  may  remain 
free  from  trouble  for  years  until  the  obstruction  forms  again.  The  obstruction 
may  be  at  the  bladder,  as  in  tumor  of  that  organ,  or  consist  in  a  paracystitis.     In 


666  DISEASES  OF  THE  KIDNEYS 

the  feiniile  j)elvic  adliesioiis,  ni'iii^lasiiis,  and  cysts  may  press  ii]hiii  I  lie  iinltT  ami 
impede  the  urinary  flow. 

The  secondary  effects  of  this  condition  upon  the  kidney  are  disastrous  if  it  is 
long  continued  and  severe.  The  pressure  acting  upon  the  renal  tissues  causes 
atrophy  and  wasting  so  that  finally  the  kidney  structure  largely  disappears  and 
in  its  place  only  a  large  collection  of  fluid,  surrounded  by  fihrous  tissue  and  rem- 
nants of  renal  tissue,  remain.  So  large  may  the  tumor  grow  that  it  projects  down- 
ward into  the  abdomen,  and  it  has  even  been  mistaken  for  ascites.  The  other 
kidney  may  be  similarly  affected,  but  often  it  undergoes  hypertrophy  to  compensate 
for  the  inability  of  its  mate. 

Symptoms. — The  presence  of  symptoms  depends  largely  upon  the  rapidity  of 
the  accumulation  of  fluid  and  the  size  of  the  renal  pelvis.  If  it  develops  slowly 
and  if  a  previous  attack  has  enlarged  the  pelvic  capacity,  much  fluid  may  be  present 
without  the  patient  presenting  any  symptoms.  If,  on  the  other  hand,  the  fluid 
rapidly  accumulates,  pain  may  be  very  severe.  When  stricture  is  the  cause  the 
accumulation  is  usually  slow,  but  when  a  twist  or  a  calculus  closes  the  ureter  it  is 
speedy  and  painful.  In  the  slow  cases  sharp  pain  may  be  replaced  bj'  a  sense  of 
weight  and  dragging.  A  very  characteristic  sign  in  some  cases,  when  the  obstruction 
is  suddenly  removed,  is  a  profuse  jloiv  of  wine  which  fills  the  bladder  rapidly, 
although  it  may  have  been  emptied  but  a  short  time  before.  The  timior  which 
may  have  been  present  in  such  a  case  disappears  with  the  flow. 

Diagnosis. — Palpation  of  the  abdomen  reveals  in  some  cases  a  mass  projecting 
from  beneath  the  floating  ribs,  in  which  fluctuation  may  be  detected.  When  the 
history  of  the  causes  and  symptoms  is  as  clear  as  has  just  been  detailed  the  diagnosis 
is  not  difficult,  but  the  history  is  frequently  not  clear.  In  children  such  a  mass 
has  been  mistaken  for  an  enlarged  spleen  and  for  a  sarcoma  of  the  kidney  or  of  the 
retroperitoneal  glands.  (See  Tumors  of  the  Kidney.)  In  other  cases,  if  the 
kidney  is  floating  and  hydronephrotic,  the  tumor  may  be  taken  for  an  ovarian 
cyst.  In  still  other  instances  the  tumor  may  so  fill  the  abdomen  as  to  lead  to  a 
diagnosis  of  ascites.  Thus,  Sutton  has  recorded  a  case  in  which  the  cyst  held  no 
less  than  thirty  gallons.  Aspiration  of  the  fluid  may  reveal  that  it  contains  some 
urea  or  that  it  partakes  of  a  urinous  odor. 

Prognosis. — The  prognosis  depends  entirely  upon  the  cause  of  the  difficulty 
and  the  state  of  the  other  kidney.  When  the  closure  is  congenital  and  complete, 
death  ensues  in  a  few  days.  When  the  closure  is  due  to  a  twist  of  the  ureter  or  to  a 
calculus,  much  depends  upon  whether  the  flow  is  entirely  stopped  and  how  long 
it  is  arrested.  A  single  attack  followed  by  sudden  relief  may  never  be  repeated. 
When  the  disease  is  bilateral  the  gradual  involvement  of  the  kidneys  may  result 
in  uremia,  or  if  infection  of  the  kidneys  ensues  suppuration  may  develop. 

Treatment. — It  is  evident  that  no  medicinal  treatment  can  be  curative  in  hydro- 
nephrosis. Morphine  and  atropine  hypodermically  to  allay  pain  and  relieve  spasm 
may  be  useful  at  a  time  when  the  obstruction  is  complete  and  the  accumulation 
of  fluid  rapid.  If  the  condition  is  due  to  a  floating  kidney  with  twisting  of  the 
ureter,  the  replacing  of  the  kidney  in  its  normal  position  may  give  relief.  In 
other  instances  the  temporary  assumption  of  the  knee-chest  position  is  curative. 
If  the  attacks  occur  very  frequently,  it  may  be  wise  to  suture  the  kidney  in  place. 

When  hydronephrosis  occurs  in  a  woman,  ureteral  catheterization  is  of  value: 
first,  because  it  withdraws  the  accumulated  fluid,  and,  second,  because  if  a  stricture 
is  present  a  catheter  may  dilate  the  stricture  and  so  exercise  a  curative  influence. 
But  catheterization  of  the  ureter  is  a  much  more  delicate  procedure  than  catheter- 
ization of  the  bladder,  and  there  is  greater  danger  of  infecting  the  ureter  and 
kidney,  so  that  the  greatest  possible  caution  in  regard  to  asepsis  must  be  secured. 
In  certain  cases  where  the  accumulation  of  fluid  is  very  rapid,  and  where  the 
symptoms  are  urgent,  aspiration  has  been  practised,  but  this  is  not  devoid  of  danger, 


CYSTIC  DISEASE  OF  THE  KIDNEY 


667 


and  gives  relief  in  only  about  50  per  cent,  of  the  cases.  Morris  directs  that  the 
needle  is  best  inserted  at  the  most  bulging  point,  but  that  if  no  such  point  is  manifest 
it  should  be  driven  in  half-way  between  the  last  rib  and  the  crest  of  the  ilium  and 
between  two  and  two  and  a  half  inches  behind  the  anterior  superior  spine  of  the 
ilium,  if  it  is  the  right  kidney  which  is  in  trouble.  An  aspirating  needle  should  be 
used  instead  of  a  trocar  and  cannula.  When  repeated  aspirations  are  required 
for  relief,  nephrotomy  is  necessary. 

CYSTIC  DISEASE  OF  THE  KIDNEY. 

Cysts  of  the  kidney  occur  as  congenital  malformations  and  as  those  acquired  in 
later  life.  There  is  perhaps  no  more  striking  object  to  be  found  in  a  collection  of 
pathological  specimens  than  a  congenital  cystic  kidney.  This  condition  not  rarely 
affects  both  kidneys,  which  is  an  important  point  to  bear  in  mind  if  any  operation 
on  one  kidney  is  thought  of.  These  cystic  kidneys  are  not  composed  of  one  large 
cyst,  but  of  a  multitude  of  cysts  massed  together  regardless  of  shape  and  size, 


Congenital  cystic  kidney.     (Kast  and  Rumpler.) 


and  separated  by  fibrous  bands  or  by  strands  of  atrophied  renal  tissue.  The  con- 
tents of  the  cyst  is  usually  a  clear  yellow  fluid  with  an  acid  reaction  and  containing 
urinary  salts,  but  occasionally  the  fluid  is  opaque  and  may  contain  small  amounts 
of  blood.  The  causes  and  processes  by  which  these  cysts  are  developed  are  not 
definitely  known,  but  it  is  thought  they  are  formed  by  extraordinary  dilatation 
of  the  tubules  or  of  Bowman's  capsules.    Shattock  believes  they  are  due  to  mal- 


668  DISEASES  OF  THE  KIDXEYS 

(levc'l()])mont  of  the  inesoiici)liron.  Such  kidneys  often  weigh  several  ponntls. 
Although  congenital  in  origin,  it  is  to  be  remembered  tliat  life  may  be  contiiuied 
far  into  adult  years  before  they  give  any  trouble. 

Congenital  cystic  kidney  (Fig.  1  Hi)  may  project  well  below  the  ribs  ;inil  give 
rise  to  a  diagnosis  of  sarcoma,  hydronephrosis,  or  of  enlarged  spleen. 

Cysts  of  the  kidney,  single  or  multiple;  may  be  present  in  kidneys  which  dthcrwise 
show  no  abnormalities,  and  these  cysts  may  be  smaller  than  a  pea  or  larger  than 
an  orange.  Their  contents  may  be  clear  or  brown  in  color,  and  may  be  gelatinous 
in  character. 

Attention  has  already  been  called  to  the  small  cysts  which  are  seen  on  the  surface 
of  the  kidneys  in  chronic  interstitial  nephritis.  At  times  it  is  difficidt  to  determine 
whether  the  kidney  is  the  site  of  acquired  or  congenital  cysts  when  these  cysts 
become  large  and  multiple. 

Echinococcus  cysts  of  the  kidney  also  occur.     (See  article  on  Parasitism.) 

The  symptoms  of  congenital  cystic  kidney  are  in  no  way  peculiar  unless  the 
kidney  be  large  enough  to  project  in  the  manner  described.  Aside  from  this  sign 
the  patient  presents  no  signs  of  renal  disease  until  the  cyst,  by  increase  in  growth 
and  resulting  decrease  in  renal  tissue,  develops  renal  failure,  and  the  signs  of  chronic 
nephritis  ensue.  In  some  cases  a  sudden  attack  of  uremia  may  be  the  first  symptom 
of  renal  difficulty.  When  the  condition  persists  and  adult  life  is  reached,  there  may 
be  a  hicih  arterial  tension,  and  hypertrophy  of  the  heart,  as  in  ordinary  chronic  nephritis. 
Often  they  interfere  but  little  with  the  life  of  the  patient.  In  the  museum  of  the 
Jefl'erson  Medical  College  is  a  cystic  kidney  weighing  seven  pounds,  diagnosed 
during  life  by  the  late  Dr.  J.  M.  Da  Costa,  and  carried  by  a  busy  practitioner  of 
medicine  for  over  two  years  afterward.     The  other  kidney  was  but  slightly  affected. 

Beyond  the  use  of  pain-relieving  drugs,  there  is  nothing  that  can  lie  done  for 
these  cases.  Operative  procedure  is  contra-indicated  in  the  sense  of  nephrectomy, 
because  the  other  kidney  is  so  often  diseased  that  it  is  unable  to  carry  the  burden 
of  elimination  if  left  by  itself. 


TUMORS  OF  THE  KIDNEY. 

The  kidney  is  not  rarely  the  seat  of  morbid  growths.  They  may  be  benign  or 
malignant.  The  benign  growths  are  the  fibromata,  which  chiefly  aft'ect  the  pyramids 
of  the  kidney,  and  less  commonly  the  lipomata  and  angiomata.  Occasionally 
|)apilloma  of  the  mucous  mendjrane  of  the  pelvis  of  the  kidnc\-  develojjs.  The 
most  common  malignant  growth  in  the  kidney  is  sarcoma,  which  is  by  no  means 
\ery  rare  in  young  children,  and  often  grows  to  a  very  great  size.  Sarcoma  of  the 
kidney  secondary  to  sarcoma  elsewhere  is  also  met  with  in  adults.  Endothelioma 
may  develop.  These  are  all  vascular  and  often  bleed,  producing  hematuria.  Ade- 
noma of  the  kidney  usually  springs  from  the  cortical  tissues,  but  it  may  grow  to  so 
large  a  size  that  it  takes  the  place  of  most  of  the  renal  tissue.  They  occur  frequently 
in  children  and  are  walled  off  from  the  rest  of  the  kidney  by  a  fibrous  sheath. 
Adenoma  is  found  in  two  forms,  the  papillary  and  ah-eolar.  Not  rarely  considerable 
areas  of  necrosis  develop  in  these  tumors.  Cancer  of  the  kidney  as  a  primary 
growth  is  rare.     As  a  secondary  growth  it  is  more  common. 

Of  all  the  tumors  att'ecting  the  kidney  those  arising  from  ectojiic  adrenal  tissue 
are  probably  the  most  frequent.  Such  tumors,  called  "hypernephromata,"  vary 
in  size  from  almost  microscopic  masses  to  growths  larger  than  an  adult  head. 
In  their  earlier  development  such  neoplasms  are  benign,  but  later  tend  to  involve 
adjacent  structures,  and  by  metastasis  the  lungs.  If  they  occur  on  the  right  side, 
the  liver  is  often  affected.  These  tumors  are  soft,  vascular,  yellowish,  or  IiIikhI- 
tinged  masses  developing  in  the  kidney,  and  often  cause  hematuria. 


NEPHROLITHIASIS 


G69 


The  symptoms  of  renal  tumor,  if  the  growth  is  benign,  are  not  marl<eci,  unless 
it  grows  large  enough  to  produce  pressure. 

When  the  tumor  is  malignant,  free  hematuria,  with  clots  moulded  to  the  shape 
of  the  ureter,  may  be  present.  Pain  develops  only  when  the  growth  presses  on 
neighboring  parts  or  on  adjacent  nerve 
trunks,  or  when  the  weight  of  the  growtii 
is  such  as  to  cause  a  sense  of  weight  in  the 
loin.  Severe  attacks  of  colicky  pain  may, 
however,  be  present  when  a  clot  is  being 
forced  through  the  ureter.  In  some  cases 
marked  loss  of  flesh  takes  place,  but  children 
with  renal  sarcoma  often  remain  remarkedly 
w^ell  nourished.  The  tumor,  if  large,  may 
project  well  forward  in  the  belly  and  give 
rise  to  the  belief  that  it  is  an  enlarged 
spleen  or  liver  (Fig.  117).  This  error  is 
frequently  made.  The  colon  may  give  tym- 
pany on  percussion  over  the  growth,  showing 
that  it  springs  from  behind  that  part  of  the 
bowel.  Sarcoma  of  the  kidney  must  be 
separated  from  sarcoma  of  the  retroperito- 
neal space.  Care  should  be  taken  that  it  is 
not  confused  with  cystic  kidney,  or  hydro- 
nephrosis, for  the  malignant  growth  may  be 
nodular  and  very  elastic,  or  even  give  a  sense 
of  fluctuation  on  palpation. 

There  is,  of  course,  no  medical  treatment, 
of  this  state.  In  some  cases  nephrectomy  of 
the  sarcomatous  kidney  has  been  performed 
in  young  children  with  good  results,  but 
there  is  usually  a  metastasis  elsewhere,  which 
ultimately  takes  life. 


NEPHROLITHIASIS. 


Definition. — This  condition  is  often  called 
"stone  in  the  kidney,"  or  "renal  calculus." 
It  is  due  to  the  formation  in  the  tissues  of 
the  kidney,  or  in  its  calyces  or  pelvis,  of  con- 
cretions composed  of  solids  derived  from  the 
urine. 

Etiology  and  Pathology. — The  concretions,  when  in  the  pelvis  of  the  kidney, 
may  be  single  or  multiple,  and  very  great  variations  in  their  size  maj'  be  met  with. 
In  some  instances  they  are  so  small  as  to  be  scarcely  larger  than  grains  of  sand; 
in  other  cases  they  may  be  as  large  as  a  pea  or  bean,  and  in  still  other  instances  a 
large  calculus  may  form  which  completely  fills  the  renal  pelvis  and  projects  itself 
into  the  ureter  and  into  the  calyces  and  infundibula,  forming  what  is  called  a 
"coral  calculus."  The  latter  form  is,  of  course,  never  passed  from  the  kidney,  but 
the  smaller  stones  often  become  engaged  in  the  ureter,  and  in  their  passage  through 
it  to  the  bladder  cause  intense  pain.  Not  rarely  the  fine  renal  sand  passes  so  readily 
that  it  attracts  no  attention  until  it  is  seen  in  the  urine. 

Not  only  are  concretions  found  in  the  calyces  and  pelvis,  but  also  in  the  tissues  of 
the  kidney.    Thus,  formations  of  uric  acid  may  take  place  in  the  tips  of  the  pyramids 


Sarcoma  of  the  right  kidney.  Tlie  dark 
line  on  the  abdomen  is  a  blue-pencil  outline 
of  the  tumor.     (Le  Conte.) 


670  DISEASES  OF  THE  KIDNEYS 

after  birth  and  cause  much  pain  in  tiie  first  month  of  life.  Again,  accumulations 
of  sodium  and  ammonium  urate  are  not  rarely  found  in  adults  at  tlie  tips  of  the 
pyramids,  particularly  in  gouty  invalids,  and  in  very  old  persons  a  deposit  of 
lime-salts  is  found  in  streaks  in  the  pyramids. 

The  concretions  just  spoken  of  may  he  formed  of  a  number  of  urinary  solids, 
such  as  uric  acid,  calcium  oxalate  or  phosphate,  urate  or  carbonate.  Cystin  and 
xanthin  also  are  ingredients.  The  mere  existence  of  these  substances  in  the  urine 
is  not  the  cause  of  the  formation  of  stone,  ho\ve\er,  for  if  this  were  true  everyone 
would  have  calculus.  There  are  at  least  two  additional  factors  present,  one  of 
which  is  the  presence  of  an  albuminoid  substance,  which  serves  to  glue  together 
tiny  particles  of  these  solids,  and  a  condition  in  which  there  is  an  abnormal  tendency 
to  crystallization  of  these  bodies.  The  bacterial  origin  of  gallstones  and  the 
presence  of  micro-organisms  in  the  nuclei  of  renal  calculi  suggest  a  similar  origin 
for  both. 

The  most  common  ingredient  of  stone  is  uric  acid  or  the  urates.  Stones  of 
this  character  are  met  with  in  people  who,  because  of  small  quantities  of  fluid 
ingested,  have  a  scanty  urinary  flow,  or  who,  by  reason  of  great  activity  of  the 
sweat  glands,  have  little  urine.  As  a  consequence  of  concentration  and  high 
activity  of  the  urine,  the  uric  acid  and  urates  are  readily  separated  in  solid  form 
and  held  together  by  the  albuminous  matrix.  Stones  of  this  character  are  quite 
hard,  and  their  surface  is  smooth  and  reddish. 

Phosphatic  calculi  are  of  the  most  common  occurrence  after  those  formed  from 
uric  acid  and  the  urates.  They  are  composed  of  calciiun  phosphate,  ammonio- 
magnesic  jihosphate,  or  both,  but  they  are  rarely  found  in  the  kidney,  being 
generally  developed  in  the  bladder.  They  are  usually  formed  when  the  urine  is 
persistently  ammoniacal. 

Next  to  phosphatic  calculi,  those  formed  of  calcium  oxalate  are  most  commonly 
met  with.  They  are  peculiar  in  respect  to  their  great  hardness  and  their  roughened 
surface  (mulberry  calculi).  Sometimes  when  they  are  small  they  are  smooth  and 
rounded,  "hemp-seed  calculi."  They  are  dark  in  hue  and  not  infrequently,  on 
being  split,  they  are  found  to  be  formed  about  a  nucleus  of  uric  acid.  Oxalate 
stones  are  only  met  with  in  those  who,  because  of  digestive  or  metabolic  disorders, 
pass  considerable  amounts  of  oxalates  in  the  urine. 

The  effects  of  the  presence  of  stone  in  the  renal  pelvis  are  not  always  marked. 
Indeed,  calculi  may  be  present  for  years  without  causing  any  discomfort  whatever. 
Sometimes  they  suddenly  cause  trouble  if  the  patient  suffers  from  a  fall  which 
causes  the  stone  to  damage  the  lining  membrane  of  the  pelvis,  and  as  a  result 
hematuria  may  ensue,  or  the  stone  may  be  started  from  its  nest,  and,  proceeding 
to  travel  down  the  ureter,  cause  an  attack  of  colic.  In  still  other  cases  the  stone 
may  cause  a  hydronephrosis  by  plugging  the  orifice  of  the  ureter.  Again,  the 
damage  done  by  the  sudden  movement  of  a  stone  against  the  tissues  may  open  a 
path  for  infection  and  consequent  pyelitis  or  even  pyelonephritis. 

Frequency. — In  certain  parts  of  the  world  stone  is  very  prevalent,  notably  in 
some  counties  in  England.  This  is  probably  due  to  certain  mineral  ingredients 
of  the  water  which  is  taken  for  drinking  purposes.  Stone  is  also  very  commonly 
met  with  in  China  and  in  India.  The  late  Dr.  Kerr,  a  Chinese  missionary,  removed 
hundreds  of  vesical  calculi  during  his  residence  in  China.  So  far  as  I  have  been 
able  to  discover,  stone  is  not  much  more  prevalent  in  one  part  of  the  United  States 
than  in  another. 

Prognosis. — The  prognosis  of  nephrolithiasis  depends  entirely  upon  the  question 
of  the  state  of  the  kidney  tissues  about  the  stone  or  stones.  In  many  cases  the 
stone  produces  no  trouble  for  years.  If,  as  the  result  of  an  injury  or  infection, 
the  surrounding  tissues  become  diseased,  the  state  of  the  patient  may  become 
serious  from  pain  or  from  sepsis. 


NEPHROUTHIASIS  671 

Symptoms. — As  just  stated,  stones  may  be  in  the  kidney  for  years  witJiout  cavsing 
any  signs.  When  they  escape  into  the  ureter  they  cause  renal  colic,  which  is  due 
to  three  causes:  first,  blocking  of  the  ureter  results  in  obstruction  to  urinary  flow 
which  causes  distention;  second,  the  pressure  of  the  urine  on  the  stone  forces  it 
forward  through  the  narrow  canal,  often  wounding  its  lining,  and,  finally,  the 
walls  of  the  ureter  are  spasmodically  contracted  because  of  the  presence  of  the 
stone.  The  pain  is  often  so  severe  as  to  be  a  horrible  agony.  I  have  seen  a  strong 
and  brave  man  grovel  on  the  floor  groaning  with  anguish,  and  vomiting  because 
of  its  severity.  The  pain  extends  into  the  -pelvis  and  the  inner  side  of  the  thigh  on 
the  affected  side,  and  even  into  the  testicle  and  penis.  It  also  radiates  into  the 
back  of  the  chest.  These  symptoms  may  persist  for  an  hour  or  for  several  hours. 
In  the  latter  instances  there  are  often  temporary  remissions  in  the  pain.  Not 
rarely  the  bladder  is  exceedingly  irritable,  and  the  patient  continually  passes  small 
quantities  of  urine  which  contains  traces  of  blood  from  the  affected  ureter,  but 
most  of  the  urine  comes  from  the  normal  side. 

In  cases  of  suspected  renal  calculus  the  urine  should  be  examined  microscopically 
for  blood  cells,  both  during  and  between  attacks.  They  are  practically  never 
absent  when  a  calculus  is  lodged  in  a  ureter. 

When  both  kidneys  are  affected,  total  suppression  of  urine  due  to  obstruction 
of  the  ureter  or  to  reflex  irritation  may  ensue,  and  the  resulting  toxemia  produce 
death.  It  is,  however,  a  noteworthy  fact  that  this  state  is  rarely  rapid  in  onset 
or  rapidly  fatal.  The  patient  often  lives  for  many  days,  unless  there  has  been 
renal  disease  present  for  some  time  with  some  degree  of  toxemia.  I  have  recently 
seen  a  case  in  consultation  in  which  no  urine  had  been  passed  for  a  week,  and  the 
catheter  obtained  nothing  from  the  bladder,  yet  the  patient  was  conscious  and 
alert  when  spoken  to,  appearing  drowsy  only  when  left  alone.  This  is  a  state  quite 
separate  from  ordinary  uremia,  and  has  been  called  "  latent  uremia."     (See  Uremia.) 

After  an  attack  of  renal  colic  has  passed,  pain  and  soreness  are  felt  for  some 
hours  or  days  in  the  affected  loin,  and  tenderness  on  pressure  may  be  elicited. 

Diagnosis. — The  pain  of  renal  colic  must  be  separated  from  that  of  acute  appen- 
dicitis, that  of  gallstone  colic,  and  from  neuralgia.  It  must  also  be  distinguished 
from  the  pain  due  to  hydronephrosis  resulting  from  a  twist  in  the  ureter.  Some- 
times a  diaphragmatic  pleurisy  may  mislead  us.  The  peculiar  radiation  of  the 
pain  into  the  groin,  penis,  and  inside  of  the  thigh  is  diagnostic.  The  pain  of  gall- 
stone is  radiated  into  the  back,  and  is  often  associated  with  jaundice.  Neuralgia 
does  not  cause  bloody  urine.  Twist  of  the  ureter  can  be  predicated  by  finding  a 
floating  kidney.  Pleurisy  is  defined  by  the  area  of  the  pain,  by  fixation  of  the 
diaphragm,  and  by  a  friction  sound  in  some  cases.  A  valuable,  but  by  no  means 
absolutely  reliable,  method  of  diagnosis  is  the  use  of  the  Roentgen  rays,  which 
may  or  may  not  reveal  a  stone,  and  which  sometimes  has  caused  the  surgeon  to 
operate  when  no  stone  has  been  found. 

Treatment. — The  treatment  of  nephrolothiasis  may  be  divided  into  two  parts: 
that  devoted  to  the  relief  of  the  patient  at  the  time  of  the  attack  of  renal  colic, 
and  that  devoted  to  the  prevention  of  the  formation  of  new  stones  or  an  increase 
in  the  size  of  those  already  present.  For  the  relief  of  the  attack  of  renal  colic, 
a  hypodermic  injection  of  J  grain  of  morphine,  with  y^^  grain  of  atropine,  should 
be  given  at  once;  or,  if  atropine  is  known  to  be  disagreeable  in  its  effects  upon 
the  patient,  nitroglycerin  may  be  used  hypodermically,  for  the  double  purpose 
of  aiding  in  relaxing  the  spasm  and  because  it  tends  to  prevent  the  after-disagreeable 
effects  of  the  opiate.  If  the  heart  is  in  a  satisfactory  condition,  chloroform  may 
be  given  by  inhalation,  and  if  the  patient  will  lie  quietly  enough  to  permit  it,  hot 
applications  may  be  made  over  the  painful  kidney. 

In  the  intervals  between  the  attacks  the  patient  should  be  instructed  to  drink 
large  quantities  of  some  pure  water  like  Poland  water,  or  one  of  the  Lithia  waters. 


672  DISEASES  OF  THE  KIDSEYS 

which  depend  chiefly  for  their  effects  upon  their  j)urity  rather  than  upon  their 
Hthia.  If  the  urine  is  aikahne,  lithia  is  contra-indicated,  and  under  these  circum- 
stances it  is  well  not  only  to  use  copious  drauf^hts  of  water,  hut  to  direct  the 
patient  to  take  uritone,  urotropin,  or  benzoate  of  ammonium,  for  the  purpose  of 
making  the  urine  acid. 

When  the  urine  is  excessively  acid,  it  is  advisal)lc  for  the  patient  not  only  to 
drink  large  quantities  of  water,  but  also  to  take  15  or  20  grains  of  bicarbonate  of 
potassium  three  or  four  times  a  day.  In  other  instances  the  citrate  of  potassium 
may  be  given.  vSometimes  good  results  follow  the  use  of  (clcstins  Vichy  water 
when  the  urine  is  acid.  If  an  examination  of  the  urine  reveals  the  presence  of 
a  large  number  of  urates,  it  must  be  borne  in  mind  that  these  have  their  origin 
in  disordered  gastro-intestinal  functions,  and  the  diet  must  be  carefully  regulated, 
and  nitromuriatic  acid  given  in  full  doses.  Sometimes,  too,  these  cases  are  benefited 
by  the  administration  of  such  intestinal  antiseptics  as  salol,  or  aspirin,  in  tlie  dose 
of  5  or  10  grains  three  times  a  day. 

The  patient  should  be  forbidden  to  drink  sny  sweet  wines  or  beer,  and  the  only 
form  of  alcoholic  stimulant  permitted  should  be  rye  or  Scotch  whiskey.  If  the 
patient  can  do  without  any  alcohol  f.t  all,  it  is  much  better  for  him  to  be  content 
with  non-alcoholic  drinks. 

If  the  patient  is  one  who  is  accustomed  to  leading  a  sedentary  life,  he  should 
be  instructed  that  an  amount  of  exercise  which  is  sufficient  to  produce  healthy 
fatigue  is  absolutely  essential;  but  if  he  exercises  he  should  also  drink  copiously 
of  water. 

When  pain  in  the  kidney  is  continuous  or  so  frequent  in  its  recurrence  that  the 
enjoyment  of  life  is  impaired,  or  if  there  is  any  evidence  of  the  tissues  of  the  pelvis 
of  the  kidney  or  of  the  kidney  itself  being  irritated  or  infected,  the  question  of 
operative  interference  must  be  carefully  considered,  and  the  patient  advised  to 
seek  surgical  relief. 

PERINEPHRIC  ABSCESS. 

An  abscess  sometimes  forms  around  the  kidney  by  the  extension  of  infection 
from  the  pelvis  of  this  organ,  because  of  transmitted  lymphatic  infection  from  a 
suppurative  appendicitis,  from  injury  to  the  tissues  by  a  blow  or  fall,  by  extension 
of  infection  from  spinal  disease,  from  perforation  of  the  stomach  or  bowel  followed 
by  subdiaphragmatic  abscess,  and  rarely  after  acute  infections  fevers,  as  typhoid 
fever.  The  pus  may  cause  pain  and  bulging  orcr  flic  kiilnei/;  it  may  burrow  upward, 
and  escape  into  the  thorax,  or  downward  and  resemble  a  psoas  abscess.  The  pus 
is  usually  very  foul  and  distinct  septic  symptoms  may  be  present.  On  the  other 
hand,  I  have  seen  at  least  two  cases  in  which  there  was  little  pain  and  no  fever. 
There  was  nothing  more  than  some  discomfort,  with  swelling,  over  the  kidney. 
Not  rarely  the  spine  is  fixed,  and  the  leg  on  the  afi'ected  side  is  drawn  up  when  the 
patient  lies  down. 

Treatment. — The  treatment  is,  of  course,  operative.  The  patient's  vitality 
should  be  supported  by  food  and  stimulants. 

DISORDERS  OF  URINARY  SECRETION. 

Anuria. — Anuria  is  a  condition  in  which  there  is  a  total  sujjpression  of  urine. 
It  arises  as  the  result  of  thrombosis  of  the  renal  vessels,  and  an  intense  acute  nephri- 
tis such  as  that  which  follows  the  ingestion  and  elimination  of  ver\'  irritant  poisons 
as  cantharides  and  turpentine.  Sometimes  complete  anuria  also  follows  the 
administration  of  ether  when  this  anesthetic  has  been  given  over  a  long  period 
of  time  and  in  too  large  quantities.  It  is  particularly  prone  to  occur  if  the  kidneys 
are  already  in  a  state  of  irritation.     In  other  instances  total  suppression  of  urine 


DISORDERS  OF   URINARY  SECRETION  07:} 

results,  reflexly,  from  the  irritation  produced  by  nephrolithiasis.  In  most  instances 
when  this  occurs  both  kidneys  are  affected.  Partial  or  complete  anuria  also 
sometimes  occurs  after  operations  upon  the  genito-urinary  tract.  A  careful  distmc- 
tion  should  be  made  between  anuria  when  no  urine  is  secreted  and  retention  of 
urine  in  which  no  urine  is  passed,  but  in  which  the  bladder  is  found  to  be  well  filled. 

Treatment. — The  treatment  of  anuria  varies  somewhat  with  the  cause.  When 
the  arrest  of  secretion  is  due  to  the  presence  of  stone,  an  operation  is  theoretically 
demanded,  but  usually  the  diagnosis  as  to  the  cause  is  not  completed  before  the 
patient's  condition  has  become  so  grave  that  operative  interference  is  of  questionable 
propriety.  When  the  suppression  of  secretion  is  not  due  to  stone,  but  to  reflex 
irritation  or  spasm  of  the  renal  vessels,  I  have  known  full  doses  of  nitroglycerin 
given  every  three  or  four  hours,  hypodermically,  to  relax  the  bloodvessels  and 
cause  free  urinary  flow.  This  is  particularly  apt  to  occur  if,  simultaneously,  the 
patient  receives  a  large  injection  of  cool  water  by  the  bowel.  If  saline  solution 
is  used,  care  should  be  taken  that  it  is  not  of  more  than  0.6  per  cent,  strength,  since 
strong  saline  solutions  abstract  liquids  from  the  tissues  instead  of  being  absorbed. 
In  these  instances  our  desire  is  that  fluid  shall  enter  the  tissues,  find  its  way  to  the 
bloodvessels  and  so  flush  the  kidneys.  Usually  about  one  quart  of  liquid  should 
be  given  by  gentle  hydrostatic  pressure.  Hot  compresses,  or  poultices,  may  be 
laid  across  the  loins,  and  if  there  is  any  reason  to  believe  that  renal  congestion  is 
present,  three  or  four  dry  or  wet  cups  may  be  applied  over  each  kidney.  In  some 
instances  moderate  doses  of  the  bromides  and  the  vegetable  salts  of  potash,  like 
the  citrate,  are  advisable.  If  the  heart  is  strong  the  patient  may  be  subjected  to  a 
hot  pack  or  may  be  given  a  Turkish  bath  by  elevating  the  bedclothes  and  allowing 
hot  air  to  surround  his  body.  Small  doses  of  pilocarpine  may  be  given  as  a  diuretic, 
particularly  if  the  heart  is  guarded  by  strychnine.  The  difficulty  in  using  large 
doses  of  pilocarpine  is  that  it  is  prone  to  produce  pulmonary  edema. 

Hematuria. — Bloody  urine,  or  hematuria,  is  a  condition  in  which  there  is  found 
in  the  urine  not  only  the  coloring  matter  of  the  blood,  but  red  blood  corpuscles 
as  well.  It  sometimes  occurs  with  the  stage  of  onset  in  acute  fevers  and  in  certain 
cases  of  leukemia.  It  is  also  met  with  in  certain  forms  of  malarial  infection  of  the 
estivo-autumnal  type,  and  in  cases  of  infarction  of  the  kidney  arising  during  an 
attack  of  endocarditis  or  from  other  causes.  Hematuria  is  a  prominent  symptom 
in  renal  tuberculosis.  (See  Tuberculosis).  When  there  is  stone  in  the  pelvis 
of  the  kidney  or  any  part  of  the  conducting  tract,  and  the  patient  is  jarred  or  jolted, 
the  stone  may  cause  sufficient  local  damage  to  produce  bloody  urine.  Parasites 
such  as  the  Filaria  sanguinus  hominis  and  the  Bilharzia  may  produce  the  same 
condition.  Blood  also  appears  in  the  urine  as  the  result  of  papilloma,  cancer, 
or  other  neoplasm  of  the  bladder,  ureter,  renal  pelvis,  or  kidney,  ulceration  of  the 
urethra,  and  of  injuries  to  the  genito-urinary  tract  by  falls  or  blows.  Sometimes, 
too,  it  develops  in  the  course  of  scurvy  and  purpura  hemorrhagica.  In  acute, 
and  even  in  chronic  parenchymatous  nephritis,  the  urine  sometimes  contains 
small  amounts  of  blood,  but  they  are  visible  only  under  the  microscope. 

The  appearance  of  the  urine  when  it  contains  blood  is  quite  characteristic. 
It  is  not  only  dark  red  in  hue,  but  it  is  opaque  and  contains  considerable  sediment, 
which  is  chiefly  composed  of  fibrin  and  blood  corpuscles.  In  pure  renal  hematuria 
the  voided  urine  is  more  of  a  smoky  hue,  the  red  cells  are  of  the  shadow  or  phantom 
type  and  clots  are  rarely  if  ever  present.  If  the  urine  is  very  alkaline,  the  red 
blood  corpuscles  may  be  dissolved  rapidly  or  become  colorless  and  difficult  to  see. 
Clots  formed  before  the  urine  is  passed  nearly  always  arise  from  hemorrhage  in  the 
bladder,  but  occasionally  moulds  of  the  ureters  may  appear.  An  examination 
by  means  of  the  cystoscope  or  urethroscope  may  be  necessary  to  determine  the 
source  of  the  hemorrhage,  and  if  the  blood  comes  from  the  kidney  it  may  be  neces- 
sary to  catheterize  the  ureters  to  determine  which  kidney  is  damaged. 
43 


(174  mSk'ASKS  OF   Till':   KIDXKYS 

There  are  occasional  instances  of  liematuria  in  which,  even  at  autopsy,  no 
sufficient  cause  can  be  found.  These  include  the  angioneurotic  hematuria  of 
KIcmpcrcr,  the  renal  hemophilia  of  Senator,  and  Gull's  "renal  epistaxis." 

Treatment. — Treatment  of  hematuria  depends  largely  upon  its  cause.  The 
patient  should  be  put  absolutely  at  rest.  If  the  blood  comes  from  the  kidney 
there  is  no  treatment  which  can  be  relied  upon  as  being  efficacious,  ("hloridc 
of  calcium  in  the  dose  of  5  grains  three  or  four  times  a  day  may  be  given  well  diluted 
with  water  to  increase  the  coagulability  of  the  blood.  Gallic  acid,  tannic  acid, 
and  sulphuric  acid  have  been  largely  used  by  some  practitioners,  but  it  is  doubtful 
if  they  really  exercise  any  definite  influence.  If  any  one  of  them  does  act  as  a 
styptic  it  is  probably  sulphuric  acid.  Ten  drops  of  the  aromatic  acid  may  be 
given  every  three  or  four  hours,  well  diluted,  and  counter-irritation  may  be  applied 
in  the  shape  of  cups  or  hot  compresses  over  the  kidneys.  Counter-irritants  like 
mustard,  turpentine,  and  cantharides  should  be  avoided,  as  they  may  be  absorbed 
and  increase  renal  irritation.  The  patient  should  be  protected  from  cold.  If  the 
hemorrhage  comes  from  the  bladder,  an  injection  of  a  pint  of  normal  salt  solution 
containing  |  to  1  ounce  of  adrenalin  chloride  solution  1: 1000  should  be  injected. 

When  the  hemorrhage  comes  from  the  urethra  a  similar  plan  of  treatment  can 
be  resorted  to,  simply  instilling  the  adrenalin  into  the  portion  of  the  urethra  v\hich 
is  bleeding.  The  objection  to  the  use  of  substances  which  cause  a  coagulation 
of  the  blood  is  that  they  produce  clots,  which  may  become  septic  or  give  rise  to 
obstruction. 

Hemoglobinuria. — In  all  probability  hemoglobinuria  occurs  most  frequently 
as  a  complication  of  malarial  infection.  There  is  much  doubt  as  to  the  actual 
cause  of  this  condition.  In  some  instances  it  is  probably  due  to  the  destructive 
action  of  the  malarial  parasite  on  the  blood,  but  it  would  seem  probable  that  in 
other  instances  it  is  due  to  an  associated  infection  or  a  condition  which  quinine 
cannot  be  expected  to  remedy.  Indeed,  a  large  number  of  cases  are  now  on  record 
in  which  the  administration  of  quinine  has  been  followed  by  hemoglobinuria  or 
hematuria.  This  condition  is  to  be  distinctly  separated  from  hematuria,  for  in 
this  case  no  blood  corpuscles  are  present,  but  only  the  hemoglobin  or  coloring 
matter  of  the  blood.  Its  presence  does  not  indicate  any  lesion  in  the  genito-urinary 
tract.  Strictly  speaking  true  hemoglobinuria  is  not  present,  but  methemoglobin- 
uria.  The  urine  is  clear,  but  may  be  quite  dark  in  hue,  and  deposits  on  standing 
a  heavy,  reddish-brown  sediment.     It  usually  gives  the  reaction  for  albumin. 

Hemoglobinuria  arises  from  the  ingestion  of  a  large  number  of  poisons,  such  as 
poisonous  mushrooms,  chlorate  of  potash,  pyrogallic  acid,  and  some  of  the  coal-tar 
products.  Not  long  since  I  had  under  my  care  a  physician  who  suffered  from 
repeated  attacks  of  hemoglobinuria  whenever  he  tinkered  with  his  automobile, 
which  was  stored  in  a  small,  tightly  closed  shed  in  which  the  fumes  of  gasoline 
were  quite  concentrated.  He  never  suffered  with  hemoglobinuria  before  these 
exposures,  and  since  avoiding  them  has  had  no  return  of  his  trouble.  Hemoglobin- 
uria sometimes  follows  severe  burns.  It  may  also  develop  in  Raynaud's  disease. 
The  discoloration  of  the  urine  produced  by  carbolic  acid  is  not  due  to  hemoglobin- 
uria, but  to  a  dark,  oxidized  educt,  which  is  in  part  hydrochinon. 

Hem.vtinuria.  Under  the  name  of  proxj'smal  hematinuria,  sometimes  called 
hemoglohimiric  afrigore,  a  condition  rarely  occurs  in  which  the  urine  varies  in  color 
from  a  port-wine  to  a  chocolate-brown,  or  almost  black  hue,  the  alteration  in  its 
appearance  lasting,  however,  for  but  a  few  hours.  Its  specific  gravity  usually 
ranges  from  1.025  to  1.027.  The  urea  is  increased.  The  quantity  of  blood  which 
is  represented  has  been  estimated  as  equivalent  to  from  seven  to  twelve  parts  in 
one  hundred  of  urine.  Blood  corpuscles  are  very  rarely  foimd  in  the  fluid.  The 
urine  not  only  contains  hemoglobin,  but  considerable  quantities  of  albumin  and 
globulin.     Not  infrequently  hyaline  and  granular  casts  are  present.     This  condition 


DISORDERS  OF   URINARY  SECRETION  675 

is  chiefly  larovol-ced,  apparently,  by  exposure  to  cold — that  is,  by  chilling  of  the 
surface  of  the  body.  Aside  from  exposure  to  cold  and  chilling  of  the  surface  of 
the  body,  severe  muscular  exercise  seems  to  be  a  causative  factor,  and  not  infre- 
quently there  is  also  a  tendency  to  vasomotor  disorders.  Indeed,  it  is  probable 
that  a  large  part  of  the  disorder  lies  in  an  abnormal  vasomotor  condition.  Gilman 
Thompson  has  reported  two  typical  cases  and  summarized  the  literature.  It 
appears  that  during  the  past  forty  years  only  20G  cases  have  been  reported,  and 
that  most  of  these  have  appeared  in  England,  Germany,  and  France,  and  that 
very  few  indeed  have  been  reported  as  occurring  in  the  United  States  and  Canada. 
The  condition  affects  males  very  much  more  frequently  than  females,  there  being 
only  about  4  per  cent,  of  females  in  the  20G  cases  so  far  reported.  The  period  of 
life  at  which  it  commonly  occurs  is  between  thirty  and  forty  years,  but  cases  have 
been  reported  as  late  as  the  sixty-fourth  year.  At  the  time  of  the  attack  there  is 
usually  a  sharp  rise  of  temperature,  amounting  to  102°  or  103°,  but  this  falls  to 
normal  almost  as  rapidly  as  it  rises,  the  febrile  period  lasting  only  a  few  hours. 
Chills  are  often  present,  and  may  be  the  first  symptom  of  the  attack.  Jaundice, 
which  is  hematogenous  in  origin,  develops.  Some  persons  have  thought  that  the 
jaundice  is  hepatogenous,  but  this  is  unlikely  in  view  of  the  fact  that  the  urine  is 
not  bile-stained  and  the  stools  are  not  lacking  in  bile. 

Paroxysmal  hemoglobinuria  is  to  be  separated  from  the  hemoglobinuria  met 
with  in  some  cases  of  malaria  by  the  fact  that  the  latter  is  a  disease  of  tropical 
or  semitropical  regions,  whereas  paroxysmal  hematuria  usually  occurs  in  cold 
climates.     In  one  case  the  malarial  organism  is  present  and  in  the  other  it  is  absent. 

Paroxysmal  hematuria  is  also  associated  with  a  neurotic  condition,  with  urticaria 
and  with  localized  areas  of  cyanosis.  A  number  of  investigators  have  advanced 
the  theory  that  hemoglobinuria  is  due  to  the  presence  in  the  blood  of  a  hemolytic 
substance  which  acts  only  when  the  temperature  is  lowered  below  normal,  an 
intermediary  body  activated  by  a  complemental  bodj'. 

Treatment. — The  treatment  of  hemoglobinuria  consists  in  avoidance  of  exposure 
to  cold  and  to  causes  which  produce  nervous  excitement.  Tj'son  has  suggested  the 
use  of  suprarenal  gland;  Thompson  suggests  the  use  of  thyroid  extract;  Saundby 
commends  calcium  chloride;  and  Chvostek  believes  that  inhalations  of  nitrite  of 
amyl  may  be  useful  to  abort  an  attack.  If  the  circulation  is  feeble,  rapidly 
acting  diffusible  stimulants  like  Hoffmann's  anodyne,  aromatic  spirit  of  ammonia, 
and  small  doses  of  spirit  of  chloroform  are  advantageous. 

The  treatment  of  hemoglobinuria  cannot  be  direct.  Copious  draughts  of  water 
to  flush  the  kidneys,  careful  attention  to  the  state  of  the  bowels,  protection  from 
exposure  of  the  surface  of  the  body  to  cold,  and  the  use  of  foods  which  are  not 
highly  seasoned  and  irritating  to  the  liver  and  the  kidneys  are  the  only  measures 
which  the  physician  can  institute.  When  the  cause  of  the  condition  is  malaria 
the  debatable  question  of  administering  quinine  must  be  discussed  and  decided. 
(See  Treatment  of  Malarial  Fever.) 

Albuminuria. — Albuminuria  is  a  term  applied  to  a  condition  of  the  urine  in 
which  serum  albumin,  serum  globulin,  and,  by  some  writers,  other  urinary  proteids, 
including  nucleo-albumin,  albumose,  peptone,  or  fibrin  is  found  in  it.  While  it  is 
true  that  delicate  chemical  tests  will  frequently  reveal  traces  of  albumin  in  the 
urine,  it  is  also  a  fact  that  any  quantities  which  can  be  appreciated  by  the  use  of 
heat  and  nitric  acid  or  by  the  potassium  ferrocyanide  or  mercuric  iodide  tests  are 
to  be  regarded  as  abnormal. 

As  albumin  is  a  colloid  substance  and  therefore  does  not  readily  diffuse  through 
animal  membranes  it  does  not  pass  through  the  bloodvessels  of  the  kidneys  and 
renal  tubules  unless  these  structures  have  undergone  some  degenerative  change, 
or  are  subjected  to  a  pressure  which  they  cannot  withstand.  Sometimes,  too, 
albuminuria  may  be  due  to  changes  in  the  blood  itself,  whereby  its  albuminous 


676  DISEASES  OF  THE  K/DXEYS 

intjredicnts  are  altered  or  the  renal  texture  is  secondarily  afVected.  The  presence 
of  albumin  in  the  urine  when  disease  of  the  conducting  apparatus  can  be  excluded 
(accidental  albuminuria  may  occur  through  contamination  of  the  urine  by  vaginal 
discharges)  is  therefore  indicative  in  the  vast  majority  of  instances  of  some  renal 
lesion,  and  as  chronic  parenchymatous  nephritis  and  chronic  interstitial  nephritis 
are  the  most  common  renal  diseases,  it  is  usually  iuflicative  of  one  of  these  maladies 
or  of  a  subacute  nephritis  complicating  one  of  the  acute  infectious  diseases.  Twenty 
years  ago  albuminuria  was  considered  as  pathognomonic  of  Bright's  disease.  We 
now  know  that  albumin  often  appears  in  the  urine  when  Bright's  disease  is  not 
present. 

As  a  general  rule  it  may  be  stated  that  the  quantity  of  albumin  is  in  direct  ratio 
to  the  severity  of  the  renal  lesion,  but  there  are  certain  notable  exceptions  to  this, 
as  in  the  case  of  chronic  contracted  kidney,  in  which  disease  the  kidney  is  seriously 
affected,  yet  the  albumin  is  always  in  small  c)uantity  and  may  be  absent  at  times. 

Albuminuria  is  not  rarely  met  with  in  cases  of  congestion  of  the  kidney  due  to 
cardiac  failure.  Under  these  circumstances  the  cjuantity  of  albumin  present  may 
be  very  large,  almost  as  great  as  that  which  is  found  in  chronic  parenchymatous 
nephritis.  It  is  due  under  these  circumstances  to  a  structural  and  probably 
nutritive  alteration  brought  about  by  passive  renal  congestion,  and  the  use  of 
cardiac  stimulants  usually  results  in  its  disappearance,  at  least  to  some  degree. 
So,  too,  albuminuria  may  develop  in  certain  persons  after  severe  and  prolonged 
exercise,  as  in  soldiers  after  a  long  march,  or  in  athletes  after  a  long  run.  One 
cause  of  this,  at  least,  is  feebleness  of  the  heart  from  exhaustion. 

In  still  other  cases  what  is  known  as  "Cyclic  Albuminuria"  comes  on,  which 
is  sometimes  due  to  exposure  to  cold,  and  at  other  times  seems  causeless.  Cyclic 
albuminuria  is  sometimes  called  the  "albuminuria  of  adolescence,"  and  is,  as  its 
name  implies,  intermittent  and  is  usually  not  present  when  the  patient  rises  in 
the  morning,  but  appears  as  the  day  progresses.  The  upright  posture  is  in  some 
cases  sufficient  to  induce  the  condition — "orthostatic"  albuminuria.  Usually 
the  urine  is  above  the  normal  specific  gravity  and  contains  no  casts.  As  its  name 
indicates,  it  occurs  at  puberty,  in  easily  fatigued,  overgrown,  pallid  children.  It 
usually  disappears  when  puberty  is  passed  and  the  system  is  established  on  an 
adult  basis. 

In  certain  persons  the  ingestion  of  excessive  quantities  of  albumin  in  food  also 
produces  albuminuria. 

A  very  high  arterial  tension  due  to  cardiovascular  disease  may  also  cause  this 
symptom.  While  it  is  true  that  the  cardiovascular  disease  usually  results  in 
some  impairment  of  the  kidney,  it  is  also  a  fact  that  reducing  arterial  pressure  in 
these  cases  by  the  use  of  nitroglycerin  often  stops  the  albumiiuiria. 

Albuminuria  may  be  due,  as  already  stated,  to  changes  in  the  condition  of  the 
blood  itself,  met  with  in  certain  cases  of  anemia,  and  in  diseases  like  purpura, 
scurvy,  and  other  conditions  which  cause  marked  changes  in  the  circulating  fluid. 

Tests. — Albumin  is  best  detected  in  the  urine  by  the  general  practitioner  by 
the  use  of  the  so-called  heat  and  nitric  acid  tests,  which  may  be  used  separately 
or  in  conjunction.  A  test-tube  is  two-thirds  filled  with  urine,  which  if  cloudy 
should  be  filtered,  and  if  alkaline  acidified,  and  the  ui)j)er  part  of  it  is  held  over  a 
lighted  alcohol  lamp  so  that  tlic  fluid  in  tliis  portion  of  tlie  tulie  soon  boils.  Under 
these  circumstances  if  all)umin  is  present  the  upper  portion  of  the  urine  becomes 
clouded  from  coagulated  albumin,  but  the  portion  below  remains  clear  until  the 
coagulated  albumin  is  precipitated.  If  earthy  jihosphates  are  present  some  cloudi- 
ness of  the  fluid  develops,  but  the  addition  of  a  few  drops  of  nitric  acid  disperses 
the  cloud  if  it  is  due  to  the  phosphates,  but  does  not  do  so  if  it  is  due  to  albumin. 
IMany  physicians  use  a  somewhat  less  accurate  test,  which  consists  in  placing 
5   to   1    drachm  of  nitric  acid  in  a  test-tube,   and  allowing  an  equal  quantity 


DISORDERS  OF   URINARY  SECRETION  077 

of  urine  to  trickle  down  the  side  of  the  tube  so  that  it  overlies  the  acid.  If  alhumiii 
is  present  a  layer  of  albumin  appears  at  the  point  of  juncture  of  the  two  fluids. 
Sometimes,  if  marked  intestinal  putrefaction  is  present,  a  reddish-brown,  but 
transparent  zone,  appears  at  this  level  also. 

For  the  purpose  of  making  a  delicate  test  the  potassium  ferrocyanide  method 
may  be  employed.  The  writer  has  found  it  most  convenient  to  use  for  this  purpose 
the  so-called  urinary  test  tablets  which  are  now  placed  upon  the  market.  Into 
30  minims  of  urine  is  placed  a  citric  acid  tablet  for  the  purpose  of  acidification. 
To  this  is  then  added  a  tablet  of  potassium  ferrocyanide,  and  the  tube  is  shaken 
or  allowed  to  stand  still  until  both  tablets  are  completely  dissolved,  when  if  albumin 
is  present  tiny  flocculi  may  be  seen  floating  in  the  fluid,  which  settle  to  the  bottom 
of  the  test-tube  when  it  is  placed  at  rest.  This  is  a  delicate  test  for  albumin,  and 
has  the  advantage  that  it  does  not  precipitate  mucin,  peptones,  phosphates,  urates, 
or  vegetable  alkaloids.  If  the  physician  does  not  wish  to  use  these  tablets,  he  may 
add  to  a  test-tube  half-full  of  urine  5  or  6  c.c.  of  a  freshly  prepared  solution  of 
potassium  ferrocj'anide  of  the  strength  of  one  in  twenty,  adding  10  to  15  drops  of 
acetic  acid.  In  other  instances  the  physician  may,  if  he  chooses,  employ  potassio- 
mercuric  iodide  test  tablets  in  the  same  manner,  with  equally  good  results.  When 
the  potassium  mercuric  iodide  acid  test  is  used,  the  cloudiness  due  to  albumin 
does  not  break  up  into  flocculi,  as  it  does  when  potassium  ferrocyanide  is  employed. 

The  following  facts  in  regard  to  these  tests  should  be  remembered.  If  the 
specimen  of  urine  is  very  alkaline,  more  than  one  citric  acid  tablet,  or  an  extra 
quantity  of  acid  solution  should  be  added.  If  cloudiness  is  produced  by  the  acid, 
it  is  due  to  mucin,  uric  acid,  or  some  oleoresin,  as,  for  example,  when  copaiba  or 
cubebs  have  been  taken  internally.  If  the  urine  is  warmed  the  urates  dissolve, 
but  the  mucin  remains.  The  precipitate  produced  by  the  oleoresins  clears  up 
by  boiling,  but  returns  as  soon  as  the  urine  cools  slightly,  ^^'hen  the  tablet,  or 
solution,  of  potassium  mercuric  iodide  or  potassium  ferrocyanide  is  added  to  the 
acidulated  urine,  and  cloudiness  is  produced,  the  urine  must  be  heated.  If  the 
reaction  is  due  to  albumin  the  precipitate  remains  undissolved,  but  if  it  clears  up 
it  may  consist  of  peptones  or  derivatives  of  vegetable  alkaloids  if  the  mercury  test 
has  been  employed.  When  the  potassium  ferrocyanide  test  is  used  peptones 
are  not  precipitated,  and  may  therefore  be  excluded. 

For  the  quantitative  estimation  of  albumin  Esbach's  method  is  most  commonly 
employed.  It  consists  in  using  a  graduated  test-tube  which  is  called  an  albumino- 
meter.  This  test-tube  is  marked  with  the  letter  "U,"  and  higher  up  with  the 
letter  "R";  below  the  letter  "U"  are  graduate  lines  from  1  to  7.  Urine  is  placed 
in  the  tube  to  the  level  of  the  letter  "U,"  and  the  following  solution  is  then  added 
until  the  fluid  in  the  tube  reaches  the  letter  "R."  The  solution  used  consists  of 
10  grams  of  picric  acid;  20  grams  of  citric  acid;  1000  c.c.  of  distilled  water.  The 
tube  is  now  corked  and  inverted  several  times  until  the  test  solution  and  the  lu-ine 
are  completely  mixed.  It  is  then  allowed  to  stand  on  a  rack  in  a  perpendicular 
position  for  twenty-four  hours.  At  the  expiration  of  the  twenty-four  hours  the 
albumin  is  found  to  be  at  the  level  of  one  of  the  numbers  cut  on  the  side  of  the 
tube,  and  this  represents  the  number  of  grams  of  albumin  per  litre.  If  it  is  desired 
to  know  the  percentage  of  albumin,  a  decimal  point  is  placed  in  front  of  the  figure. 
In  cases  where  the  quantity  of  albumin  is  so  great  that  it  cannot  be  measured 
by  the  ordinary  Esbach  tube,  the  urine  should  be  diluted  with  water,  and  the  result 
in  grams  multiplied  by  the  number  of  times  the  urine  has  been  diluted. 

There  is  no  excuse  for  neglecting  examination  of  the  urine  for  albumin.  In 
the  absence  of  other  apparatus  and  reagents  the  urine  may  be  acidified  with  vinegar, 
boiled  in  a  spoon  or  cup,  and  if  necessary  poured  into  a  glass  for  inspection. 

From  what  has  been  said  it  must  be  evident  that  the  significance  of  albuminuria 
varies.     Usually,  except  in  the  case  of  chronic  interstitial  nephritis,  its  importance 


678  DISEASES  OF  THE  KIDNEYS 

from  a  prognostic  standpoint  is  in  direct  relation  to  its  quantity;  its  cause  is  also 
an  important  factor  concerning  prognosis.  The  presence  of  tube  casts  with  the 
albumin  is  also  of  great  importance,  particularly  if  these  tube  casts  arc  granular 
and  contain  fatty  globules.  Tube  casts  should  always  be  sought  for  in  tiie  urine, 
if  need  be  with  the  aid  of  the  centrifuge,  but,  on  the  other  hand,  it  should  be  remem- 
bered that  if  the  centrifuge  is  thoroughly  employed,  there  are  few  specimens  of 
urine  which  will  not  reveal  an  occasional  cast. 

No  one  perhaps  has  studied  more  carefully  than  has  Leube  tliis  question  of 
albuminuria.  His  view  is  that  while  in  many  cases  physiological  albuminuria 
does  occur,  particularly  after  severe  exercise,  we  should  nevertheless  regard  all 
such  instances  with  suspicion.  Washburn,  in  studying  the  records  of  life  insurance 
cases  who  were  supposed  to  have  physiological  albuminuria,  found  that  the  death 
rate  among  them  was  17.5  per  cent,  instead  of  9  per  cent.,  as  it  should  have  been. 

A  careful  study  must  be  made  of  the  heart,  kidney,  lungs,  and  other  organs 
before  the  patient  is  given  a  favorable  prognosis. 

Wright  and  Ross  have  shown  that  it  is  sometimes  possible  to  differentiate  the 
albuminuria  of  renal  disease  and  phj'siological  albuminuria  by  increasing  the  coagu- 
lability of  the  blood  through  the  use  of  calcium  lactate.  (For  dose  see  article  on 
Purpura.)  If  the  use  of  this  drug  arrests  the  albuminuria  it  does  not  depend  upon 
actual  renal  disease. 

While  casts  may  be  present  in  the  lu-ine  of  patients  who  are  thought  to  be  healthy, 
but  who  have  albuminuria,  these  casts  should  disappear  if  the  patient  rests  in  bed, 
and  they  should  not  be  epithelial  casts.  If  they  are  present,  then  it  is  not  physio- 
logical albuminuria.  It  is  perhaps  best  to  say  that  albuminuria  ought  not  be 
present,  and  that  its  existence  at  least  excites  suspicion  of  some  renal  change. 
But  it  does  not  necessarily  mean  Bright's  disease,  and  I  have  seen  more  than  one 
case  in  which  distinct  albuminuria  was  present  without  the  association  of  casts 
for  more  than  fifteen  years. 

Psmria. — Pus  in  the  urine  may  arise  from  pyelitis,  pyelonephritis,  cystiti", 
urethritis,  vaginitis,  or  the  rupture  of  an  abscess  into  the  urinary  passages  from 
contiguous  parts.  When  pus  is  in  urine,  it  gives  it  a  peculiar  opacity,  and  on 
sedimentation  the  bottom  of  the  vessel  contains  a  somewhat  ropy  mass,  presenting 
a  wavy  surface.  It  is  to  be  distinguished  from  the  phosphatic  deposits  mixed  with 
mucus  by  the  fact  that  it  is  not  so  white,  and  does  not  so  closely  resemble  white  or 
pinkish  powdered  chalk.  Further  than  this,  the  phosphates  are  usually  cleared  up 
by  boiling  or  by  the  addition  of  acid,  but  urine  containing  pus  is  not  so  altered. 

The  treatment  of  pyuria  depends  upon  the  cause  of  the  presence  of  pus.  If 
there  is  an  abscess  in  the  kidney  surgical  measures  are  required,  but  if  the  pus  is 
due  to  a  pyelitis  or  cystitis  the  use  of  substances  which  exercise  a  mild  antiseptic 
influence  is  to  be  resorted  to,  at  least  for  a  time.  For  this  purpose  the  patient 
may  receive  10  grains  of  uritone  or  urotropin  three  times  a  day  in  sparkling  water, 
or  10  grains  of  benzoate  of  ammonium  three  times  a  day  in  capsule.  For  the 
methods  and  drugs  to  be  employed  for  irrigating  the  bladder  the  reader  is  referred 
to  works  on  genito-urinary  diseases. 

Chyluria. — Chyluria  is  a  condition  in  which  the  urine  presents  a  milky  appear- 
ance owing  to  an  admixture  of  fat.  It  may  occur  in  some  cases  of  pregnancy  and 
during  lactation.  In  other  instances  it  follows  injury  to  the  lymphatics  of  the 
abdominal  cavity.  The  most  common  form  of  chyluria  is  that  which  comes  on  as  a 
complication  or  symptom  of  infection  by  the  parasite  Filoria  sanguinis  hominis. 
This  condition,  as  pointed  out  elsewhere,  is  met  with  most  commonly  in  India, 
China,  and  in  the  Straits  Settlements,  and  its  cause  is  the  obstruction  of  the  lym- 
phatics produced  by  the  presence  of  the  parasites  within  them.  Xot  rarely  urine, 
when  chylous,  coagulates  in  the  vessel  holding  it  or  becomes  gelatinous  in 
appearance. 


DISORDERS  OF   URINARY  SECRETIONS  679 

Phosphaturia. — ^This  term  is  applied  to  a  condition  of  the  urine  in  which  it 
contains  an  excess  of  phosphates  and  is  supposed  by  some  to  be  associated  with 
unusual  activity  of  the  nervous  system,  particularly  in  connection  with  that  degree 
of  excessive  nervous  strain  which  is  often  productive  of  neurasthenia,  ^\hethe^ 
this  view  is  correct  is  debatable.  There  can,  however,  be  no  doubt  of  the  fact 
that  in  certain  of  the  diseases  characterized  by  great  loss  of  flesh,  such  as  tubercu- 
losis, an  excess  of  phosphates  is  present  in  the  urine.  Such  a  condition  also  arises 
in  acute  atrophy  of  the  liver  and  in  certain  forms  of  grave  anemia.  On  the  other 
hand,  acute  diseases  running  a  febrile  course,  and  supposed  to  be  characterized 
by  a  great  amount  of  tissue  breakdown,  are  not  accompanied  by  this  manifestation. 
In  some  instances  in  which  there  is  an  excess  of  phosphates  present  in  the  urine 
the  patient  is  also  diabetic,  and  in  still  others  the  patient,  while  suffering  from 
polyuria  and  phosphaturia,  and  who  has  such  diabetic  symptoms  as  thirst  and  loss 
of  flesh,  nevertheless  does  not  develop  a  glj'cosuria,  sugar  being  constantly  absent. 
It  has  been  thought  by  some  that  these  cases  of  so-called  "phosphatic  diabetes" 
represent  an  early  stage  of  true  diabetes,  for  in  some  of  them  glycosiu-ia  ultimately 
develops. 

The  best  remedy  for  the  purpose  of  cleaning  the  urine  of  an  excess  of  phosphates 
is  benzoate  of  ammonium  in  doses  of  10  to  20  grains  three  times  a  day. 

Oxaluria. — Oxaluria  consists  in  a  condition  in  which  urine  of  high  specific  grav- 
ity contains  on  standing,  when  decomposition  is  absent,  an  excess  of  calcium  oxalate 
crystals.  The  condition  is  an  important  one  in  that  it  frequently  points  the  way 
to  the  correct  diagnosis  and  treatment  of  patients  who  are  suffering  from  dyspepsia, 
nervous  irritability,  melancholy,  and  mental  depression  with  a  general  condition 
of  wretchedness.  It  is  said  to  be  present  in  those  cases  in  which  there  is  lack  of 
free  hydrochloric  acid  in  the  secretion  of  the  stomach.  It  also  develops  in  patients 
who  eat  pears,  cabbage,  tomatoes,  and,  occasionally,  in  those  who  take  coffee  to 
excess.  In  many  patients  it  is  an  evidence  of  faulty  metabolism  due  to  lack  of 
fresh  air  and  exercise.  The  condition  is  of  interest  from  a  therapeutic  standpoint 
because  of  the  fact  that  these  patients  often  gain  great  benefit  if  they  ^ecei^'e 
moderate  doses  of  nitrohydrochloric  acid  and  take  a  fair  amount  of  physical  exercise 
and  lead  an  out-door  life. 

Indicanuria. — Traces  of  indican,  or,  to  speak  more  correctly,  indoxjd  sulphate 
of  potassium,  are  present  in  normal  urine,  being  derived  from  the  indol  which 
is  formed  in  the  intestine  by  the  decomposition  of  proteids  through  the  action  of 
bacteria.  If  this  indol  is  absorbed  from  the  intestine  into  the  blood,  it  is  oxidized 
and  forms  the  indexed  sulphate  of  potassium  just  named. 

When  indicanuria  is  marked,  it  is  an  evidence  of  an  excessive  amount  of  intestinal 
putrefactive  change,  and  the  disco\'ery  of  indicanuria  in  a  patient  who  is  suffering 
from  the  symptoms  of  auto-intoxication  is,  therefore,  of  value  from  a  diagnostic 
standpoint.  An  estimation  of  this  substance  in  the  urine  is  also  useful  to  differ- 
entiate intestinal  obstruction  from  ordinary  severe  constipation,  for  in  the  former 
indicanuria  is  usually  marked,  and  in  the  latter  the  trace  of  indican  which  is  present 
is  usually  not  above  the  normal.  In  rare  instances,  owing  to  decomposition  of 
the  indoxyl  sulphate  of  potassium  before  it  escapes  from  the  body,  the  urine  is 
blue  when  it  is  passed,  but  in  the  majority  of  cases  in  which  a  blue  urine  has  appeared 
it  has  been  found  that  the  patient  has  taken  methylene  blue  or  some  similar  aniline 
dye,  either  as  a  medicine  or  in  foodstuffs.  The  presence  of  indican  in  the  urine  is 
determined  by  heating  to  the  boiling  point  5  c.c.  of  nitric  acid  in  a  test-tube  and 
adding  5  c.c.  of  urine.  If  indican  is  present  in  excess,  a  bluish  ring  develops  at 
the  point  of  contact  between  the  two  fluids,  and  if  2  c.c.  of  chloroform  are  added 
and  the  liquids  mixed  by  shaking,  and  the  test-tube  then  set  aside  to  stand,  it 
will  be  found  that  the  layer  of  chloroform  which  soon  separates  has  a  \-iolet 
color. 


080  DISEASES  OF  THE  KIDXEYS 

Lithuria. — riulcr  this  lieading  is  mentioned  a  condition  in  wliicii  an  excess  of  uric 
acid  occurs  in  the  urine,  chiefly  in  association  with  sodium  and  ammonium,  and 
sometimes  with  potassium,  lithium,  and  calcium.  An  examination  of  the  urinary 
sediment  under  the  microscope  may  reveal  small,  reddish  grains  or  crystals,  looking 
under  the  microscope  like  particles  of  red  pepper.  There  is  no  condition  wiiich  is 
so  little  understood  at  the  present  time  as  is  this  one.  Almost  every  layman,  and 
a  multitude  of  doctors,  continually  speak  of  being  "full  of  uric  acid,"  meaning 
hy  this  that  they  have  muscular  stiffness,  or  that  the  urine  shows  an  excess  of 
urates,  or  even  uric  acid  crystals.  In  the  majority  of  instances  this  excessive 
deposit  of  urates,  or  uric  acid,  depends  not  upon  any  ahnorniality  in  bodily  metabol- 
ism, but  upon  conditions  of  the  urine  which  cause  the  precipitation  or  deposition 
of  these  solids.  There  is  either  a  condition  of  acidity  or  a  minimum  c[uantity  of 
mineral  salts,  and  as  a  result  precipitation  takes  place.  For  this  so-called  "uric 
acid  diathesis,"  physicians  prescribe  large  cjuantities  of  lithium  and  copious  draughts 
of  water.  There  can  be  no  doubt  that  the  water  is  advantageous,  but  the  lithium 
only  does  good  until  a  certain  degree  of  alkalinity  is  reached,  when  it  is  of  little 
value,  and  if  the  doses  are  large  it  acts  as  a  depressant  to  the  general  system.  It 
is  quite  true  that  persons  who  eat  heartily,  drink  alcohol,  and  take  no  exercise  are 
not  infrequently  overloaded  with  effete  materials  representing  imperfect  metab- 
olism, which  cause  disagreeable  symptoms.  It  is  also  perfectly  true  that  exercise, 
a  proper  diet,  and  the  use  of  plenty  of  drinking  water  will  overcome  these  symptoms, 
I)ut  this  does  not  prove  that  the  patient  has  been  a  sufferer  from  the  so-called  "  uric 
acid  diathesis." 

Melanuria. — Melanuria  is  a  condition  in  which  the  urine  at  the  time  it  is  passed 
or  shortly  after  its  exposure  to  the  air,  becomes  intensely  dark  in  hue,  owing  to 
the  presence  in  it  of  melanin.  It  is  found  in  certain  conditions  in  which  this  sub- 
stance is  produced  in  the  body  by  pathological  processes,  such  as  melanotic  growths. 
If  a  solution  of  ferric  chloride  is  added  to  the  urine,  it  becomes  inky  black.  If 
caustic  potash  is  added,  it  becomes  at  first  violet  and  then  claret  colored,  and  if 
acetic  acid  is  added  to  this  mixture  it  may  become  blue.  The  test  most  commonly 
employed  is  the  solution  of  ferric  chloride  mentioned. 

Myelopathic  Albumosuria. — The  presence  in  the  urine  of  the  so-called  Bence- 
Jones  albumose  or  proteid  has  by  a  number  of  observations  been  shown  to  be 
most  suggestive  of  the  rather  rare  tumor  of  bone  known  as  multiple  myeloma  or 
medullary  osteosarcoma,  "  Kahler's  disease."  The  test  is  quite  simple.  The 
urine,  if  not  distinctly  acid,  should  be  made  so  with  acetic  acid  and  then  heated. 
At  50°  C,  if  it  contains  this  albumose,  it  becomes  milky;  at  G0°  C.  it  deposits  a 
thick  precipitate  which  clings  to  the  sides  of  the  tube  or  collects  on  the  surface. 
Further  heating  to  100°  C.  causes  the  almost  complete  disappearance  of  the  pre- 
cipitate, which,  however,  re-forms  as  the  urine  cools. 


DISEASES  OF  THE  DUCTLESS  GLANDS  AND 
LYMPHATIC  SYSTEM. 


DISEASES  OF  THE  THYROID  GLANDS. 

GOITRE. 

Definition. — Under  the  terms  goitre,  bronchocele,  thyreocele,  or  struma  are  included 
almost  all  enlargements  of  the  thyroid  gland,  but  the  application  of  so  general 
a  term  is  not  to  be  regarded  with  favor.  It  is  better,  therefore,  to  consider  the 
various  diseases  of  the  thyroid  as  inflammatory  (traumatic  strumitis),  infectious 
(tuberculous  or  syphilitic  strumitis),  and  parasitic  (echinococcic)  strumitis.  Of 
the  remaining  so-called  hypertrophies  of  the  gland  it  may  be  said  that  some  of 
them  at  least  are  apparently  not  of  the  nature  of  neoplasms,  and  to  these  the 
term  "siviple"  or  "benign  goitre"  is  applied;  whereas,  in  the  case  of  those  enlarge- 
ments which  are  due  to  the  development  of  tumors  within  the  gland,  we  apply 
the  term  "necplastic  goitre,"  as,  for  example,  endotheliomatous,  sarcomatous,  and 
cancerous  growths  (malignant  goitre).     (See  Tumors  of  the  Thyroid.) 

With  regard  to  some  of  the  simple  or  benign  goitres,  it  is  still  unsettled  as  to 
whether  they  are  neoplastic,  that  is,  adenomatous,  in  every  instance.  In  some 
cases  they  are  undoubtedly  adenomatous.  In  still  other  cases  the  greatly  enlarged 
gland  may,  under  the  microscope,  have  a  histological  formation  like  that  of  the 
normal  organ.  To  this  type  of  goitre  the  name  "hyperplastic  goitre"  is  applied, 
including  those  varieties  characterized  by  reproduction  of  the  parenchyma  of  the 
gland  and  called  by  some  writers  "parenchymatous  goitre."  When  the  enlarged 
gland  contains  cysts  developing  from  its  acini,  the  mass  is  called  a  "  cystic  goitre." 
Cystic  goitres  result  from  the  distention  of  the  gland  spaces,  with  absorption  of 
the  intervening  walls,  thereby  giving  rise  to  cavities  of  various  sizes.  The  contents 
of  these  cysts  may  be  gelatinous  or  colloid.  In  some  instances  the  enlargement 
depends  upon  dilatation  of  bloodvessels,  and  apparentlj^  upon  the  overgrowth  and 
dilatation  of  new  bloodvessels,  forming  the  so-called  vascular  goitre,  and  not  rarely 
there  is  a  blending  of  two  or  more  of  the  types  already  mentioned.  Such  conditions 
are  known  as  "mixed  goitres."     (See  Tumors  of  the  Thyroid.) 

In  ordinary  goitre  there  takes  place  an  increase  in  the  size  of  the  alveoli  in  the 
thyroid  gland  and  a  simultaneous  formation  of  new  glandular  tissue.  Side  by 
side  with  this  increase  there  is  often  colloid  degeneration,  and  when  this  degenera- 
tive process  is  marked  the  state  is  called  colloid  struma  or  colloid  goitre.  Not 
uncommonly  still  other  degenerative  changes  take  place,  in  which  the  walls  of  the 
alveoli  break  down,  and  in  this  way  several  cavities  are  thrown  together,  forming 
cysts,  which  may  hold  colloid  matter  and  blood  derived  from  the  vessels  in  the 
alveolar  walls.  This  is  called  cystic  goitre.  In  still  other  cases  the  bloodvessels 
of  the  gland  become  dilated,  so  that  a  telangiectatic  state  develops.  Finally, 
it  sometimes  happens  that  all  of  these  changes  take  place  in  the  same  gland,  and 
upon  them  may  be  superimposed  acute  inflammation  and  even  malignant  growth. 
The  increase  in  size  may  be  limited  to  a  single  part  of  the  gland  or  be  widely  diffused. 

Etiology. — The  cause  of  ordinary  enlargement  of  the  thyroid  gland  of  the  fibroid 
and  cystic  type  is  unknown,  but  there  can  be  no  doubt  that  it  depends,  at  least 

(681) 


682  DISEASES  OF  THE  TIIYROW  GLANDS 

in  part,  upon  the  character  of  the  drinking-water  used.  My  former  colleague, 
Professor  Keen,  has  investigated  a  very  remarkable  prevalence  of  the  fliseasc  in  the 
interior  of  the  State  of  Pennsylvania,  in  which  the  relationship  of  water  supply 
and  goitre  is  extraordinary,  a  very  large  number  of  the  people  on  one  side  of  a 
mountain  ridge  being  affected,  and  those  across  the  divide  escaping.  The  disease 
is  also  very  common  in  some  parts  of  Michigan  and  especially  so  in  Switzerland. 
The  suggestion  of  Grasset  that  goitre  is  of  protozoal  origin  has  not  been  favorably 
received.  In  support  of  his  view  he  calls  attention  to  the  fact  that,  like  malaria, 
goitre  is  endemic  in  certain  areas,  and  he  is  inclined  to  believe  that  the  thyroid 
enlargement  is  analogous  to  the  splenic  tumor  of  chronic  malarial  infection.  The 
disease  is  more  frequent  in  women  than  in  men,  and  in  adults  than  in  children, 
in  which  class  it  is  very  rare. 

Symptoms. — The  symptoms  of  goitre  are  usually  of  no  consequence  until  the 
growth  is  large  enough  to  be  seen  or  until,  by  its  pressure  on  the  adjacent  tissues, 
it  causes  difficulty  in  breathing  and  interferes  with  swallowing  or  with  the  function 
of  the  vagus  nerves.  The  goitre  may  involve  all  of  the  gland,  its  isthmus,  or  either 
one  of  the  lateral  lobes.  Rarely  aberrant  goitres  arise  in  ectopic  or  misplaced 
thyroid  tissues,  and  they  may  be  intrathoracic  or  occur  at  the  base  of  the  tongue 
(lingual  goitre).  In  still  other  instances  they  have  been  known  to  develop  along 
the  course  of  the  thyroglossal  ducts  or  in  adjacent  areas.  The  degree  to  which 
the  cervical  tissues  are  displaced  in  those  cases  in  which  the  growth  is  chiefly  in 
one  lobe  is  remarkable.  I  once  sent  to  Dr.  Keen  for  operation  a  patient  whose 
hyoid  bone  was  pushed  to  one  side  so  that  it  rested  nearly  under  his  right  ear. 

Treatment. — There  is  no  medicinal  treatment  of  much  value  in  goitre.  Painting 
the  part  with  iodine  and  the  use  of  various  counter-irritant  ointments  have  been 
resorted  to,  but  they  have  no  real  effect  upon  the  growth.  If  it  becomes  very 
large,  it  must  be  excised  if  the  pressure  symptoms  are  severe. 


SWELLING  OF  THE  THYROID. 

This  occurs  from  two  chief  causes,  namely,  from  inflammation  and  from  hyper- 
emia or  congestion.  Some  writers  have  described  an  angioneurotic  form.  When 
the  swelling  is  due  to  inflammation  it  may  arise  from  infection  of  the  gland,  as  in 
typhoid  fever  or  other  acute  infectious  diseases,  and  may  follow  vaccination  or 
sepsis;  or,  again,  it  may  be  due  to  tuberculosis  of  the  gland,  or  to  syphilis  with  the 
formation  of  gummata.  Occasionally  marked  swelling  arises  from  trauma,  and 
this  may  be  acute  or  chronic. 

It  is  asserted  by  Fothergill  that  there  are  recorded  five  cases  of  enlargement 
of  the  fetal  thyroid  due  to  the  administration  of  potassium  chlorate  to  the  mother. 

Some  years  ago  I  reported  the  case  of  a  woman  who,  in  stooping  in  a  dark  room, 
struck  her  neck  against  the  edge  of  a  chair  and  at  once  felt  violent  pain  in  the 
thyroid  gland.  The  gland  rapidly  became  swollen,  and  the  i)atient  presented 
all  the  symptoms  seen  in  persons  to  whom  large  doses  of  thyroid  gland  have  been 
given,  such  as  headache,  a  rapid  pulse,  and  a  tendency  to  syncope.  In  still  another 
case,  seen  by  me,  an  army  surgeon  on  the  fighting  line  received  a  severe  blow  on 
the  thyroid,  and  developed  a  chronic  enlargement  of  the  tiiyroid  gland,  with  some 
tachycardia  and  nervous  and  circulatory  disorders. 

The  thyroid  gland  is  also  found  enlarged  by  hyperemia  in  young  girls,  particularly 
at  the  menstrual  period,  and  in  young  women  in  their  first  pregnancy.  It  also 
occurs  in  young  persons  who  sufl'er  from  cardiac  disease.  Such  an  enlargement 
usually  passes  away  when  the  cause  is  removed. 

Sometimes  thyroiditis  occurs  in  the  insane,  but  its  etiology  anrl  symptomatology 
need  further  stud\-. 


EXOPHTHALMIC  GOITRE  683 


TUMORS  OF  THE  THYROID  GLAND. 


The  tumors  of  this  gland  are  adenoma,  in  wliicli  state  the  condition  is  practically 
that  of  goitre  as  already  described,  carcinoma,  sarcoma,  and  endothelioma.  The 
sarcomata  are  usually  primary.  Morf  has  been  able  to  collect  l)ut  .39  instances 
of  carcinoma  of  the  thyroid;  he  himself  adds  1  case.  Of  the  173  cases  of  cancer 
of  the  thyroid  collected  by  Orcel,  14  invaded  the  trachea. 

Carcinomata  are  also  usually  primary  and  undergo  metastasis  to  nearby  tissues 
or  even  to  distant  structures.  The  growth  may  develop  in  the  parenchyma  or  in 
the  connective  tissue  of  the  gland. 

An  interesting  form  of  tumor  of  the  thyroid  is  the  so-called  carcinosarcoma,  or 
mixed  tumor  of  this  gland. 

Occasionally  old,  quiescent  goitres  may  become  malignant,  undergoing  either 
sarcomatous  or  carcinomatous  denegeration. 

An  anomalous  condition  in  this  group  of  affections  is  thyroid  metastasis,  consist- 
ing in  the  growth  of  typical  thyroid  tissue  at  points  distant  from  the  glands.  These 
growths  are  quite  commonly  in  bones  and  are  seldom  malignant.  The  thyroid 
itself  may  show  no  change. 

EXOPHTHALMIC  GOITRE. 

Definition. — Exophthalmic  goitre  is  often  called  "Basedow's  disease,"  "Parry's 
disease,"  or  "Graves'  disease."  Parry  described  it  (1825)  ten  years  before  it 
was  described  by  Graves  (1835)  and  fifteen  years  before  it  was  described  by  Basedow 
(1840).  Exophthalmic  goitre  is  an  entirely  different  disease  from  ordinary  goitre 
or  simple  enlargement  of  the  thyroid  gland.  It  is  a  malady  in  which,  as  its  name 
implies,  there  is  protrusion  of  the  eyeballs,  and,  in  addition,  palpitation  of  the 
heart,  with  a  very  rapid  pulse.  There  are  fine  tremors  in  the  hands,  arms,  and 
head,  and  disordered  vascular  tone.  A  tendency  to  abnormal  sweating  of  the 
palms  of  the  hands,  and  great  mental  depression  is  often  present. 

Satterthwaite  recognizes  acute,  subacute,  and  chronic  forms  of  Graves'  disease, 
and  says  we  may  speak  of  acute  or  temporary  and  essential  or  chronic  forms.  A 
secondary  form  is  that  in  which  an  old  goitre  takes  on  the  symptoms  of  Graves' 
disease. 

Frequency. — In  10,603  cases  admitted  to  the  Jefferson  Hospital,  there  were  11 
cases  of  exophthalmic  goitre,  or  1  in  964.  In  the  University  Hospital,  out  of 
35,076  cases,  there  were  48  cases  of  exophthalmic  goitre,  or  1  in  730.  Of  7270 
cases  treated  at  the  Dispensary  for  Nervous  Diseases  at  the  Orthopedic  Hospital 
and  Infirmary  for  Nervous  Diseases,  Eshner  found  that  30  were  exophthalmic 
goitre,  or  1  in  242.     It  is  therefore  by  no  means  a  rare  disease. 

Etiology. — The  cause  of  exophthalmic  goitre  is  not  known,  but,  as  is  the  case 
with  most  diseases  of  obscure  causation,  a  multitude  of  factors  have  been  named  as 
possible  causes  for  its  development,  varying  all  the  way  from  rheumatism  and 
tonsillitis  to  fright  and  traumatism.  The  disease  is  very  much  more  frequent  in 
women  than  in  men.  Thus,  out  of  1839  cases  collected  from  various  sources, 
1553  were  females  and  286  males,  a  proportion  of  about  6  to  1,  and  its  average 
age  incidence  is  between  sixteen  and  forty  years.  Cases  are  on  record  in  which 
it  has  affected  children  as  young  as  two  and  a  half  years.  In  some  statistics, 
collected  by  me  some  years  ago,  it  was  shown  that  there  is  a  very  distinct  hereditary 
influence  present  in  many  cases.  There  can  be  little  doubt  that  the  symptoms 
which  are  present  in  exophthalmic  goitre  are  dependent  upon  excessive  internal 
secretion  of  the  thyroid  gland,  or,  if  not  upon  excessive  secretion,  to  the  entrance 
into  the  general  system  of  more  of  the  active  principle  of  the  thyroid  gland  than 
is  normal. 


684  DIfiEASES  OF  THE  TUYRniD  CLAXDS 

Pathology  and  Morbid  Anatomy. — So  far  as  the  morbid  clianges  are  concerned, 
tlierc  is  an  excess  of  fat  in  tiie  orl)it  as  eom])ared  to  the  qnantity  of  fat  in  other 
portions  of  tlie  body. 

The  heart  may  be  normal  or  dihited.  Not  rarely  there  is  simic  iiininc  rehixatidu 
of  the  sphincteric  fibres  around  the  mitral  orifice  of  the  heart.  I'lie  thyroid  is 
enlarged,  the  veins  covering  it  are  dilated  and  numerous,  and  the  arteries  su])pl\ing 
its  tissues  are  enlarged  and  tortuous.  On  the  other  hand,  certain  observations 
have  shown  that  in  many  instances  there  is  no  remarkable  change  in  the  \'ascularity 
of  the  organ. 

Regarding  the  histology  of  the  thyroid  there  is  not  at  present  a  unanimity  of 
opinion.  Some  pathologists  regard  the  changes  as  specific  and  that  therefore  it 
is  possible  to  make  the  diagnosis  of  exophthalmic  goitre  by  study  of  microscoj)ic 
sections  alone.  Others  do  not  believe  this  possible  and  the  question  appears 
unsettled.  This  can  be  said,  however,  that  evidence  in  favor  of  the  former  view  is 
increasing,  especially  from  those  who  have  the  opportunity  to  study  a  great  deal 
of  material.  Mistaken  clinical  diagnoses  undoubtedly  underlie  some  of  the  dis- 
crepancy between  reports. 

Observers  in  the  Mayo  clinic,  from  a  study  of  over  1,200  eases  of  exoplithalmic 
goitre  and  probably  twice  that  many  simple  cases,  have  reached  some  very  definite 
conclusions  on  this  subject.  Wilson  states  that  during  1911  and  1912  every  jjatient 
diagnosed  clinically  as  true  exophthalmic  goitre  and  subjected  to  thyroidectomy, 
furnished  a  thyroid  that  showed  primary  parenchymatous  hypertrophy  and  hyper- 
plasia, signifying  increased  functional  activity  of  the  gland.  Histologically  this 
means  an  increase  of  working  tissue — parenchyma  cells — within  previously  formed 
acini.  There  is  an  increased  number  of  lining  epithelial  cells  in  a  single  layer, 
due  to  infolding  of  alveolar  walls  and  papilla  formation,  or  a  reduplication  of  layers. 
A  large  amount  of  thin  secretion  is  shown  by  a  poorly  staining  alveolar  content — 
colloid. 

Kocher,  from  a  most  e.xhaustive  study,  reaches  a  similar  conclusion,  namely; 
that  there  are  no  specific  or  pathognomonic  gland  elements  but  instead  there  are 
changes  in  the  normal  parenchyma  in  the  way  of  increased  size  and  number  of 
epithelial  cells  and  fluidification  of  colloid. 

Wilson  also  finds  that  the  stage  of  the  goitre  can  be  estimated  with  considerable 
accuracy  from  the  pathological  study  alone  in  about  80  per  cent,  of  the  cases  and 
the  severity  of  the  toxic  symptoms  in  about  75  per  cent.  These  findings  lead  him 
to  the  conclusion  that  the  relationship  of  primary  hypertrophy  and  hyperplasia 
of  the  parenchyma  of  the  thyroid  to  true  exophthalmic  goitre  is  as  direct  and  as 
constant  as  is  primary  inflammation  of  the  kidney  to  the  symptomatology  of  true 
Bright's  disease.  Plummer  reaches  the  conclusion  that  exophthalmic  goitre  is  a 
definite  clinical  complex  always  associated  with  hyperplasia  of  the  thyroid.  Black- 
ford and  Sanford  have  found  that  fresh  extract  from  exoijhthalmic  thyroids  and 
the  sera  of  certain  patients  contain  a  powerful  depressor  substance  that  materially 
lowers  blood  pressure. 

The  thymus  gland  is  persistent  and  hypertrophic,  and  enlarged  in  a  \ery  con- 
siderable proportion  of  cases,  but  a  microscopic  examination  of  it  does  not  show 
pathological  changes  in  most  instances.  Thus  ("apelle  fount!  a  thymus  persistans 
hyperplastica  in  95  per  cent,  of  all  fatal  cases.  There  is  reason  to  believe  that 
the  .symptoms  are  due  not  only  to  the  enlarged  thyroid  but  to  the  thymus  as  well. 
The  parathyroids  may  be  atrophied. 

Certain  alterations  have  been  described  in  the  sym])athetic  system  and  in  the 
central  nervous  system,  but  it  has  not  been  proved  that  these  ha^■e  any  close  rela- 
tionship with  the  disease. 

Symptoms. — The  protrusion  of  the  ei/ebaUs,  even  when  it  is  present  to  a  moderate 
degree,  is  so  striking  that  attention  is  directed  to  this  symptom  almost  as  soon  as 


EXOPHTHALMIC  GOI THE 


685 


the  patient  is  seen.  It  varies  greatly  in  degree.  In  some  cases  the  eyeballs  may 
be  so  prominent  that  it  is  impossible  for  the  lids  to  completely  close,  whereas  in 
others  the  exophthalmos  may  be  very  slight  indeed.  While  it  is  true  that  the 
exophthalmos  may  not  be  equally  developed  on  both  sides,  it  is  nearly  always 
bilateral,  although  a  few  instances  of  unilateral  cxophthalmf)s  ha^■e  been  reported. 
Under  the  name  of  von  (Iraefe's  sign,  a  conditi(jn  is  found,  in  which,  if  the  jwtient 
is  directed  to  look  at  the  floor,  the  upper  eyelid  does  not  follow  the  eyeball  in  its 
downward  movement  as  rapidly  as  it  should.  This  symptom  is  not  always  present. 
Stelwag's  sign  consists  in  a  widening  of  the  palpebral  fissure,  with  retraction  of  the 
lids,  to  such  an  extent  that  the  sclerotic  coat  of  the  eye  is  seen  above  and  below 
the  iris.  This  very  distinctly  increases  the  exophthalmic  effect.  With  this  symp- 
tom there  is  also  diminished  reflex  excitability,  so  that  winking  is  delayed  when  a 
sudden  movement  is  made  toward  the  patient.  Under  the  name  of  Mobkis'  sign 
is  described  a  condition  in  which  there  is  a  lack  of  power  of  convergence,  so  that 
if  a  pencil  is  brought  near  the  patient's  face  the  eyes  do  not  converge,  as  they  do 
in  a  normal  individual. 

Fig.  118 


J^^''  '      Ji 

\ 

-'%J%*^y:' 

r 

1  ■ 

^^ 

L/X  !„/>:..-■ 

■V    '.     ..^ 

Exophthalmic  goitre.     The  illustration  shows  the  enlarged  thyroid  gland.     The  exophthalmos  was  so 
great  that  the  lids  had  to  be  sewed  together  to  protect  the  eyes. 


Notwithstanding  the  exophthalmos,  vision,  as  a  rule,  is  not  interfered  with,  but 
ulceration  of  the  cornea  sometimes  occurs  as  the  result  of  the  inability  of  the 
eyelids  to  protect  the  eye.     (See  Fig.  118.) 

The  increase  in  the  size  of  the  thyroid  gland  is  usually  not  very  great,  and  it 
never  becomes  as  large  as  in  many  cases  of  ordinary  goitre. 

On  inspection  the  gland  may  seem  to  pulsate,  and  on  palpation  it  often  transmits 
a  thrill  to  the  finger-tip.  If  the  stethoscope  be  placed  over  the  gland,  a  distinct 
hvmming  murmur  can  be  heard.  This  same  murmur  is  also  detected,  even  more 
clearly,  if  the  stethoscope  be  lightly  placed  over  the  carotid  arteries. 

The  gland  is  never  very  hard,  but  may  be  soft  and  fluctuating,  and  is  apt  to 
vary  in  size  considerably'  from  week  to  week  or  from  day  to  day.  Tachycardia 
is  practically  always  present  in  these  cases.     The  jmlse  varies  from  90  to  100  or 


686  DISEASES  OF  THE  THYROID  GLANDS 

even  200  beats  a  iiiiiiiite,  the  ordinary  rajjid  pulse  l)eing  very  much  increased  on 
exertion  or  excitement. 

If  the  finger-tips  of  the  patient  are  rested  upon  the  finger-tips  of  the  physician, 
there  can  be  felt  not  infrequently  a.  fine  tremor,  sometimes  called  "railroad  bridge 
tremor,"  owing  to  its  resemblance  to  the  sensation  produced  in  one's  feet  when 
standing  upon  a  railroad  bridge  during  the  time  a  train  is  passing  over  it.  In 
other  instances  the  tremor  is  very  marked  and  coarse  in  character. 

The  patient  nearly  always  complains  of  feebleness  and  mental  depression,  and 
in  some  cases  melancholia  may  be  so  profound  as  to  result  in  suicide,  as  in  a  patient 
recently  under  my  observation.  An  irritating  nervous  cough  and  occasional  attacks 
of  dysjmea  may  occur,  and  cases  are  on  record  in  which  the  patient  has  suddenly 
died  from  urgent  dyspnea,  which  has  had  its  origin  in  intense  swelling  of  the  thyroid 
gland,  so  that  it  has  pressed  upon  the  trachea  in  much  the  same  manner  as  does 
the  enlarged  thymus  in  status  lymphatictis.  Another  symptom  which,  when  it 
develops,  must  always  be  regarded  with  alarm,  is  excessive  and  obstinate  vomiting. 
This  condition  may  speedily  pass  by,  but  in  some  cases  it  has  persisted  until  death 
has  ensued.  Sudden  attacks  of  diarrhea  are  not  rare.  The  digestion  is  fairly 
good,  but  the  appetite  is  uncertain,  and  the  patient  craves  abnormal  things  as  she 
does  in  hysteria.  Oftentimes  a  constant  "rifting  up"  of  wind  gives  great  annoy- 
ance. The  nervousness  is  so  intense  that  in  many  cases  the  patient's  life  is  almost 
unbearable  because  of  the  irritation  produced  by  noises  and  other  sources  of  irrita- 
tion which  ordinarily  would  not  be  noticed.  Nervous  chills  or  trcmlilings  are 
often  a  source  of  great  annoyance  to  the  patient,  and  the  palms  of  the  hands  are 
prone  to  be  wet  with  excessive  perspiration.  Patches  of  pigmentation  on  the  skin 
often  develop.  There  is  usually  distinct  loss  of  weight  and  strength.  In  those 
cases  in  which  there  is  a  persistent  thymus  (about  40  per  cent.)  the  symptoms 
consist  in  absence  of  Mobius'  sign,  slight  exophthalmos,  profuse  sweating,  diarrhea, 
no  glycosuria  and  some  eosinophilia.  Palpation  in  the  episternal  notch  may 
reveal  fulness,  and  pressure  causes  oppression.  The  ,T-rays  may  reveal  an  enlarged 
thymus  but  they  sometimes  fail  to  do  so  even  if  the  thymus  be  present. 

Prognosis. — A  certain  number  of  cases  of  exophthalmic  goitre  undoubtedly 
Tecover,  but  they  are  always  liable  to  relapse.  Rapid  loss  of  flesh  and  strength, 
marked  tachycardia,  persistent  vomiting,  and  diarrhea  are  all  of  them  symptoms 
which  would  cause  us  to  give  a  guarded  or  unfavorable  prognosis,  whereas,  if 
the  symptoms  are  mild,  we  have  a  right  to  feel  correspondingly  encouraged.  Some- 
times exophthalmic  goitre  may  last  so  short  a  time  as  a  few  days  or  weeks.  In 
other  instances  it  may  continue  for  many  years. 

Treatment. — The  treatment  of  exophthalmic  goitre  is  not  very  satisfactory. 
When  the  thyroid  gland  was  first  used  as  a  therapeutic  agent  it  was  given  to  a 
considerable  number  of  persons  suffering  from  exophthalmic  goitre,  with  the  idea 
that  it  might  do  good,  but  from  the  first  it  must  have  been  manifest  that  it  could 
not  be  of  value  because  the  patient  is  sufTering  from  too  much  thyroid  secretion, 
and  the  addition  of  more  of  the  thyroid  substance  must  in  consequence  be  disad- 
vantageous. 

Lepine  has  recommended  antithyroid  serum  in  the  treatment  of  Graves'  disease. 
This  serum  is  obtained  from  animals  immunized  against  hyperthAToidism.  Under 
the  name  of  thyroid  serum  Mobius  has  given  us  serum  derived  from  sheep  from 
wliich  the  thyroid  gland  has  been  removed  six  weeks  before.  The  dose  is  1  to  5 
c.c.  three  times  a  day,  given  by  the  mouth.  A  similar  preparation  is  prepared 
in  this  country  by  Parke,  Davis  &  Co.,  and  is  called  "Thyroidectin."  The  dose 
is  5  to  10  grains  t.  i.  d.,  in  capsules. 

Recently  Pfahler  and  a  number  of  others  have  recorded  a  consideraljle  number 
of  cases  treated  by  the  use  of  the  Roentgen  rays  over  the  gland.  They  assert  that 
at  least  75  per  cent,  of  these  cases  are  distinctly  benefited  by  this  plan. 


EXOPHTHALMIC  GOITRE  687 

Still  another  physiological-pathological  plan  of  treatment  has  been  introduced 
by  Beebe  and  Rogers,  based  upon  the  well-known  fact  that  it  is  possible  to  pro- 
duce a  condition  in  the  blood  of  an  animal  so  that  its  serum  will  have  a  selective 
destructive  affinity  for  a  given  organ  when  injected  into  another  animal,  partic- 
ularly the  kidney,  the  pancreas  and  liver.  It  occurred  to  them  that  it  might  be 
possible  to  utilize  this  fact  for  the  partial  destruction  or  inhibition  of  the  function 
of  the  thyroid  in  cases  of  exophthalmic  goitre  in  which  the  acti\'ity  of  this  gland 
is  too  great.  This  plan  has  given  brilliant  results  in  a  few  cases  but  signally 
failed  in  others.  According  to  Beebe  and  Rogers  the  cases  characterized  by  a 
hard,  nodular,  irregular  thyroid,  the  so-called  chronic,  toxic  cases  with  a  good 
deal  of  varicosity  of  the  thyroid  veins,  respond  very  poorly  to  the  treatment, 
and  as  might  be  expected  the  smaller  the  thyroid  and  the  less  the  exophthalmus 
the  better  is  the  prognosis. 

In  most  instances  the  patient  should  receive  a  carefully  carried  out  rest  cure, 
extending  over  a  period  of  from  four  to  six  weeks,  with  regulation  of  the  diet  and 
massage  and  electricity.  Sometimes  a  course  of  hydrotherapy  is  advantageous, 
and  change  of  air  and  scene  is  particularly  valuable  if  the  patient  has  been  subjected 
to  nervous  stress.  All  forms  of  exercise  or  gayety  which  tend  to  exhaust  the  nervous 
system  should  be  forbidden. 

The  drugs  which  seem  to  be  of  most  benefit  are  those  which  belong  to  the  class 
of  sedatives.  When  the  heart's  action  is  very  excessive,  I  have  known  full  doses 
of  tincture  of  veratrum  viride  to  be  most  advantageous,  in  that  they  quiet  the 
heart  not  only  by  depressing  its  muscle,  but  also  by  stimulating  the  pneumogastric 
nerve.  In  other  instances  the  bromides  may  be  employed.  In  still  other  cases 
I  have  seen  gelsemium  employed  to  advantage. 

The  disadvantage  of  opium  or  morphine,  for  the  production  of  nervous  quiet, 
is  the  danger  of  establishing  the  "habit."  This  is  a  very  real  danger  in  these 
patients,  because  of  their  lack  of  nervous  equilibrium.  Sometimes  belladonna 
may  be  given  with  advantage  to  quiet  the  circulatory  and  nervous  excitement. 

A  very  large  number  of  operations  have  been  performed  upon  patients  with 
exophthalmic  goitre,  with  the  object  of  curing  the  disease.  In  some  instances 
the  thyroid  arteries  have  been  tied.  In  others  the  capsule  of  the  gland  has  been 
stripped  from  it  and  made  fast  in  the  wound,  so  that  the  tissues  will  slirivel.  In 
still  another  class  of  cases  the  cervical  sympathetic  has  been  cut,  and  Jaboulay 
has  strongly  advocated  this  measure.  The  value  of  operative  procedure  is,  how- 
ever, well  summed  up  by  my  colleague,  J.  Chalmers  Da  Costa,  who  says : 

"Treat  most  cases  medically  and  by  rest;  if  medical  treatment  fails,  consider 
the  advisibility  of  surgical  treatment. 

"Do  not  operate  if  there  is  great  hysteria;  if  the  gland  is  very  large,  thyroidectomy 
will  fail ;  if  the  gland  is  very  small,  it  will  do  no  good  to  remove  it. 

"If  the  symptoms  are  urgent,  if  the  goitre  is  distinct,  but  not  excessively  large, 
if  it  has  relapsed  under  medical  treatment,  or  if  the  patient  refuses  to  submit  to 
the  necessary  restrictions  of  medical  treatment,  perform  thyroidectomy. 

"Take  Kocher's  advice,  and  do  not  promise  cure,  but  realize  that  the  patient 
may  die  or  there  may  be  a  partial  cure. 

"When  thyroidectomy  is  performed  do  not  remove  the  entire  gland.  Remove 
one  lobe  only,  or  one  lobe  and  a  half  or  two-thirds  of  the  remaining  lobe.  Even 
so-called  complete  thyroidectomies  are  not  often  really  complete,  as  a  remnant 
of  the  processus  pyramidalis  is  usually  left  behind.  In  addition  to  removing  a 
part  of  the  gland,  take  Kocher's  advice  and  tie  three  of  the  four  thyroid  arteries. 

"Do  not  give  a  general  anesthetic,  but  produce  local  anesthesia  (Kocher).  A 
general  anesthetic  is  very  dangerous  in  goitre  operations." 

Halsted  and  others  have  shown  that  not  only  should  the  thyroid  be  operated 
upon  but  that  the  thymus  must  be  in  part  at  least  resected  if  a  cure  is  to  be  induced. 


GS8  DISEASES  OF  THE  TJIYRO/l)  CiLAXDS 

MYXEDEMA. 

Definition. — Myxedema  is  a  disease  in  wiiicli  extraordinary  nutritional  changes 
take  place  in  the  body  as  the  result  of  absence,  atrophy,  removal,  or  inactivity  of 
the  thyroid  gland.  When  the  condition  is  due  to  operative  removal  of  the  gland 
it  is  I'alled  cachexia  strumipriva.  It  is  characterizerl  by  a  j)eculiar  swelling  of 
the  subcutaneous  tissues,  by  falling  of  the  hair,  by  mental  failure,  and  liy  feebleness 
of  the  circulation.  Myxedema  is  closely  related  to  cretinism  in  cliildren.  It  is 
sometimes  called  "Athyrea"  and  "Gull's  disease." 

Etiology. — The  cause  of  myxedema  is  failure  of  the  body  to  recei\'e  the  normal 
quantity  of  secretion  from  the  thyroid  gland.  In  this  sense  it  may  be  considered 
the  antithesis  of  exophthalmic  goitre.  The  cause  of  the  atrophy  or  inactivity  of 
the  gland  is  unknown. 

Myxedema  occurs  more  frecjuently  in  married  than  in  single  women,  and  it 
appears  most  commonly  after  thirty  years  of  age.  It  aft'ects  women  and  men  in 
the  proportion  of  (1  to  1. 

Pathology  and  Morbid  Anatomy. — When  the  thyroid  gland  undergoes  atrophy, 
when  it  is  removed  by  surgical  operation,  and  when,  as  the  result  of  a  specific 
infection,  as  actinomycosis  or  morbid  growth,  its  function  is  destroyed,  myxedema 
ensues.  In  most  cases  the  atrophy  of  the  thyroid  gland  can  be  readily  recognized, 
but  in  others  the  gland  may  seem  larger  than  normal.  This  increase  in  size  may 
be  due  to  infiltration,  tumors,  cysts,  subacute  or  chronic  inflammatory  processes 
leading  to  an  overgrowth  of  the  connective  tissue  of  the  gland,  and  is  not  a  sign  of 
any  actual  increase  in  glandular  structure. 

The  state  of  the  subcutaneous  tissues  is  very  remarkable.  They  are  puffy  and 
swollen,  and  if  incised  are  found  infiltrated  with  a  mucoid  or  jelly-like  material. 
This  material  is  present  in  such  excessive  quantities  that  the  cutaneous  glands  are 
pressed  upon  and  their  nutrition  interfered  with,  so  that  the  skin  becomes  dry  and 
harsh,  and  the  hair  falls  out.  Nor  does  this  process  of  infiltration  cease  with  the 
involvement  of  the  subcutaneous  tissues,  for  in  the  liver  and  in  the  kidneys  the 
cells  are  pushed  apart  and  compressed.  The  kidneys  are  larger  than  normal,  and 
considerably  toughened  in  texture. 

Frequency. — Myxedema  is  a  rare  disease,  particularly  in  the  United  States. 
Physicians  connected  with  large  hospitals  may  see  a  case  only  once  in  many  years. 

Symptoms. — The  symptoms  of  myxedema  are  infiUration  of  the  tU-surs  of  the 
entire  body,  so  that  they  appear  at  first  glance  to  be  dropsical,  but  they  do  not 
"pit"  on  pressure  and  are  quite  firm  and  resistant.  The  .skin  is  dri/,  pallid,  and 
poorly  nmtrished,  the  hair  falls  till  only  a  few  strands  are  left,  and  the  eyebrows 
disappear.  The  expression  is  altered  by  the  obliteration  of  the  facial  lines,  and 
by  the  stupidity  from  which  the  patient  suft'ers,  for  a  form  of  mental  inertia  develops. 
As  the  disease  advances  muscular  feebleness  often  arises,  so  that  the  patient  falls, 
and  there  may  be  difficulty  in  holding  the  head  erect.  The  temperature  is  slightly 
subnormal,  the  heart  \s feeble,  and  albuminuria  is  sometimes  present.  It  is  important 
to  bear  in  mind  that  not  infrequently  the  symptoms  of  myxedema  are  so  slightly 
developed  for  some  years  that  a  diagnosis  is  not  made.  A  tendency  to  obesity, 
mental  torjjor,  physical  inertia  and  some  associated  pallor  should  arouse  the  sus- 
picion of  the  presence  of  the  disease  in  its  larval  form. 

Prognosis. — The  prognosis  depends  entirely  upon  the  treatment.  If  no  specific 
treatment  is  resorted  to  death  invariably  ensues  as  a  result  of  general  asthenia 
or  from  some  intercurrent  malady.  If  specific  treatment  is  adequate  recovery 
usually  takes  place,  provided  the  patient  is  seen  before  the  disease  is  very  far 
advanced. 

Treatment. — Aside  from  the  use  of  antitoxin  in  diphtheria,  there  is  no  therapeutic 
measure  which  produces  such  extraordinary  results  and  acts  in  so  specific  a  manner 


CRETINISM  080 

as  the  administration  of  thyroid  gland  in  myxedema  and  in  cretinism.  The  dried 
thyroid  gland  of  the  sheep  should  be  given  the  patient  in  gradually  ascending 
doses,  beginning  with  2  grains  in  capsule  twice  or  thrice  a  day,  and  gradually 
increasing  the  amount  until  10  to  15  grains  are  taken  daily,  provided  the  patient 
does  well  on  these  doses  and  seems  to  need  large  quantities.  When  the  extract 
of  the  thyroid  gland  is  used,  the  dose  is  \  grain  three  times  a  day  to  start  with. 
Meltzer  states  that  the  extract  and  dried  gland  prepared  by  Parke,  Davis  &  Co. 
have  given  him  the  best  results.  When  overdoses  are  taken  symptoms  of  cardiac 
weakness  develop.  These  are  dangerous  and  should  be  controlled  by  the  use  of 
strychnine  and  by  insisting  that  the  patient  remain  in  bed  for  several  days.  Indeed, 
rest  in  bed  is  the  safer  plan  whenever  ascending  doses  are  being  employed.  After 
thyroid  gland  has  been  given  long  enough  to  cause  great  improvement,  so  that  the 
patient  is  practically  well,  it  is  essential  that  about  one-half  the  dose  be  continued 
indefinitely  or  at  certain  periods,  in  order  to  prevent  a  relapse,  for  the  sheep's 
thyroid  must  take  the  place  of  the  wasted  gland  in  the  neck. 

A  full  proteid  diet  is  essential. 

As  these  patients  are  very  susceptible  to  cold,  they  should  be  carefully  clothed 
and  sent  to  a  warm  climate  in  the  winter  months,  if  possible. 


CRETINISM. 

Definition. — Cretinism  is  sometimes  called  congenital  myxedema,  or  the  myx- 
edema of  childhood,  and  depends  upon  the  same  causes  as  does  myxedema,  in 
that  the  curious  sj' stemic  changes  which  develop  in  the  patient  are  the  result  of  an 
absence  of  the  secretion  of  the  thyroid  gland. 

Cretinism  occurs  in  two  forms,  as  endemic  cretinism  and  sporadic  cretinism. 

The  conditions  leading  to  thyroid  absence  or  inadequacy  are  not  known.  It 
is  true  that  in  some  instances  the  results  of  the  marriage  of  near  relatives  or  the 
presence  of  a  tuberculous  history  has  seemed  to  indicate  that  there  might  be  some 
connection  between  these  factors  and  the  development  of  the  disease,  but  in  most 
cases  these  causes  are  absent. 

Symptoms. — The  symptoms  of  cretinism  rarely  develop  before  the  end  of  the 
second  year,  but  the  symptoms  may  be  noticeable  from  the  time  the  child  is  twelve 
months  of  age,  when  the  parents  usually  consider  that  the  child  is  somewhat  "  back- 
ward." At  this  time  it  is  found  to  be  stunted  and  mentaUy  dull.  The  head  and 
the  hands  and  feet  may  seem  unduly  large  in  proportion  to  the  size  of  the  trunk  and 
limbs.  The  face  is  stupid  and  heavy,  and  the  eyes  dull.  The  palpebral  openings 
are  narrow  and  elongated,  and  the  Jiose  is  broad  and  flat,  with  heavy  nostrils.  The 
lips  are  coarse,  are  apt  to  protrude,  are  usually  held  apart,  and  not  infrequently 
there  is  a  good  deal  of  dribbling  of  saliva.  The  tongue  is  swollen,  and  there  seems 
to  be  some  weakness  of  the  cervical  muscles,  so  that  the  head  is  not  well  carried 
on  the  shoulders.  An  anteroposterior  curvatxire  of  the  spinal  column  is  often  present, 
so  that  the  abdomen  is  very  much  protruded.  The  legs  are  short  and  bent,  as  in 
rickets,  and  the  skin  is  sallow  and  greasy.  The  hair  is  scanty  and  brittle,  and  the 
skin  is  badly  nourished.  The  temperature  is  subnormal,  but  there  are  no  important 
changes  in  either  the  urine  or  the  blood.  The  most  marked  alterations  from  normal 
in  the  blood  are  a  diminution  in  the  quantity  of  hemoglobin.  In  many  instances 
the  child  has  little  more  intelligence  than  that  which  is  needed  to  take  its  food. 
In  other  cases  it  is  vicious  and  dirty. 

An  autopsy  in  a  case  of  cretinism  usually  reveals  an  absence  of  the  thyroid 
gland,  its  place  being  taken  by  a  few  fatty  granules,  or  by  a  fibrocystic  growth. 
On  opening  the  skull  there  is  found  to  be  an  excess  of  intraventricular  and  inter- 
arachnoid  fluid. 
44 


690 


DISEASES  OF  THE  THYROID  CH.WDS 


Diagnosis. — There  is  no  difFiculty  in  diaf^nosticatinj;  fretinisni  if  a  typical  case 
is  presented.  Given  a  patient  snlTerinp;  from  rickets  and  idiocy,  some  resemblance 
to  trne  cretinism  may  be  present,  but  the  state  of  the  skin  and  hair  and  the  absence 
of  the  thyroid  gland  in  true  cretinism  render  a  separation  possible. 


5" 

i 

V 

it , 

A  case  of  crctiuism,  showi 


the  improvement  produced  lo'  tli' 
(Davisson's  case.) 


aduiiiii>iralinu  uf  lli; 


lid  gland. 


Prognosis. — The  prognosis  in  cretinism  is  very  good,  even  better  than  in  the 
myxedema  of  adults,  provided  the  treatment  is  instituted  while  the  i)atient  is 
yet  a  child  in  years.  If  the  patient  has  survived  till  adnlt  years  are  reached,  the 
results  are  not  so  satisfactory  and  extraordinary. 

Treatment. — The  treatment  consists  in  the  administration  of  thyroid  gland  or 
thyroid  extract,  beginning  with  j  of  a  grain  of  the  extract  three  times  a  day  and 
gradually  increasing  it,  or  using  1  or  2  grains  of  the  dry  glanfl  once,  twice,  or  thrice 
a  day,  according  to  the  size  and  age  of  the  child.  Under  the  administration  of 
these  substances  the  most  remarkable  change  takes  place  in  the  patient.  The 
first  noticeable  alteration  is  a  great  decrease  in  body  weight,  with  a  similar  decrease 
in  the  bulkiness  of  the  child.  The  skin  becomes  more  moist  and  appears  better 
nourished,  and  the  expression  improves.  There  is  also  an  improvement  in  the 
color  of  the  skin  and  in  the  quantity  of  hemoglobin  in  each  blood  corpuscle.  Still 
later,  after  this  primary  decrease  in  weight,  a  real  im])rovemcnt  in  nutrition  takes 
place,  and  the  child  begins  to  gain,  so  that  it  no  longer  looks  stunted,  but  appears 
more  like  a  healthy  individual.  The  mental  improvement  is  perhaps  the  slowest 
part  of  the  cure,  and  in  some  instances  the  mind  never  fully  reaches  the  development 
of  that  of  a  healthy  child,  although  the  nutrition  of  the  body  may  be  excellent. 
The  effect  of  the  administration  of  thyroid  upon  the  growth  of  the  teeth  is  equally 


TETANY  691 

remarkable  with  that  upon  the  general  nutrition.  Before  thyroid  is  given  the 
milk  teeth  are  usually  badly  formed  and  rapidly  deeay ;  but  if  thyroid  is  administered 
freely  before  the  permanent  teeth  appear,  they  are  often  developed  as  they  would 
be  in  the  jaws  of  a  healthy  child. 


DISEASES  OF  THE  PARATHYROID  GLANDS. 


TETANY. 

Tetany  is  a  condition  in  which  intermittent  unilateral  or  bilateral  tonic  and 
painful  spasm  afi'ects  certain  muscle  groups,  usually  of  the  upper  limbs,  although 
occasionally  it  involves  the  legs  as  well.  It  is  sometimes  called  "tetanilla,"  or 
"idiopathic  muscular  spasm."  The  disease  is  exceedingly  rare  in  America,  but 
comparatively  common  in  certain  European  countries,  notably  Sweden  and  Austria. 
It  is  probable  that  tetany  is  merely  a  symptom  of  several  different  conditions. 
One  type  of  it  occurs  in  epidemic  form  in  Austria,  particularly  during  the  months 
of  March  and  April,  affecting  chiefly  youths  between  fifteen  and  twenty-fi^'e  years 
of  age.  These  persons  usually  belong  to  the  lower  walks  of  life.  Occasionally 
it  develops  in  women,  particularly  at  the  time  of  pregnancy  or  during  nursing. 
a  very  few  cases  have  been  reported  in  children  below  puberty  and  in  persons  of 
advanced  years. 

Etiology. — Tetany  is  sometimes  due  to  atrophy  of  the  parathyroid  bodies.  It 
has  been  frequently  reported  as  occurring  in  persons  who  are  suffering  from  chronic 
gastro-intestinal  disorders,  particularly  cases  of  gastric  dilatation,  and  it  has  occurred 
in  such  cases  after  the  gastric  contents  have  been  removed  by  lavage.  It  seems 
to  be  more  frequent  in  persons  who  follow  certain  occupations  than  in  others. 
Thus,  out  of  314  male  patients  mentioned  by  Frankl-Hochwart  no  less  than  141 
were  shoemakers  and  41  were  tailors.  This  has  caused  certain  persons  to  believe 
that  certain  types  of  tetany  were  of  the  nature  of  an  occupation  neurosis.  Tetany 
sometimes  develops  in  those  who  have  suffered  partial  or  total  extirpation  of  the 
parathyroid  gland.  It  is  also  met  with  in  children  who  are  suffering  from  rickets. 
It  is  also  a  complication  of  chronic  gastric  dilatation  arising  from  any  cause.  In 
some  cases  tetany  is  a  manifestation  of  hysteria. 

Pathology  and  Morbid  Anatomy. — As  few  of  these  cases  come  to  autopsy,  we  know 
little  concerning  their  morbid  anatomy.  In  a  few  instances  autopsy  has  revealed 
hyperemia  and  minute  hemorrhages  in  the  anterior  cornua  of  the  spinal  cord,  but 
it  is  very  doubtful  if  these  are  characteristic  of  the  malady. 

Symptoms. — The  prodromal  symptoms  of  tetany  are  usually  those  indicative 
of  a  toxemia.  The  patient  first  suffers  from  some  aching  or  'paiii  in  the  extremities, 
and  may  have  headache  and  dizziness,  and  feel  heavy  and  stupid.  As  already 
stated,  the  disorder  usually  affects  one  or  both  arms  and  involves  in  particular 
the  muscles  of  the  forearms  and  hand,  causing  the  palm  of  the  ha7id  to  be  flexed 
upon  the  wrist  while  the  fingers  are  extended.  Sometimes  the  forearm  is  flexed 
at  the  elbow.  In  other  instances  the  phalanges  are  flexed  and  the  distal  phalanges 
extended.  When  the  lower  extremities  are  affected,  the  feet  and  toes  show  some- 
what similar  contractures.  The  toes  may  overlap  one  another  and  be  forcibly  flexed, 
and  the  foot  may  be  bent  at  the  ankle  in  the  position  of  club-foot.  Occasionally 
in  very  severe  cases,  some  of  the  muscles  of  the  trunk  and  those  of  the  neck  and 
throat  may  be  involved,  and  even  the  ocular  muscles  may  contract,  so  that  a  form 
of  nystagmus  is  present.     It  is  a  noteworthy  fact,  first  enunciated  by  Trousseau, 


692  DISEASES  OF   THE  PARATIIYROIT)  GLANDS 

that  pressure  exercised  upon  the  affected  limb  will  generate  an  attack,  provided 
that  the  nerve  trunks  or  the  bloodvessels  are  affected  by  the  pressure.  This  is 
known  as  "Trousseau's  symptom."  The  pressure  must  be  continued  from  thirty 
seconds  to  five  minutes  to  produce  an  effect.  While  the  presence  of  Trousseau's 
symptom  is  pathognomonic  of  tetany,  its  absence  does  not  disprove  tlie  presence 
of  the  disease. 

Under  the  name  of  "Trousseau's  sign"  tapping  of  the  nerves  of  the  arms,  or 
legs,  when  surrounded  by  an  elastic  band,  may  induce  the  spasm.  Spasm  may 
also  be  induced  if  the  facial  nerve  is  irritated  in  this  manner  (Chvostek's  sign). 
Under  the  name  of  "Erb's  sign"  lies  the  fact  that  the  motor  nerves  manifest  a 
marked  increase  in  electrical  irritability,  particularly  with  the  galvanic  current. 
Hoffmann  has  pointed  out  that  the  superficial  sensory  nerves  are  also  exceedingly 
sensitive,  and  that  moderate  pressure  upon  them,  which  ordinarily  would  not  be 
felt,  may  cause  a  severe  pain  similar  to  that  produced  by  striking  the  ulnar  nerve 
at  the  elbow  ("Hoft'mann's  sign").  If  the  irritation  of  the  motor  nerve  is  repeatedly 
produced,  a  marked  increase  in  the  excitability  of  the  tributary  muscles  follows. 
Occasionally,  nervous  lesions  appear  in  the  skin  such  as  urticaria  or  herpes,  pigmen- 
tation, and  loss  of  the  hair  and  nails.  An  attack  of  tetany  may  last  from  a  few 
minutes  to  several  days.  It  may  be  so  moderate  that  it  can  be  overcome  by  the 
will  of  the  patient,  or  so  severe  that  the  limb  is  entirely  beyond  control.  If  an 
attempt  is  made  to  reduce  the  spasm  by  force  it  causes  great  pain,  and  if  the  con- 
tractions of  the  muscles  are  marked  and  cramp-like  the  pain  is  also  severe.  The 
attack  passes  oft'  gradually  and  is  often  followed  by  impaired  sensation  and  loss 
of  power  in  the  affected  parts.  There  is  no  loss  of  consciousness  in  the  great 
majority  of  cases  but  in  severe  cases  the  movements  may  be  as  severe  as  in  true 
epilepsy. 

Diagnosis. — ^The  development  of  comparatively  localized  tonic  spasms  in  associa- 
tion with  the  other  symptoms  already  described  renders  the  diagnosis  of  tetany 
quite  easy.  The  disease  must  be  separated  from  Jacksonian  epilepsy  and  hysteria. 
This  can  be  done  by  the  development  of  Trousseau's,  Chvostek's,  and  the  other 
signs  just  named,  by  the  absence  in  tetany  of  the  various  stigmata,  including  the 
reversal  of  the  color  fields,  found  in  hysteria.  It  is  differentiated  from  Jacksonian 
epilepsy  by  the  prolonged  character  of  the  attack  and  the  fact  that  it  can  be  pro- 
duced at  the  will  of  the  physician.  Hysterical  contractures  sometimes  assume 
the  form  of  tetany,  and  cases  of  apparently  true  tetany  may  have  hysterical  features. 

Prognosis. — The  prognosis  as  to  life  is  good  unless  the  provoking  cause  is  in 
itself  serious,  as,  for  example,  when  the  parathyroid  glands  have  been  removed.  In 
other  words,  in  no  instance  does  tetany  itself  threaten  vitality,  although  the  under- 
lying cause  of  the  tetany  may.  Most  cases  recover.  Some  suft'er  from  only  one 
attack.  In  others  the  symptoms  disappear  after  many  attacks  as  soon  as  the  cause 
is  removed. 

Treatment. — This  deals  largely  with  the  removal  of  the  exciting  cause.  If 
gastric  dilatation  is  present  and  if  its  nature  is  such  that  it  can  be  benefited  by 
lavage  or  operation,  these  measures  must  be  instituted.  In  some  instances  where 
there  is  reason  to  believe  that  the  condition  results  from  auto-intoxication,  mild 
saline  purgatives,  diuretics,  and  moderate  doses  of  calomel  or  blue  mass  are  advis- 
able, and,  in  addition,  hot  packs  may  be  given  to  aid  in  the  elimination  of  poisons 
by  the  skin  and  to  act  as  nervous  sedatives.  Recent  investigations  have  shown 
that  tetany  in  animals  de\'eloping  after  tlie  removal  of  the  parathyroid  glands  can 
be  at  once  arrested  by  the  injection  of  an  extract  of  parathyroids.  Calcium  chloride 
or  lactate  often  exercise  a  remarkable  effect  for  good.  If  there  is  present  a  general 
condition  of  debility,  anemia,  iron,  arsenic,  and  similar  tonics  combined  with  an 
out-door  life  and  avoidance  of  nerve  irritation  are  essential. 


DISEASES  OF  THE  THYMUS  GLANDS 


cm 


DISEASES  OF  THE  THYMUS  GLAND. 

The  thymus  gland  is  found  well  developed  in  infants  up  to  the  second  year  of 
life,  after  which  time  it  gradually  decreases  in  size  till  it  reaches  a  degree  of  degenera- 
tion and  atrophy  in  which  it  may  be  said  to  no  longer  exist.  This  occurs  about 
the  time  of  puberty.  In  fully  developed  adults  it  is  represented  by  a  small  aggrega- 
tion of  lymphoitl  and  fatty  cells.  Very  rarely  the  thymus  persists  without  any 
change  in  its  tissues,  even  in  adult  life.     When  it  remains  large,  or  increases  in 


Hyperextension  of  the  head,  showing  how  compression  of  the  trachea  by  a  hyperplastic  thyinus  can 
take  place.  The  cervical  vertebrae  are  displaced  forward;  the  larynx  and  mediastinal  organs  are 
raised  upward;  the  thymus  is  caught  like  a  wedge  between  the  sternum  and  spinal  column.  Hence 
compression  of  windpipe.     (Klose  and  Crotti.) 

size  as  the  result  of  disease,  as  in  the  status  lymphaticus,  it  may  cause  symptoms 
by  pressing  on  the  trachea  and  the  great  vessels  of  the  neck  and  chest.  Persistent 
large  thymus  is  commonly  met  with  in  exophthalmic  goitre  and  probably  plays 
an  important  part  in  its  symptomatology.     (See  Exophthalmic  Goitre.) 

Actual  disease  of  the  thymus  gland  is  very  rare.  In  some  cases  a  state  of  so- 
called  hypertrophy  is  present,  but  this  is  rarely  a  true  hypertrophy,  the  gland  being 
swollen  and  filled  with  lymphoid  cells.     Occasionally  minute  hemorrhages  may 


694  DISEA.'^Efi  OF  THE  TIIYMCS  GL.WD 

take  place  into  its  tissues  or  hcneatli  its  cajjsiilc.  Al)scess  has  l)ecn  recorded  as 
having  occurred,  and  growths,  benign  and  malignant,  lia\-e  been  found  in  its  tissues. 
It  has  been  found  affected  by  tuberculosis. 

Many  years  ago  enlarged  thymus  was  sufjposed  to  l)c  the  cause  of  spasmodic 
croup.  That  an  enlarged  gland  may  cause  some  interference  with  respiration 
is  conceivable,  but  we  now  know  that  spasmodic  croup  is  usually  due  to  rickets 
or  postnasal  adenoids.  For  an  excellent  summary  of  the  subject  see  J.  P.  C. 
Griffith,  Nno  York  Medical  Journal,  September  4,  1909;  and  Andre  Crotti,  Jour, 
of  A.  M.  A.,  February  22,  1913. 

Enlarged  Thymus. — There  is  a  close  relationship  between  enlarged  thymus  and 
status  lyniphaticus  discussed  below.  Indeed  some  have  considered  that  it  is  the 
real  cause  of  death  in  the  latter  disease.  Death  from  enlarged  thymus  without 
general  lymphatic  tissue  does  occur  without  doubt.  As  early  as  1()14  Plater 
noted  the  frequent  presence  of  enlarged  thymus  in  cases  of  sudden  death.  Since 
then  a  large  number  of  reporters  have  recorded  such  cases.  Numerous  theories 
have  been  advanced  varying  from  hyperthymusism,  that  is,  oversecretion  of  the 
gland,  or  a  toxicosis.  Others  have  thought  that  the  gland  pressed  on  the  trachea 
or  caused  disorder  of  the  cardiac  nerves.  The  important  point  is  that  life  has  been 
saved  in  at  least  10  cases  by  excision,  partial  or  complete,  of  the  gland.  There 
have  been  chronic  cases  however  in  which  tracheal  pressure  has  been  recognized 
for  months.  Griffith  believes  that  the  condition  causing  death  may  be  pressure 
on  the  trachea  or  a  "neurosis." 

STATUS  THYMO-LYMPHATICUS. 

Definition.  —  The  term  status  thymo-lymphaticus  or  "lymphatic  constitution," 
sometimes  called  "  constitutio  h/mphatica,"  is  applied  to  a  state  which  occurs  chiefly 
in  children  or  infants,  and  which  is  characterized  by  lit/perp\asia.  of  the  lymph  nodes, 
the  thymus  gland,  and  the  spleen,  and  by  a  /(//poplasia  of  the  heart  and  arteries.  . 
The  lymphoid  bone-marrow  is  also  affected.  The  fact  of  particular  interest  is  that 
patients  with  this  condition  sometimes  suffer  sudden  death,  which,  coming  on 
in  children  who,  on  superficial  examination,  appear  unusually  robust  and  plump, 
is  all  the  more  startling. 

History. — As  long  ago  as  1614  Plater  made  note  of  the  fact  that  the  thymus 
gland  was  found  enlarged  in  certain  cases  of  sudden  death,  and  in  1830  Kopp 
described  a  form  of  difficult  breathing  which  he  called  "thymic  asthma,"  and  which 
he  considered  was  due  to  pressure  upon  the  trachea  by  an  enlarged  thymus  gland. 
This  view,  which  was  apparently  disproved  by  Friedleben  in  1S5S,  received  no 
further  support  until  in  1888  it  was  revived  by  Grawitz,  only  to  be  controverted 
again  by  Paltauf  in  1889. 

Etiology. — The  etiology  of  this  state  is  not  known,  Init  it  is  apparently  a  congenital 
fault,  and  is  associated  with  a  low  degree  of  vital  resistance  to  infection.  Hedniga 
has  reported  an  instance  in  which  out  of  a  family  of  nine  children,  five  died  of  this 
malady. 

Blumer  has  put  forward  certain  facts  which  seem  to  show  that  this  condition 
is  the  result  of  the  development  in  the  body  of  a  toxic  substance,  a  cytotoxin. 
To  this  state  the  term  lymphotoxismus  has  been  applied.  According  to  this  view, 
the  overgrowth  of  the  l\inphatic  tissues  in  the  dift'erent  parts  of  the  body  is  a 
sequence  of  the  action  of  this  jioison  and  not  the  cause  of  its  development. 

Pathology  and  Morbid  Anatomy. — An  autopsy  in  a  case  of  this  character  reveals 
an  overgrowth  and  swelling  of  the  lymph  nodes  in  the  thorax,  abdomen,  and 
cervical  and  inguinal  chains,  and  enlargement  of  the  tonsils.  The  lymph  nodes 
of  the  intestinal  tract  are  very  markedly  swollen  and  sharply  defined.  The  spleen 
appears  larger  than  normal,  and  the  lymphoid  tissue  of  the  Malpighian  bodies 


ADDISON'S  DISEASn  695 

is  in  a  state  of  overgrowth.  The  changes  in  the  thymus  gland  are,  however,  the 
most  important,  because  it  is  supposed  that  the  sud<ien  congestion,  h>])erpiasia, 
and  swelHng  of  the  gland  which  occurs  causes  death  by  pressure  upon  the  great 
vessels  of  the  neck  and  upon  the  trachea.  The  th\Toid  gland  may  also  be  enlarged. 
If  the  shafts  of  the  long  bones  are  opened,  yellow  marrow  is  found  to  be  substituted 
for  red  marrow.     The  heart  and  aorta  are  poorly  developed. 

Congestion  and  edema  of  the  lungs  have  been  found  in  some  cases  at  autopsy, 
and  in  others  atelectatic  patches  have  been  discovered.  In  all  of  these  cases  the 
pressure  upon  the  air  passages  was  responsible  for  these  changes. 

Symptoms. — There  are  no  pathognomonic  symptoms,  but  the  following  symptoms 
or  signs  are  very  suggestive.  An  enlargement  of  the  thymus  gland  and  overgrowth 
or  excessive  prominence  of  the  circumvallate  papillae  of  the  tongue.  Back  of 
these  papillae  are  enlarged  lymph  nodes  seen  by  the  aid  of  a  pharyngoscope.  The 
thyroid  gland  is  unduly  full  or  enlarged  and  the  heart  sounds  distant  and  feeble. 
There  may  be  a  soft  systolic  murmur  at  the  base  or  apex.  Lastly  there  is  manifest 
a  tendency  to  general  hyperplasia  of  all  the  lymphatic  structures.  The  child  is 
often  overgrown  and  unduly  heavy.  The  .r-rays  may  reveal  an  enlarged  thymus. 
The  recollection  of  the  possible  presence  of  this  state  should  make  the  physician 
particularly  careful  when  administering  an  anesthetic  to  a  child  of  the  lymphatic 
type,  especially  if  the  condition  to  be  relieved  is  overgrowth  of  the  lymph  tissues, 
such  as  postnasal  adenoids  and  spongy  tonsils,  as  sudden  death  may  ensue. 
Hand  has  reported  a  case  in  which  tetany  was  present.  jNIiloslavich  has  called 
attention  to  the  frequency  of  the  status  thymolymphaticus  in  suicides.  In  88 
of  110  autopsied  cases  in  soldiers  of  the  Austrian  army  he  found  evidence  of  the 
lymphatic  constitution  as  follows:  Status  thymolymphaticus  in  52;  status  lympha- 
ticus  in  23;  status  thymicus,  9;  combined  lesions,  4.  He  believes  that  this  condition 
induces  mental  changes  leading  to  suicide. 

Treatment. — We  know  so  little  of  the  cause  of  this  state,  and  so  few  cases  have 
been  subjected  to  treatment,  that  no  definite  plan  of  treatment  can  be  outlined, 
save  that  fresh  air  and  sunshine  and  iron  iodide,  and  arsenic  are  useful. 

If  the  thymic  enlargement  be  demonstrable,  operation  might  be  resorted  to. 
Rehn  opened  the  mediastinum,  drew  the  gland  forward  and  stitched  it  in  position; 
recovery  followed.  Carter  operated  on  a  case  for  tracheal  obstruction,  recognized 
the  thymic  enlargement,  and  introduced  a  tube  which  gave  temporary  relief,  but 
the  child  died.  More  recently  a  number  of  surgeons  have  advocated  extirpation 
in  whole  or  in  part. 


DISEASES  OF  THE  SUPRARENAL  GLANDS. 

ADDISON'S  DISEASE. 

Definition. — The  name  Addison's  disease  is  applied  to  a  condition  in  which  the 
patient  suffers  from  a  characteristic  pigmentation  of  the  skin,  pallor,  and  loss  of 
strength,  and  in  which  the  chief  microscopic  changes  are  alterations  in  the  supra- 
renal bodies. 

History. — Addison's  disease  gets  its  name  from  Thomas  Addison,  the  physician 
who  first  clearly  described  the  malady  in  1849  at  Guy's  Hospital,  London.  The 
condition  did  not  receive  attention  from  the  profession  in  general  until  1854,  when  - 
Addison  wrote  a  special  monograph  on  the  subject. 

Etiology  and  Pathology. — The  cause  of  Addison's  disease  is  not  known  in  the 
sense  that  we  recognize  a  cause  which  is  responsible  for  all  cases.  In  about  50 
per  cent,  of  the  cases  so  far  reported  which  have  come  to  autopsy,  tuberculosis  of 


696  DISEASES  OF  THE  SUPRARENAL  GLANDS 

the  suprarenal  glands  has  been  found.  That  this  lesion  is  not  sufficient  in  all 
cases  to  cause  the  general  systemic  manifestations  of  the  disease  is  proved  by  the 
fact  that  identical  changes  have  been  found  in  the  sujirarenal  bodies  when  none  of 
these  symptoms  have  been  present.  In  certain  cases  hemorrhages  into  tlie  supra- 
renal bodies  as  the  result  of  injuries  have  caused  the  symptoms  to  develop. 

As  a  matter  of  fact,  the  view,  as  to  the  relationship  of  these  causes  to  the  disease, 
expressed  by  Addison  fifty  years  ago  is  probably  correct,  namely,  that  any  lesion 
of  these  bodies  which  interferes  with  their  function  may  cause  the  malady. 

In  some  instances  the  disease  seems  to  be  primarily  the  result  of  pathological 
changes  in  the  semilunar  ganglia  of  the  abdominal  sympathetic  nervous  system. 
Rolleston  has  expressed  the  plausible  view  that  in  these  cases  the  disease  arises 
in  all  probability  by  reason  of  the  fact  that  the  glands  are  cut  off  in  circulation  and 
nerve  supply  by  growths  or  inflammatory  exudates. 

Morbid  Anatomy. — The  common  lesion  in  cases  of  Addison's  disease  is,  as  already 
stated,  tuberculosis,  and  next  to  this  in  frequency  is  atrophy.  The  tuberculous 
change  is  of  the  fibrocaseous  tj'pe,  except  in  rare  instances,  and  usually  begins  in 
the  medulla  of  the  gland.  The  stage  of  infiltration  is  followed  by  caseation  and 
commonly  more  or  less  fibrosis;  in  other  words,  there  is  an  attempt  at  healing. 
The  fibrocaseous  area  may  be  restricted  to  the  adrenal  or  extend  beyond  it.  Calci- 
fication is  not  uncommon,  and  pyogenic  infection  may  cause  abscess.  The  tuber- 
culous process  may  be  primary  and  confined  to  the  adrenal  body,  as  in  the  two 
cases  reported  by  Symes  and  Fisher. 

In  the  form  of  the  disease  in  which  atrophic  changes  occur  in  the  glands,  the 
wasting  may  be  so  complete  that  only  a  small  fibrous  mass  remains  to  indicate 
their  former  existence.  In  still  others  an  overgrowth  of  fibrous  tissue  resembling 
the  sclerosis  found  in  the  other  organs  of  the  body  may  take  place,  with  secondary 
atrophy  of  the  parenchyma.  Peterson  has  collected  26  such  cases.  In  still  other 
cases  the  glands  have  been  found  to  be  the  seat  of  hemorrhage  (adrenal  apoplexy), 
thrombosis  of  the  vessels,  or  malignant  disease.  The  changes  found  in  the  semi- 
lunar ganglia  and  in  the  plexuses  composing  the  abdominal  sympathetic  system 
are,  as  already  stated,  in  all  probability,  indirect  causes  of  the  disease,  although 
Hale  White  has  shown  that  changes  take  place  in  these  tissues  in  ordinary  individ- 
uals as  the  result  of  advancing  age.  It  is  difficult  to  determine,  therefore,  whether 
the  reports  of  changes  in  these  tissues  made  by  some  observers  have  been  really 
etiological  factors  in  the  disease.  Further,  a  very  large  proportion  of  cases  in 
which  Addison's  disease  has  been  present  have  failed  to  show  alterations  in  the 
semilunar  ganglia  or  in  the  abdominal  sympathetic.  In  some  cases  a  hyperplasia 
of  the  lymphoid  structures  in  the  alimentary  canal  has  been  noted. 

That  there  have  been,  and  are  in  existence  at  present,  several  theories  as  to 
the  lesions  which  result  in  Addison's  disease  must  have  been  CAndent  from  what  has 
already  been  said.  The  only  ones  that  have  received  general  recognition  have 
been  the  "nervous  theory,"  that  the  disease  was  due  to  changes  in  the  abdominal 
nervous  apparatus;  or  the  original  theory  of  Addison,  that  it  is  due  to  failure  of 
the  suprarenal  glands  to  carry  out  their  normal  function.  The  nervous  theory 
has  now  been  generally  cast  aside,  and  we  have  left  Addison's  own  proposition 
modified  by  our  extended  knowledge  of  internal  glandular  secretion.  Space  does 
not  permit  a  discussion  of  the  views  for  and  against  this  opinion.  These  can  be 
found  exhaustively,  and  most  capably,  discussed  by  Rolleston  in  Allbutt's  Si/stnn 
of  Medicine,  vol.  iv.  Suffice  it  to  say,  that  the  opinion  generally  held  today  is 
'that  these  symptoms  come  on  because  the  suprarenal  secretion  fails  to  find  its 
way  into  the  general  economy.  Changes  in  the  sympathetic  nervous  system  may 
also  be  a  factor. 

Finally,  it  is  not  to  be  forgotten  that  Addison's  disease  may  be  present  without 
noticeable  lesions  in  the  suprarenal  bodies,  and  it  is  also  a  fact  that  these  bodies 


ADDISON'S  DISEASE  697 

may  be  almost  completely  destroyed  by  a  growth  or  by  tuberculosis  without  any 
symptoms  of  this  malady  developing. 

The  pigmentation  of  the  skin  is  due  to  the  deposition  of  pigment  in  the  cells  of 
the  Malpighian  stratum,  and  according  to  Earkshevitcli,  who  studied  the  skin 
removed  from  a  living  subject,  in  the  subjacent  tissues.  The  pigmented  cells  are 
supposed  to  obtain  their  pigment  from  the  hemoglobin  of  the  blood,  but  they 
contain  no  iron.  The  discoloration  of  the  mucous  membranes  is  due  also  to  the 
deposit  of  pigment.  The  pigmentation  of  the  mucous  membranes  is  in  patches, 
and  Mann  asserts  that  it  is  deposited  only  where  the  parts  are  rubbed  or  subjected 
to  causes  that  produce  hyperemia. 

Symptoms. — The  symptoms  of  Addison's  disease  are  chiefly  those  which  are 
represented  by  the  term  general  asthenia.  The  patient  gives  the  history  of  being 
easily  tired  and,  indeed,  of  a  constant  sense  of  fatigve.  Even  after  a  night's  rest 
he  feels  as  weary  in  the  morning  as  when  the  went  to  bed.  The  sensation  of  feeble- 
ness is  associated  with  profound  muscular  weakness  as  the  disease  progresses,  but 
there  is  little  or  no  true  emaciation.  The  term  "  invvncihle  languor"  used  by 
Rolleston  well  describes  the  patient's  state.  An  examination  of  the  heart  shows 
its  muscle  is  greatly  enfeebled,  so  that  the  cardiac  sounds  are  lacking  in  normal 
tone.  The  jnilse  is  soft,  and  easily  extinguishable  by  the  pressure  of  the  finger. 
The  extremities  are  cold  and  the  general  body  temperature  may  be  subnormal. 
Anemia  is  well  marked,  but  usually  not  excessive,  the  blood  cells  being  decreased 
to  3,000,000  or  a  little  lower. 

No  mention  as  yet  has  been  made  among  this  list  of  symptoms  of  the  one  char- 
acteristic manifestation  of  the  malady  which  is  practically  pathognomonic,  namely, 
the  -pigmentation  of  the  skin.  While  its  peculiarities  would  naturally  lead  one  to 
speak  of  it  first,  mention  of  it  has  been  delayed  because  its  appearance  is  often 
delayed  until  the  other  symptoms  are  quite  well  developed.  In  other  words, 
it  usually  follows  and  does  not  precede  the  constitutional  manifestations  of  the 
disease.  There  are,  however,  rare  exceptions  to  this,  and  cases  have  been  recorded 
in  which  the  pigmentation  has  been  present  for  long  periods  before  any  other  signs 
"  of  Addison's  disease  developed.  The  pigmentation  may  be  over  the  entire  body, 
but  as  a  rule  it  is  in  patches,  and  chiefly  affects  the  skin  of  the  face,  of  the  neck, 
and  the  extensor  surfaces  of  the  hands  and  forearms.  If  the  mucous  membrane  of 
the  mouth  is  examined  the  lips  at  the  point  of  contact  are  noticeably  darkened  and 
the  edges  of  the  tongue,  particularly  on  its  under  surface,  may  show  discoloration 
as  if  ink  had  been  taken  into  the  mouth. 

Diagnosis. — Except  in  well-defined  cases  it  may  require  weeks  or  months  of 
watching  to  determine  that  a  patient  has  this  malady.  Pregnancy  not  rarely  is 
associated  with  the  presence  of  pigmented  spots  on  the  skin,  but  the  condition 
of  the  uterus  and  its  contents  prevent  a  mistake  being  made  as  to  the  cause.  In 
some  cases  of  hypertrophic  cirrhosis  of  the  liver  there  may  be  in  addition  to  jaundice 
very  marked  pigmentation.  I  have  under  my  care  at  the  time  this  is  written  a 
man  who  has  hypertrophic  cirrhosis,  jaundice,  and  such  deep  pigmentation  of  the 
skin  that  he  looks  as  if  coated  with  coal-dust.  In  such  a  case  the  state  of  the  liver 
reveals  the  cause. 

In  the  rare  malady  called  diabetes  bronze,  in  which  there  is  hypertrophic  cirrhosis, 

jaundice,  diabetes,  and  pigmentation  of  the  skin,  the  state  of  the  liver  and  urine 

will  aid  in  the  differentiation.     In  certain  cases  of  advanced  pulmonary  tuberculosis 

'  the  skin  is  pigmented  a  dirty  brown,  and  in  patches  may  be  considerably  discolored, 

but  here  the  pulmonary  state  prevents  confusion  as  to  its  cause. 

The  prolonged  use  of  arsenic  may  have  a  similar  effect,  not  only  on  the  extremities, 
but  on  the  skin  of  the  chest  and  abdomen,  which  may  become  much  darker  than 
normal  without  any  neuritis  being  present.  In  syphilitics  the  site  of  old  eruptions 
may  be  stained,  and  in  vagabonds  who  are  infested  with  lice,  and  have  been  much 


098  DTSEA.'^E,'^  OF  THE  SUPRAREXAL  CLAXDS 

exposed  to  the  wcatlier,  areas  of  discoloration  of  the  si<iii  may  l)e  present.  It  is 
said  tiiat  the  discoloration  of  the  si\in  called  chronic  arjjyria,  due  to  the  ])rolonged 
use  of  silver  internally,  has  been  confused  with  the  state  of  the  skin  in  Addison's 
disease.  This  would  be  scarcely  possible  if  the  observer  had  ever  seen  a  case  of 
chronic  silver  poisoning,  for  the  discoloration  of  argyria  is  a  peculiar  lividity  rather 
than  the  appearances  of  a  pigmentation,  and  it  is  uniform  on  exposed  parts  of  the 
body. 

As  Addison's  disease  is  due  in  a  large  proportion  of  cases  to  tuberculosis  of  the 
adrenal  bodies,  the  tuberculin  test  may  be  employed  to  give  additional  information 
in  the  case;  but  even  if  this  test  is  positive  the  possibility  of  tuberculous  foci  else- 
where giving  the  reaction,  and  the  fact  that  syphilitics  sometimes  react,  should 
make  us  hesitate  before  resting  too  heavily  upon  this  means  of  diagnosis.  (See 
Tuberculin,  in  section  on  Tuberculosis.) 

Prognosis.  —  It  may  be  stated  that  given  a  patient  with  Addison's  disease 
developed  so  far  that  a  diagnosis  is  certain,  then  death  from  the  malady  is  certain 
also.  Lewin  in  a  collection  of  500  cases  found  that  5  were  cured  and  28  improved. 
In  the  2  cases  I  have  seen,  1  of  which  is  now  under  observation,  the  disease  had, 
at  times,  certainly  been  arrested  in  its  progress  under  the  use  of  full  doses  of  supra- 
renal gland.  Because  of  the  gradual  development  of  the  malady,  its  average 
duration  is  difficult  to  determine,  but  its  course  is  not  very  rapid.  Wilks  believes 
it  to  be  about  eighteen  months,  but  in  some  cases  it  lasts  for  years.  \'ery  rapidly 
fatal  cases  are  also  on  record. 

Treatment. — The  question  of  the  proper  plan  of  treatment  of  Addison's  disease 
cannot  be  answered  positively  until  the  pathologist  is  able  to  give  us  a  clear  con- 
ception of  the  morbid  processes  which  produce  the  chain  of  symptoms  already 
described.  The  very  fact  that  different  pathological  changes,  or  diseases,  afifect 
the  suprarenal  bodies,  and  so  produce  the  symptoms  of  this  malady,  indicates 
that  the  therapy  must  vary  with  the  cause.  Theoretically  the  use  of  suprarenal 
gland  of  the  sheep  is  indicated  in  every  case,  bait  practical  experience  has  shown  that 
only  in  a  small  proportion  of  those  cases  in  which  it  has  been  used  has  it  done  good. 
It  is  not,  therefore,  to  be  compared  to  the  value  of  thyroid  gland  in  myxedema  or 
cretinism.  It  has  been  proved  that  suprarenal  gland  has  little  effect  on  blood 
pressure  if  it  is  taken  by  the  stomach,  and  that  its  active  principle  when  in  concen- 
trated form  often  causes  abscess  when  it  is  given  hypodermically.  Probably  the 
best  plan  is  to  give  the  patient  adrenalin  chloride  in  normal  salt  solution  by  hypo- 
dermoclysis  every  day  or  every  other  day,  using  1  to  2  drachms  of  the  adrenalin 
chloride  (1: 1000  solution),  as  put  upon  the  market,  to  a  half-pint  or  pint  of  saline 
fluid.  When  the  desiccated  gland  is  used  by  the  mouth,  from  2  to  10  grains  may 
be  given  three  times  a  day  in  capsule.  It  is  unfortunately  true  that  even  when 
the  adrenalin  gland  is  freely  used,  the  disease  is,  at  the  best,  only  delayed  in  its 
progress  in  most  cases. 

Adams  has  collected  97  cases  treated  with  suprarenal  gland.  Of  these  7  were 
made  worse,  43  experienced  no  real  benefit,  81  showed  marked  impro\cment,  and 
IG  were  said  to  be  cured.  In  the  successful  cases  the  gland  was  given  solely  by 
the  mouth.  If  the  patient  is  at  all  feeble  he  should  be  kept  in  bed,  not  only  because 
in  this  manner  we  conserve  his  flagging  energies,  but  also  l)ecause  a  number  of 
cases  of  syncope  and  sudden  death  from  this  disease  have  occurred  in  patients 
who  have  made  a  sudden  efl'ort.  An  easily  digested  diet,  the  avoidance  of  purga- 
tives which  may  induce  dangerous  purging,  and  the  use  of  iron  and  arsenic  as 
tonics  form  the  rest  of  the  treatment. 


ACROMEGALY  699 


DISEASES  OF  THE  PITriTARY  BODY. 

DYSPITUITARISM. 

A  number  of  remarkable  disturbances  of  nutrition  and  growth  are  now  known 
to  be  due  to  perverted  function,  or  loss  of  function,  of  the  anterior  and  posterior 
lobes  of  the  pituitary  body.  They  vary  according  to  whether  the  secretion  of  the 
lobes  is  increased  or  decreased.  In  many  instances  a  lesion  in  the  cella  turcica 
is  revealed  by  the  .r-rays  or  the  surgeon.  Those  in  which  the  secretion  of  the  anterior 
lobe  is  increased  are  chiefly  acromegaly  and  gigantism. 

ACROMEGALY. 

Definition.  —  Acromegaly  is  a  slowly  developing  chronic  disease  of  nutrition 
characterized  by  an  overgrowth  of  the  extremities  and  head,  and,  to  a  less  degree, 
of  the  trunk,  with  associated  curvature  of  the  dorsal  and  cervical  spine.  It  is 
sometimes  called  "Marie's  disease,"  because  INIarie  first  described  it  in  1886. 

Etiology. — The  condition  arises  frorii  disease  of  the  anterior  lobe  of  the  pituitary 
body  caused  by  hypersecretion  of  this  lobe.  Acromegaly  rarely  appears  before 
the  thirtieth  year,  but  several  cases  have  been  recorded  at  an  earlier  age. 

Symptoms. — The  appearance  of  a  patient  suffering  from  this  disease  is  so  peculiar 
and  striking  that  there  is  no  difficulty  in  diagnosis,  if  the  malady  is  well  developed. 
The  massive  and  gigantic  appearance  of  the  head,  of  t)[i&  features  of  the/acp,  and, 
on  closer  inspection,  the  enlargement  of  the  hands,  and  the  increase  in  the  length 
of  the  long  bones,  combined  with  the  kyphosis  of  the  spine,  make  the  clinical  picture 
complete.  The  upper  part  of  the  forehead  appears  low  because  of  the  abnormally 
prominent  superciliary  ridges,  and  this  effect  is  exaggerated  by  the  projection  of 
the  lower  jaw.  As  a  consequence,  the  shape  of  the  face  is  elliptical.  The  skin  of 
the  face  is  thick  and  sallow  and  greasy  in  appearance,  and  lies  upon  the  forehead 
in  heavy  transverse  creases.  The  cheeks  appear  sunken,  chiefly  because  of  the 
great  overgrowth  of  the  malar  bones.  The  nose  is  not  only  greatly  enlarged,  but 
often  increases  in  size  more  rapidly  than  the  other  features,  so  that  it  seems  out  of 
proportion  with  the  rest  of  the  head.  The  nostrils  are  hea^y,  thick,  and  immovable. 
Not  rarely  the  superior  maxillary  bone  fails  to  develop  as  rapidly  as  nearby  tissues, 
and  as  a  consequence  the  upper  jaw  may  seem  sunken,  an  effect  increased  by  the 
enormous  nose  above  and  the  overgrown  lower  jaw  below  it.  This  effect  is  also 
increased  by  the  great  enlargement  and  tMchening  of  the  lower  lip.  An  examina- 
tion of  the  mouth  will  reveal  the  fact  that  the  iongxie  and  ^l^mla  are  broader  and  thicker 
than  normal.  The  thorax  on  inspection  will  be  seen  to  be  greatly  increased  in  its 
anteroposterior  diameter,  which  is  in  excess,  as  compared  to  its  lateral  diameter. 
The  ribs  are  enlarged  and  the  clavicles  thickened,  but  the  abdomen  often  appears 
sunken  because  of  the  projection  forward  of  the  lower  part  of  the  thorax.  The 
muscles  may,  in  the  early  stages,  seem  increased  in  size  and  in  power,  but  the 
dominant  tendency  is  to  muscular  atrophy.  No  changes  of  importance  take  place 
in  the  internal  viscera.  Blindness,  partial  or  complete,  may  develop,  due  to  optic 
neuritis.     Rarely  nystagmus  and  squint  have  appeared.     (See  Figs.  122  and  123.) 

The  subjective  symptoms — that  is,  those  complained  of  by  the  patient — consist 
in  headache,  dimness  of  vision,  and  pains  in  the  joints.  There  is  usually  slowness 
of  thought  and  perhaps  actual  drowsiness. 

Diagnosis. — Acromegaly  must  be  differentiated  from  gigantism,  leontiasis  ossea, 
myxedema,  arthritis  deformans,  osteitis  deformans,  and  pulmonary  hypertrophic 
osteo-arthropathy.  Perhaps  the  most  frequent  error  in  diagnosis  is  that  of  confusing 
mjTvedema  with  acromegaly,  but  in  myxedema  there  is  never  any  actual  increase 


700 


DT.'^EAfiES  OF  THE  PITJITARY   BODY 


in  the  size  of  the  bones.     The  face  in  myxedema  is  round  and  full  instead  of  ellip- 
tical, and  the  ends  of  the  fingers  are  swollen  and  thickened  instead  of  the  whole 


Acromegaly,  showing  the  large  hands,  nose,  and  superciliary  ridges. 


ACROMEGALY  701 

hand  being  manifestly  enlarged,  as  in  the  disease  under  consideration.  Again, 
in  myxedema  the  skin  is  pale,  puffy,  and  waxen  in  appearance,  devoid  of  hair  and 
also  of  wrinkles,  whereas  in  acromegaly  the  skin  upon  the  face  is  wrinkled  and  there 
is  no  marked  falling  of  the  hair. 

Gigantism  is  separated  from  acromegaly  by  the  fact  that  there  is  a  symmetrical 
overgrowth  all  over  the  body,  whereas,  as  has  already  been  pointed  out,  the  enlarge- 
ment in  acromegaly  affects  chiefly  the  extremities  and  the  tissues  of  the  face. 
Further  than  this,  in  gigantism  the  ends  of  the  bones  are  not  enlarged  to  such  an 
extent  as  to  be  out  of  proportion  to  the  shaft,  and  in  acromegaly  this  disproportion 
is  quite  constant.     (See  below.) 

Leontiasis  ossea  is  characterized  by  the  development  of  bony  tumors  or  osteo- 
phytes on  the  face  and  cranium  which  produce  great  deformity,  but  there  is  no 
marked  enlargement  of  any  one  feature  nor  of  the  extremities. 

Osteitis  deformans  is  differentiated  from  acromegaly  by  the  fact  that  the  long 
bones  are  chiefly  affected,  are  apt  to  be  curved,  and  so  produce  great  deformity. 
But  there  is  no  marked  enlargement  and  the  deformity  is  very  apt  to  be  asymmetri- 
cal. In  osteitis  deformans  the  facial  bones  are  rarely  affected,  but  the  cranial 
bones  are  involved  in  the  pathological  process;  whereas,  in  acromegaly  it  is  the 
facial  bones  which  are  affected,  the  other  cranial  bones  being  but  slightly  diseased. 
Finally,  and  perhaps  most  important,  the  face  of  a  case  of  osteitis  deformans  is 
broadened  in  its  upper  portion  and  narrowed  in  its  lower  portion,  giving  it  a  triangu- 
lar appearance;  whereas,  in  acromegaly  the  lower  part  of  the  face  is  broad,  and 
therefore  the  general  effect  is  elliptical. 

In  pulmonary  hypertrophic  osteo-arthropathy  there  is  enlargement  of  the  hands 
and  feet,  but  no  enlargement  of  the  face,  and  there  is  always  found  marked  chronic 
pulmonary  lesion,  such  as  bronchiectasis,  empyema,  or  other  serious  thoracic 
disease.  A  close  examination  of  the  hands  and  feet  will  show  that  the  enlargement 
is  confined  chiefly  to  the  joints,  and  that  the  whole  hand  is  not  thickened  and 
increased  in  size  as  in  acromegaly. 

Gigantism  occurs  instead  of  acromegaly  from  hypersecretion  of  the  anterior 
lobe  of  the  pituitary,  in  cases  in  which  the  epiphyseal  centres  have  not  undergone 
ossification. 

The  cases  in  which  there  is  hypersecretion  of  the  posterior  lobe  are  divisable  as 
follows : 

The  Type  Frohlich  are  characterized  not  by  overgrowth  of  bone  but  by  excessive 
adiposity  and  the  peculiarity  that  in  males  the  fat  is  deposited  in  the  regions  char- 
acteristic of  its  distribution  in  females.  There  is  arrested  development  of  the 
genitals,  a  lack  of  growth  of  hair,  a  small  stature,  a  subnormal  temperature  and  an 
extraordinary  tolerance  of  an  excess  of  carbohydrate  food.  Thus,  such  cases  can 
ingest  over  150  grams  of  glucose  or  100  grams  of  levulose  without  developing 
glycosuria.  There  are  present  also  various  psychoses.  Such  patients  are  usually 
children. 

The  Type  Burnie  is  due  apparently  to  hypersecretion  of  both  the  anterior  and 
posterior  lobes  and  is  characterized  by  dwarfism,  atrophy  of  the  genitals,  internal 
and  external,  adiposity  and  optic  nerve  atrophy  and  is  due  probably  to  the  growth 
of  a  tumor  in  the  gland. 

The  Type  Cxishing  apparently  depends  upon  an  alternating  hyposecretion  and 
hypersecretion  of  one  or  the  other  lobe.  These  cases  may  present  the  chief  symp- 
toms already  described  as  to  overgrowth  of  the  bones  and  adiposity  with  lack  of 
development  of  the  sexual  apparatus  but  do  not  develop  acromegaly. 

Treatment. — The  treatment  is  chiefly  surgical  and  is  designed  rather  to  relieve 
symptoms  caused  by  pressure  induced  by  the  growth  in  the  gland  than  to  effect 
a  cure.     Decompression  may  be  performed  or  part  or  all  of  the  growth  removed. 


702  DISEASES  OF  THE  SPLEEN 

INIedically  the  administration  of  the  anterior  or  posterior  lobe  from  an  animal  may 
be  resorted  to  by  the  mouth,  or  an  extract  may  be  given  hypodermically.  The 
transplantation  of  the  pituitary  gland  of  an  animal  to  the  subcutaneous  tissues  of 
the  patient  may  be  tried.  Where  the  condition  arises  from  hypersecretion  these 
hitter  measures  are  of  course  useless. 


INFANTILISM. 

Infantilism  is  an  anomaly  of  development  characterized  by  the  persistence  of 
the  morphological  characters  of  childhood  in  an  individual  who  has  reached  or 
passed  the  age  of  puberty  (Meige).  This  delay  of  physical  development  is  accom- 
panied by  a  delay  in  psychical  development  (Hutinel).  There  are  two  chief  types 
of  infantilism:  the  Brissaud  type  is  associated  with  thyroid  deficiency;  whereas 
the  Lorain  type  is  associated  with  other  conditions,  and  presents  a  picture  of  quite 
a  different  character.  The  first  type  is  often  overgrown;  the  second  type  has 
been  well  compared  to  the  figure  of  an  adult  seen  through  the  wrong  end  of  a  pair 
of  opera-glasses,  thereby  emphasizing  their  diminutive  stature.  As  a  matter  of 
fact,  aside  from  the  appearance  of  being  a  miniature  of  a  man,  there  are  other  abnor- 
malities which  show  in  the  expression  of  the  face  and  in  the  movements.  Predis- 
posing causes  or  direct  etiological  factors  are  tuberculosis,  congenital  syphilis  and 
disease  of  the  glands  which  carry  on  internal  secretion,  namely,  the  pituitary, 
the  suprarenal,  the  thyroid,  thymus  and  testicles.  Sometimes  the  direct  etiological 
factor  seems  to  be  heart  disease,  especially  mitral  stenosis,  or  hypertrophic  hepatic 
cirrhosis.  In  a  few  instances  gastro-intestinal  infections  characterized  by  recurrent 
attacks  of  diarrhea  seem  to  be  provocative.  In  so-called  "  celiac  disease,"  in  which 
a  child  suffers  from  a  chronic  condition  characterized  by  the  passage  of  bulky  stools, 
infantilism  sometimes  occurs  and  is  thought  to  be  due  to  pancreatic  insufficiency. 
Diabetes  and  syphilis  occurring  in  infancy  also  seem  to  be  causes,  and  various 
poisons,  such  as  lead,  mercury,  tobacco  and  carbon  bisulphide  may  induce  it. 
The  prognosis  is  unfavorable  unless  the  underlying  cause  can  be  remo\"ed  or  the 
secretion  of  an  internal  gland  substituted,  as  thyroid  extract.  If  the  pituitary 
gland  is  deficient,  an  extract  of  the  entire  gland  rather  than  of  one  lobe  should  be 
used.  Hutinel  warns  against  the  use  of  thyroid  extract  in  those  patients  who  are 
tuberculous  and  recommends  that  if  it  is  given  arsenic  should  also  be  administered. 


DISEASES  OF  THE  SPLEEN. 

Diseases  of  the  spleen  occurring  inde]5endently  of  other  diseases  may  be  said 
not  to  exist.  In  myelogenous  leukemia,  in  splenic  anemia,  in  malarial  fever,  and 
in  cases  of  hepatic  cirrhosis  or  heart  disease,  the  spleen  is  often  greatly  enlarged, 
but  in  no  case  is  this  condition  jjrimary.  So,  too,  in  the  prolonged  infectious 
fevers,  such  as  typhoid  fever,  the  spleen  is  usually'  swollen. 

In  some  cases  the  surface  of  the  spleen  may  be  traversed  by  a  crevice  or  indenta- 
tion which  almost  divides  its  body  into  different  parts,  and  in  others  there  may  be 
found  an  accessory  spleen  or  accessory  spleens  in  nearby  parts  of  the  al)d(iiiiinal 
cavity.     In  very  old  people  the  spleen  is  often  greatly  atrophied. 

An  infarct  of  the  spleen  is  due  to  an  embolus  which  usually  has  its  origin  in  the 
heart,  or  which  arises  from  some  area  of  septic  infection,  or  in  other  cases  a  thrombus 
forms  in  the  splenic  vein  and  produces  a  similar  effect.  The  latter  condition  is  the 
cause  of  the  infarct  met  with  in  typhoid  fever  and  in  leukemia. 


Df.SEASES  OF  THE  SPLEEN  703 

Abscess  of  the  spleen  as  the  result  of  septic  infection  is  by  no  means  rare,  and 
such  abscesses  always  depend  upon  infected  emboli. 

Hydatid  cyst  of  the  spleen  is  rare  not  only  because  hydatid  cyst  is  rare  in  tliis 
country,  but  also  it  seldom  develops  in  this  gland  even  in  those  parts  of  the 
world  in  which  hydatid  disease  is  common. 

Malignant  growths  in  the  spleen  are  among  the  rarest  pathological  lesions.  Pri- 
mary growths  are  practically  unknown  and  secondary  growths  are  also  very  rare. 
From  statistics  at  St.  George's  Hospital,  London,  collected  by  Walker,  it  is  found 
that  in  161  cases  of  carcinoma  involving  all  parts  of  the  body  secondary  growths 
appeared  in  the  spleen  seven  times,  and  in  .50  cases  of  sarcoma  the  spleen  was 
affected  once.  Taylor  in  677  cases  of  carcinoma,  epithelioma,  and  sarcoma  found 
secondary  growths  in  the  spleen  in  twenty-three  instances.  Sometimes  in  cases 
of  cancer  of  the  gallbladder  or  of  the  pylorus  the  growth  extends  to  the  spleen 
by  direct  invasion. 

Movable  spleen,  like  movable  kidney,  is  a  condition  in  which  this  organ  wanders 
away  from  its  normal  position  so  that  it  may  be  found  far  removed  from  its  ordinary 
area,  and  even  so  low  as  the  pelvis.  Its  displacement  is  usually  associated  with  a 
sense  of  dragging  in  the  left  hypochondrium  or  loin,  and  if  the  pedicle  becomes 
twisted  great  pain  may  be  suffered,  with  fever,  collapse,  and  finally  necrosis  of  the 
splenic  tissues.  Osier  records  a  case  in  which  this  occurred  and  in  which  abdominal 
section  resulted  in  recovery,  although  a  considerable  part  of  the  spleen  was  lost  by 
sloughing. 

It  is  necessary  to  separate  wandering  spleen  from  floating  kidney.  This  can 
be  done  by  the  discovery  of  the  splenic  notch,  by  the  greater  sense  of  resistance  in 
the  otherwise  normal  kidney,  and  by  the  presence  of  resonance  on  percussion  in 
the  splenic  area  where  splenic  dulness  is  usually  demonstrable. 

Rupture  of  the  spleen  is  a  rare  accident,  but  occurs  occasionally  in  those  who, 
while  suffering  from  great  congestion  or  enlargement  of  this  organ,  meet  with  an 
accident  in  which  the  splenic  area  is  subjected  to  a  severe  blow.  Cases  are  also 
on  record  in  which  the  spleen  has  ruptured  as  the  result  of  great  distention.  Rup- 
ture of  the  spleen  will  be  found  discussed  under  ^Malaria.  The  symptoms  are  those 
of  internal  hemorrhage  and  demand  an  immediate  abdominal  section. 

The  treatment  of  wandering  spleen  consists  in  the  wearing  of  a  bandage  and 
pad  to  retain  the  organ  in  its  place,  and,  if  need  be,  we  may  resort  to  an  operation 
to  fix  it  by  causing  adhesions  to  form  around  it.  Extirpation  of  the  spleen  has 
been  advised  in  cases  in  which  the  symptoms  are  very  distressing,  but  this  should 
be  done  only  when  the  condition  is  very  urgent. 

In  considering  disease  of  the  spleen  several  facts  must  be  borne  in  mind.  During 
embryonal  existence  it  is  an  important  factor  in  the  formation  of  red  blood  cells 
but  after  birth  this  function  ceases,  the  bone  marrow  taking  its  place.  It  is  con- 
cerned in  the  production  of  leukocytes,  chiefly  lymphocytes.  On  the  other  hand 
the  spleen  seems  to  control  the  activity  of  the  bone-marrow  and  there  is  evidence 
that  it  may  be  actively  engaged  in  hemolysis  and  for  this  reason  extirpation  may 
cure  certain  cases  of  excessive  hemolysis.  When  the  cause  of  hemolysis  is  not  in 
the  spleen  this  operation  is  useless.  Among  the  diseases  in  which  the  spleen  is 
responsible  may  be  mentioned  congenital  hemolytic  icturus,  in  which  during  the 
whole  of  a  long  life  there  is  moderate  icturus  with  sharp  exacerbations  and  more 
or  less  anemia  with  excessive  urobilinuria;  acquired  hemolytic  icturus  which 
may  last  for  years  or  cause  death  in  two  or  three  years  and  is  characterized  in 
its  severe  forms  by  jaundice,  stupor  or  delirium,  sometimes  fever,  and  as  severe 
anemia,  as  in  true  pernicious  anemia.  There  is  marked  urobilinuria  and  the  icterus 
is  not  hepatic  but  hemic.  The  dividing  line  between  this  type  and  the  splenome- 
galie  hemolytique  of  Banti  is  difficult  to  draw.     (See  Banti's  Disease.) 

There  is  still  another  class  of  cases  in  which  splenomegaly  is  associated  with 


704  DISEASES  OF  THE  SPLEEN 

anemia  and  true  hepatic  jaundice  with  or  witliout  hepatic  cirrhosis,  tlie  hepatic 
lesions  being  induced  by  thrombosis  and  rupture  of  the  bile  cai^ilhirics,  jjossibly 
due  to  excessive  hemolysis.  When  the  urine  is  loaded  with  uroljilin  this  type  may 
be  benefited  by  splenectomy.  The  dividing  line  between  Ilanot's  cirrhosis  of  the 
liver,  Banti's  disease,  and  this  condition,  is  often  impossible  to  define. 

SPLENIC  ANEMIA. 

Definition. — Among  the  types  of  si)lenomegaly  the  condition  known  as  splenic 
anemia  is  one  about  which  great  difference  of  opinion  has  existed.  Its  existence 
has  been  denied  by  some  physicians  and  asserted  by  others.  At  present  it  is 
generally  considered  that  a  distinct  morbid  state  really  exists  to  which  this  name 
may  be  applied.  It  is  essentially  a  condition  of  anemia  with  enlargement  of  the 
spleen,  and  lacks  all  of  the  additional  conditions  which  are  associated  with  this 
state  in  other  maladies,  as,  for  example,  leukemia,  lymphadenoma,  or  lymphatic 
leukemia. 

Etiology. — This  is  unknown,  but  some  suppose  it  to  be  due  to  intestinal  infection. 

Pathology  and  Morbid  Anatomy. — An  examination  of  the  spleen  in  this  disease 
shows  that  it  is  not  only  greatly  enlarged,  but  that  it  shows  signs  of  the  existence 
of  a  perisplenitis  with  localized  areas  of  capsular  thickening.  In  some  portions 
of  the  organ  old  infarcts  may  be  found  which  in  turn  ha\'e  caused  puckering  of  its 
surface  or  depressed  scars.  When  the  spleen  is  cut  it  is  found  to  be  more  resistant 
to  the  knife  than  normal,  and  it  is  somewhat  fibroid.  If  a  section  is  placed  under 
the  microscope  it  is  found  that  the  connective  tissue  is  increased  and  the  lymphoid 
elements  wasted.  The  Malpighian  bodies  are  fibroid.  There  is  also  in  some 
cases  a  marked  proliferation  of  the  endothelial  cells  which  line  the  blood  sinuses. 
These  cells  are  very  large  and  may  be  so  numerous  as  to  fill  these  spaces  till  they 
resemble  an  endotheliomatous  growth. 

Dock  and  Warthin  have  called  particular  attention  to  hyperplasia  of  the  hemo- 
lymph  nodes  and  thrombosis  of  the  splenic  vein.  The  association  of  splenic  fibrosis 
with  enlargement  and  cirrhosis  of  the  liver  constitute  the  type  studied  by  Banti 
(Banti's  disease),  and  this  is  thought  to  be  a  later  stage  of  the  process  characterized 
in  its  early  manifestations  by  splenic  enlargement.     (See  Banti's  Disease.) 

Symptoms. — The  symptoms  of  splenic  anemia  are  ixtllor,  dyspnea  on  exertion, 
and  feebleness,  associated  with  enJarciement  of  the  spJeen.  An  examination  of  the 
blood  does  not  throw  any  great  light  on  the  character  of  the  case.  Indeed,  the 
blood  changes  are  often  in  no  way  different  from  those  of  lymphadenoma  or  gumma 
of  the  spleen.  The  red  cells  number  about  3,500,000,  and  the  hemoglobin  equals 
about  50  per  cent.  When  the  disease  is  advanced  poikilocytes  and  nucleated  red 
cells  are  present.  The  white  cells  are  not  increased  as  in  leukemia,  but  usually 
are  below  the  normal  number,  amounting  to  about  4500  per  c.mm. 

Diagnosis. — The  diagnosis  of  splenic  anemia  is  very  difficult  and  should  not 
be  reached  until  a  careful  study  of  the  patient's  past  and  present  condition  has 
been  made  and  his  blood  repeatedly  examined.  A  considerable  number  of  cases 
of  so-called  splenic  anemia  have  proved  to  be  other  diseases  when  studied  longer 
or  examined  postmortem.  All  possible  causes  for  enlargement  of  the  spleen  should 
be  excluded  before  a  decision  is  reached. 

Splenic  anemia  must  be  separated  from  the  "anemia  infantum"  of  von  Jaksch, 
in  which  the  spleen  is  enlarged,  but  in  which  the  changes  in  the  blood  consist  in 
a  great  increase  in  the  white  cells  and  marked  oligocythemia.  This  condition 
must  also  not  be  confused  with  enlargement  of  the  spleen  due  to  syphilis  with  the 
formation  of  gummata;  nor  with  sarcoma  of  the  spleen;  nor  with  the  anemia  of 
chronic  malarial  poisoning,  with  secondary  splenic  enlargement,  nor  with  amyloid 
disease.     It  must  also  be  separated  from  the  anemia  associated  with  enlargement 


GAUCHE  It's  DISEASE  705 

of  the  spleen  secondary  to  cirrhosis  of  the  liver,  and  from  a  condition  described  by 
Gaucher  of  chronic  inflammation  of  the  spleen  {epitheliome  primitive).  Sometimes, 
too,  in  children  suffering  from  rickets  and  marasmus  with  gastro-intestinal  intoxica- 
tion, there  is  a  considerable  degree  of  anemia  and  some  enlargement  of  the  spleen. 
Such  cases  have  been  thought  to  represent  an  infantile  form  of  splenic  anemia, 
but  the  subsequent  history  of  the  patient  seems  to  contradict  this  view. 
Rolleston  gives  the  following  as  the  clinical  characteristics  of  splenic  anemia: 

1.  Splenic  enlargement  which  cannot  be  correlated  with  any  known  cause. 

2.  Absence  of  enlargement  of  the  lymphatic  glands. 

3.  Anemia  of  a  type  midway  between  secondary  anemia  and  chlorosis. 

4.  Leukopenia,  or  at  most  no  increase  in  the  number  of  white  blood  corpuscles. 

5.  An  extremely  prolonged  course  lasting  years. 

6.  A  tendency  to  periodic  hemorrhages,  especially  from  the  gastro-intestinal  tract. 
Prognosis. — The  prognosis  under  medical  treatment  is  always  imfavorable. 
Treatment. — The  treatment  consists  in  the  administration  of  full  doses  of  arsenic, 

but,  so  far  as  we  know,  no  method  of  medical  treatment  has  yet  been  de\used  which 
materially  alters  the  general  progress  of  the  disease. 

According  to  Harris  and  Herzog,  of  19  cases  subjected  to  splenectomy,  14  recov- 
ered. To  these  series  Scott  has  added  6  cases  with  4  recoAeries.  Queen  and 
Duval  collected  6  cases  and  added  1  original  case  in  which  removal  of  the  spleen 
was  followed  by  a  cure.  They  state  in  addition  that  a  beginning  hepatic  cirrhosis 
may  be  arrested  by  splenectomy,  although  it  is  difficult  to  understand  how  this 
operation  can  exercise  this  effect. 

BANTI'S  DISEASE. 

Under  the  name  of  Banti's  disease  a  condition  characterized  by  enlargement  of 
the  spleen,  anemia,  cirrhosis  of  the  liver,  jaundice,  and  ascites  is  met  with.  It  is 
thought  by  some  that  Banti's  disease  is  a  terminal  stage  of  splenic  anemia;  but, 
on  the  other  hand,  it  is  certain  that  this  is  not  alwaj^s  the  case.  The  disease  is  very 
rare. 

Banti's  disease  is  characterized  by  gradual  enlargement  of  the  spleen  which  may 
be  present  for  several  years  without  anjr  signs  of  illness.  Sooner  or  later  a  secondary 
less.  When  the  disease  reaches  its  terminal  stage  it  is  characterized  not  only  by 
as  low  as  1,000,000  to  the  cubic  millimeter  and  the  white  cells  as  low  as  2000  or 
anemia  develops  associated  with  leukopenia.  The  number  of  red  cells  may  be 
splenomegaly  but  cirrhosis  of  the  liver  with  jaundice  and  ascites. 

Several  clinicians  have  recently  brought  forward  evidence  that  certain  cases  of 
splenomegaly  and  Banti's  disease  are  due  to  an  infectious  agent,  and  A.  G.  Gibson 
has  reported  no  less  than  6  cases,  3  of  Banti's  disease  and  3  of  splenomegaly,  in 
which  the  spleen  contained  a  streptothrix  which  he  believed  to  be  responsible 
for  the  disease  process  present.  So  far  as  is  known  there  is  no  cure  by  the  use 
of  drugs,  although  arsenic  may  at  times  seem  to  induce  temporary  arrest.  The 
only  curative  procedure  is  splenectomy  and  this  must  be  done  in  the  early  stages 
if  a  cure  is  to  be  effected. 

Banti's  disease  is  separated  from  splenomedullary  leukemia  by  the  leukopenia 
instead  of  the  characteristic  high  white  cell  count  of  the  latter  malady.  From 
hepatic  cirrhosis,  with  or  without  jaundice,  by  the  leukopenia  and  the  history  of 
alcoholic  abuse  or  syphihs  in  cirrhosis. 

GAUCHER'S  DISEASE. 

Synonyms. — (Large-cell  Splenomegaly;  Primary  Splenomegaly;  Primary  Epithe- 
lioma of  Spleen.)     This  is  an  affection  about  which  so  many  conflicting  opinions 


706  DISEASES  OF  THE  SPLEEN 

have  l)ccn  given  that  it  is  imj)()ssil)le  to  I'orimihite  a  description  tliat  will  apply  to 
all  reported  cases.  Brill  aiitl  Mandlehaum  furnish  the  most  recent  discussion  of 
the  subject  and  conclude  that  only  14  reported  cases  really  belong  to  this  group. 
They  have  .studied  material  from  5  subjects.  Their  definition  comprises  one  of  the 
best  descriptions  of  the  disease  that  has  yet  been  offered: 

"The  characteristic  features  of  Gaucher's  disease  are  its  incidence  in  childhood, 
its  frequent  presence  in  other  members  of  the  family  of  the  same  generation,  a 
progressive  increase  in  the  size  of  the  spleen  which  often  reaches  colossal  dimensions, 
followed  by  a  similar  huge  enlargement  of  the  liver,  a  characteristic  brownish- 
yellow  discoloration  of  the  skin,  usually  restricted  to  the  face,  neck,  and  hands, 
a  peculiar  yellowish,  wedge-shaped  thickening  of  the  conjunctivic  commonly 
seen  on  both  sides  of  the  cornea,  and  the  prolonged  and  chronic  course  of  the 
disease,  -which  does  not  materially  disturb  the  health  of  the  individual.  After 
the  disease  has  been  present  for  a  considerable  time  there  is  a  definite  tendency 
to  hemorrhages,  especially  appearing  as  epistaxis,  bleeding  from  the  gums,  and 
ecchymoses  in  the  skin  following  the  slightest  trauma.  The  positive  finding  in 
the  blood,  even  in  the  early  stage  of  the  disease,  is  a  definite  leukopenia.  The 
erythrocytes,  however,  show  no  definite  change  either  in  number,  form,  size,  or 
hemoglolain  content  until  the  disease  has  existed  for  a  long  time,  when  an  anemia 
of  the  chlorotic  type  makes  its  appearance.  The  anemia  is  rarely  pronounced  at 
any  stage.  The  disease  is  not  accompanied  by  palpable  enlargements  of  the  super- 
ficial lymph  nodes.  There  is  no  jaundice  and  ascites  is  exceptional.  The  disease 
has  none  of  the  characteristics  of  malignancy,  and  usually  is  terminated  by  some 
intercurrent  affection. 

The  pathological  feature  of  the  disease  is  the  presence  in  the  spleen,  liver,  lymph 
nodes,  and  bone-marrow  of  distinctive  large  cells,  with  characteristic  cytoplasm 
and  small  nuclei.  The  enlargement  of  the  spleen  and  liver  is  due  to  the  presence 
of  these  cells  in  enormous  number.  In  well-established  cases  all  of  these  organs 
contain  pigment  giving  the  reaction  for  iron.  Whereas  the  nature  and  origin 
of  these  cells  are  still  moot  questions,  the  histological  picture  is  uniformly  character- 
istic and  pertains  to  no  other  form  of  disease." 

Etiology. — This  is  entirely  unknown. 

Treatment. — Arsenic,  the  .r-rays,  and  other  agents  have  been  used  with  l)ut 
little  effect.  Splenectomy  has  been  performed  in  8  out  of  the  14  cases  with  3  imme- 
diate deaths,  continued  enlargement  of  the  liver  in  1,  signs  of  improvement  in 
another  case,  and  the  other  3  unreported  as  to  result. 

HEMOLYTIC  SPLENOMEGALY. 

Under  this  term  Banti  has  reported  5  cases  of  a  condition  which  he  regards 
as  dift'ering  from  other  types  of  splenomegal\',  even  those  called  hemol\  tic  jaundice. 
The  disease  begins  early  in  life,  and  is  chronic,  lasting  six  to  twelve  years  or 
more  with  periods  of  improvement.  The  chief  features  are  splenomegaly,  anemia 
reaching  a  severe  grade,  and  jaundice.  The  spleen,  though  weighing  SOO  to  1,5S() 
grams,  presents  no  marked  microscopic  change.  It  is  congestetl  and  in  it  are 
found  numerous  macrophages  containing  red  cells  and  much  blood  pigment.  The 
liver  also  contains  pigment. 

No  cause  is  known  but  the  anemia  appears  due  to  a  pathological  increase  of 
hemolysis  in  the  spleen.  This  assumj^tion  is  borne  out  by  the  fact  that  removal 
of  the  s])leen  leads  to  a  rapid  and  ai)])arently  complete  cure,  one  patient  now  having 
been  well  for  nine  years.  Of  the  5  cases,  splenectomy  in  4  was  followed  by  recovery. 
The  spleen  was  not  removed  in  the  fifth  and  death  occurred.  This  necessity  for 
operative  treatment  is  the  special  point  about  the  disease  as  distinguishing  it 
from  several  other  tjT^es  of  splenomegaly. 


DISEASES  OF  THE  BLOOD. 


ANEMIA. 

Definition. — The  word  anemia  signifies  a  state  of  the  blood  in  whicli  there  is 
lacking  the  normal  quantity  of  red  cells  or  of  hemogloljin  in  these  cells.  When  the 
cause  of  this  state  is  due  to  some  disorder  of  the  blood-making  or  blood-destroying 
tissues,  it  is  called  essential  or  primary  anemia.  When  due  to  some  other  cause, 
such  as  hemorrhage  or  one  of  the  acute  infectious  diseases,  it  is  called  secondary 
anemia.  Fortunately,  most  cases  of  anemia  belong  to  this  latter  class,  and  they 
will,  therefore,  be  considered  first. 

Secondary  Anemia. 

Secondary  anemia  arises  from  a  host  of  causes  and  is  characterized  in  most 
cases  by  a  diminution  in  the  number  of  the  red  cells,  and  an  even  greater  reduction 
in  the  hemoglobin  content  of  each  cell.  In  some  cases  it  comes  on  as  a  result  of 
breathing  vitiated  air,  as  in  factory  girls  and  stenographers.  In  other  cases  it 
is  due  to  overwork  and  insufficient  or  improper  food,  and  in  still  other  cases  to 
protracted  digestive  disturbance  or  to  chronic  constipation,  which,  by  causing 
auto-intoxication,  is  the  active  factor  in  producing  the  condition.  The  late  Sir 
Andrew  Clark  was  an  earnest  exponent  of  this  view. 

Hemorrhage  is,  of  course,  a  very  potent  cause.  When  it  is  profuse  the  change 
appears  so  promptly  that  the  cause  is  evident,  but  in  many  cases  anemia  arises 
as  the  result  of  repeated  small  losses  of  blood,  as  from  hemorrhoids  when  the  patient 
is  at  stool.  Under  conditions  of  persistent  hemorrhage,  nucleated  cells  and  a  few 
poikilocytes  may  be  found.  After  a  single  large  hemorrhage  the  rapidity  of  recovery 
is  often  extraordinary,  being  more  rapid  than  when  the  loss  of  blood  has  been  pro- 
longed. Cases  are  occasionally  met  with  in  which,  by  reason  of  lack  of  regenera- 
tive power  in  the  blood-making  organs,  a  sharp  hemorrhage  is  followed  by  death  in 
a  short  time. 

Toxic  states  due  to  renal  disease  or  to  the  various  infectious  maladies,  particularly 
malaria,  acute  rheumatism,  and  syphilis,  often  cause  anemia,  and  prolonged  lac- 
tation, frequent  child-bearing,  and  the  growth  of  tumors  of  large  size  also  produce 
it.  Wlien  the  tumors  are  malignant,  the  anemia  is  also  partly  toxic.  Not  infre- 
quently we  meet  with  cases  in  which  the  anemia  is  due  to  chronic  metallic 
poisoning,  as  from  arsenic,  lead,  and  mercury.  In  other  instances  the  anemia  is 
due  to  intestinal  parasites,  such  as  the  Ankylostomum  duodenale  or  the  tapeworm. 

In  all  cases  of  marked  and  apparently'  causeless  anemia,  the  possibility  of  the 
condition  being  due  to  intestinal  parasites  should  be  borne  in  mind,  and  the  stools 
examined,  not  only  for  the  ordinary  tapeworm,  but  for  uncinaria  as  well.  Further 
than  this,  the  marked  increase  in  the  eosinophiles  in  the  blood  in  nearly  all  cases 
of  parasitic  infection  should  be  recalled.  Walker  has  collated  the  following  interest- 
ing table  in  this  connection : 

Eosinophiles.  Polymorphonuclears.        Large  mononuclears. 

Normal 1  to    4       per  cent.         60  to  60  per  cent.          5  to  8  per  cent. 

Tenia 6  to  13 

Ankylosfcoma  duodenale       .  12.43         " 

Filaria  medinensis      ...  6  to  36               " 

Filaria  loa .53                "                          23          " 

Oxyuris  vermicularis  0.4  to  13.7            " 

Bilharzia  hematobia        .      .  16  to  48               "               44  to  58         "                   12.5        " 

(707) 


708  DISEASES  OF  THE  BLOOD 

lie  makes  the  interesting  statement  that  a  practical  application  of  this  has  been 
already  made.  In  the  feces  obtained  from  one  of  the  closets  in  a  large  college  the 
eggs  of  the  Ankylostumum  duodenale  were  found.  The  pui:)ils  who  liad  used  the 
receptacle  on  the  specified  day  were  asked  to  submit  themselves  to  examination, 
but  their  feces  yielded  negative  results.  An  examination  of  the  blood  of  each 
pupil  was  made,  eosinophilia  was  observed  in  2  cases,  and  ova  siil)sequently  detected 
in  their  feces. 

Symptoms. — The  symptoms  of  secondary  anemia  ^'ary  greatly  in  different  individ- 
uals, some  patients  with  marked  pallor  presenting  no  other  noteworthy  symptoms, 
while  others  whose  cheeks  have  color,  nevertheless  suffer  from  jjalpiiaiion  and 
dyspnea  on  exertion.  It  is  important  to  bear  in  mind  that  there  are  fat  anemics 
and  red-cheeked  anemics,  and  that  many  persons  who  look  pallid  really  have  a 
normal  number  of  red  cells  and  a  normal  percentage  of  hemoglobin.  Headache, 
neuralgia,  loss  of  appetite,  co7istipation,  and  attacks  of  syncope  are  sometimes  due  to 
anemia,  and  in  women  amenorrhea  is  often  due  to  this  cause. 

Diagnosis. — The  diagnosis  between  secondary  and  primary  anemia  is  to  be  made 
by  the  history  of  the  patient,  and  chiefly  by  the  fact  that  the  abnormalities,  as  to 
the  shape  and  character  of  the  red  cells  found  in  the  primary  anemias  (which  see), 
are  far  more  marked  than  in  the  secondary  forms. 

Treatment. — In  the  treatment  of  secondary  anemia  three  things  are  absolutely 
essential:  the  removal  of  the  cause,  if  possible,  the  institution  of  a  proper  diet, 
a  hygienic  mode  of  life,  the  administration  of  iron  and  arsenic,  and  often  of 
the  bitter  tonics,  in  order  that  the  condition  of  the  blood  may  be  directly  im- 
proved. If  the  method  of  life  of  the  patient  is  unhealthy,  it  must  be  corrected, 
and,  above  all,  plenty  of  fresh  air  and  sunshine  must  be  obtained.  The  sleeping- 
rooms  should  be  well  ventilated,  and  the  patient  must  be  dieted  in  such  a  way  that 
the  bowels  are  moved  regularly  and  adequately  every  day,  at  least  once,  for  con- 
stipation, as  already  stated,  is  usually  present,  and  is  often  the  cause.  Under 
these  circumstances  aloes  and  cascara  sagrada  are  probably  the  best  laxatives  to 
administer,  particularly  if  iron  is  given.  When  persistent  diarrhea  is  the  cause 
of  the  anemia,  it  is  advisable  to  give  one  of  the  astringent  preparations  of  iron  like 
the  dried  sulphate  in  the  dose  of  J  to  |  grain  three  times  a  day.  If  the  anemia  is 
due  to  a  loss  of  blood  by  hemorrhoids,  this  loss  must  be  arrested  by  local  treatment, 
and  if  to  intestinal  parasites,  these  must  be  expelled.  The  appetite  should  be 
stimulated  by  the  use  of  drugs  like  nux  vomica,  quinine,  or  other  bitter  tonics 
like  cardamom  or  gentian.  A  good  prescription  for  many  of  these  cases  is  a  pill 
composed  as  follows: 

I^ — Ferri  redacti ^,     .     gr.  v. 

Arseni  frioxidi gr.  J- 

Ext.  nucis  vomica; gr.  v. — M. 

]''t.  in  pil.  No.  XX. 

Sig. — One  t.  i.  d.  after  meals. 

The  nux  vomica  may,  in  some  cases,  be  replaced  by  2  grains  of  ciuininc.  If  the 
digestion  is  impaired,  hydrochloric  acid  and  pepsin,  or  pancrcatln  and  bicarbonate 
of  soda,  or  taka-diastase  in  2  to  5  grain  doses  with  meals  is  advisable. 

Primary  or  Essential  Anemias. 

Chlorosis. — Definition. — Chlorosis  is  a  condition  of  the  blood  usually  met 
with  in  yoiuig  girls,  characterized  by  a  marked  diminution  in  the  quantity  of 
hemoglobin,  and  by  a  less  marked  decrease  in  the  red  cells.  Until  recently  it 
was  considered  a  secondary  anemia  but  hematologists  now  class  it  in  the  primary 
anemias  chiefly  because  it  is  believed  to  be  due,  at  least  in  part,  to  defective 
hemogenesis, 


ANEMIA 


700 


1 
p 

J|||jl|l|||| 

:::i  :  ::::::::::::: 

MM 

^ 
i 

ij  |ji  1 

=1 

ijU^. ""  w^ 

i 

^  ;    1    -— ^^ 

agT 

Age  incidence  of  chlorosis. 
(Bramwell.) 


Etiology. — There  are  still  many  who  believe  that  chlorosis  Is  a  secondary  anemia. 
It  is  certainly  associated  with  many  causes  of  secondary  anemia,  such  as  constipa- 
tion, inanition,  and  bad  air.  Whatever  influence  these  causes  may  have,  there 
can  be  no  doubt  that  the  processes  which  take  place  about  the  age  of  puberty 
in  the  female  sex  are  closely  concerned  in  its  production, 
for  the  disease  is  scarcely  ever  met  with  except  at  a  period 
of  life  near  these  changes.  Occasionally,  however,  it 
develops  in  later  life,  and  it  is  then  called  "  chlorosis  tarda." 
Bramwell  and  others  have  shown  that  there  is  also  an 
hereditary  influence. 

The  two  chief  causes  are  a  natural  predisposition  to 
anemia  and  an  inability  to  utilize  iron  from  the  food. 
Some  believe  that  the  intestinal  mucosa  is  at  fault,  others 
that  the  spleen  is  functionally  perverted,  but,  as  Ewing 
well  says,  there  can  be  no  doubt  that  chlorosis  results  from 
a  functional  insufficiency  of  the  bone-marrow,  which  is 
prone  to  occur  at  puberty. 

Pathology. — The  following  are  the  chief  changes  in  the 
blood:  The  chief  alteration  is  the  decrease  of  the  hemo- 
globin in  each  corpuscle,  so  that  a  low  color  index  is  one 
of  the  points  necessary  to  a  diagnosis  of  the  disease.  So 
low  a  percentage  of  hemoglobin  as  10  has  been  recorded 
by  Bramwell,  but  the  average  low  limit  is  from  .30 
to  40  per  cent.,  and  the  color  index  about  0.5  The 
second  change  is  a  diminution  in  the  number  of  the  red 
cells,  but  usually  this  is  not  so  marked.  Taking  the  normal  for  a  woman  as 
approximately  4,800,000  to  the  cubic  millimetre,  the  fall  is  usually  not  more  than 
from  500,000  to  1,000,000.  When  a  very  great  fall  in  the  number  of  red  cells  is 
present,  they  may  amount  to  only  2,000,000,  but  in  such  a  case  a  suspicion  of 
pernicious  anemia  comes  forward. 

If  the  chlorosis  is  severe,  the  red  cells  vary  as  to  size  and  shape,  and  a  niuuber 
of  large  red  cells,  with  a  full  complement  of  hemoglobin,  may  be  present.  As  a 
rule,  the  size  of  the  red  cells  is  reduced.  Imperfectly  formed  cells  (poikilocytes) 
are  found,  but  they  are  present  in  very  small  numbers.  Basophilic  granulation  of 
the  red  cells  has  been  particularly  well  studied  by  the  former  chief  of  my  medical 
clinic,  Dr.  J.  C.  Da  Costa,  Jr.,  and  by  Stengel,  White,  and  the  younger  Pepper. 

The  leukocytes  in  cases  of  chlorosis  do  not  suffer  much  change,  as  a  rule,  but 
some  patients  show  an  increase  of  the  lymphocytes.  Dr.  Da  Costa  has  shown  that 
most  of  these  are  large  lymphocytes,  and  that  the  lymphocytes  may  amount  to  40 
per' cent,  of  all  the  white  cells.  The  specific  gravity  of  the  blood  is  reduced  pari 
passu  with  the  hemoglobin.  Although  extravascular  coagulation  is  retarded,  in 
some  cases  there  is  a  tendency  to  thrombosis.  The  blood  picture  in  chlorosis  is 
not  characteristic,  that  is,  the  diagnosis  of  the  disease  is  not  to  be  made  from  the 
blood  findings  alone. 

Aside  from  the  blood  changes,  a  state  of  hypoplasia  of  the  tissues  of  the  heart 
and  larger  arteries  is  often  present,  but  this  condition  is  not  peculiar  to  chlorosis, 
but  to  the  lymphatic  constitution.  When  recovery  begins  to  take  place  the  number 
of  undersized  red  cells  decreases  and  the  cells  of  normal  size  increase  their  hemo- 
globin content. 

Symptoms. — The  symptoms  of  chlorosis  are  a  peculiar  pallor  of  the  skin,  which 
often  has  a  greenish  hue,  whence  the  name  "green  sickness."  The  patient  is 
nearly  if  not  always  plump  and  possessed  of  a  good  quantity  of  subcutaneous  fat. 
Occasionally  the  superficial  vessels  are  well  supplied  with  blood,  so  that  the  patient 
is  ruddy,  thereby  misleading  the  physician  who  fails  to  study  the  blood.    This 


710  DISEASES  OF  THE  BWOD 

type  is  called  chlorosis  florida.  The  subjective  symptoms  are  (Jji.ipnea  on  exertion, 
palpitation  of  the  heart,  vertiqo,  and  perhaps  attacks  of  partial  .ti/ncopc.  Constipa- 
tion is  nearly  always  marked.  Headache  is  quite  constant,  and  tliere  is  usually 
a  most  persistent  absence  of  appetite.  There  is  also  nienUil  dejirexsioii  and  upathi/. 
Physical  examination  may  reveal  a  diastolic  hemic  nuirmur  at  the  tiiird  left  costal 
cartilage,  and  over  the  right  carotid  artery  a  bruit  is  often  heard. 

The  complications  of  chlorosis  which  are  serious  are  the  development  of  thrombi 
in  the  veins  of  the  legs  and  in  the  cerebral  sinuses.  From  such  thrombi  fragments 
may  arise,  which  may  result  in  pulmonary  embolism.  Slight  fever  may  occur, 
but  the  hands  and  feet  are  usually  cold.     Amenorrhea  is  a  very  constant  symptom. 

The  blood  changes,  as  discovered  by  the  hemoglobinometer  and  hematocytometer 
have  already  been  described. 

Diagnosis. — The  well-nourished  state  of  the  chlorotic  patient  is  also  present  in 
pernicious  anemia,  but  the  differentiation  is  found  in  the  blood  picture  (see  Per- 
nicious Anemia),  for  in  that  disease  the  blood  findings  are  quite  different.  The 
irritability  of  the  heart  must  not  be  taken  for  a  sign  of  cardiac  disease  because  a 
murmur  is  present,  nor,  in  the  absence  of  urinary  changes,  should  the  pnft'y  face 
and  anlvles  be  thought  to  be  due  to  renal  disease,  unless  the  urine  reveals  albumin 
and  casts. 

Prognosis. — The  ultimate  prognosis  in  cases  of  chlorosis  is  usually  very  good,  but 
a  long  period  often  passes  without  much  improvement.  When  the  number  of 
the  red  cells  is  not  greatly  reduced  and  they  are  normal  in  shape  and  size,  recovery 
under  proper  treatment  is  usually  rapid.  This  holds  true  even  if  the  color-index 
is  very  low.  When  the  red  cells  are  as  low  as  3,000,000,  are  badly  shaped,  and 
many  of  them  undersized,  the  prognosis  as  to  rapid  recovery-  is  bad.  So,  too,  when 
the  lymphocytes  are  yery  numerous,  a  speedy  cure  is  rarely  seen.  Relapses  are 
very  frequent. 

Treatment. — The  treatment  of  chlorosis  does  not  differ  materially  from  that 
which  was  given  for  the  treatment  of  ordinary  secondary  anemia,  except  that 
chlorotic  patients  are  usually  more  obstinately  constipated,  and,  therefore,  particu- 
lar attention  must  be  given  to  the  state  of  the  bowels.  Fresh  air  and  sunshine 
are  also  very  essential  in  these  cases.  More  important  than  all,  it  must  be  remem- 
bered that  chlorotic  patients  usually  need  very  much  larger  quantities  of  iron  than 
do  ordinary  anemic  cases.  Whether  this  is  due  to  an  inability  to  absorb  iron  or 
whether  there  is  an  excess  of  sulphides  in  the  bowels,  which  change  a  goodly  portion 
of  the  iron  into  a  sulphide  of  iron,  is  not  known.  Citrate  of  iron  may  be  given  hypo- 
dermically.  During  the  winter  months  chlorotic  patients  usually  do  best  at  seaside 
resorts  or  at  places  like  Lakewood,  N.  J.,  which  are  low  in  altitude.  In  the  sum- 
mer months  they  should  be  sent  to  high  altitudes,  varying  from  3000  to  5000  feet, 
unless  tliese  high  altitudes  tend  to  increase  palpitation  of  the  heart  and  dyspnea. 

Pernicious  Anemia. — Definition. — Pernicious  anemia  is  a  disease  of  the  blood 
arising  from  faulty  hemogenesis  and  excessive  hemolysis  or  blood  disintegra- 
tion. It  is  a  fatal  malady  characterized  by  three  chief  changes,  viz.,  an  extraordi- 
nary decrease  in  the  numlier  and  alterations  in  the  morphology  of  the  red  cells  and 
by  certain  changes  in  the  bone-marrow.  It  is  sometimes  called  "Addison's 
anemia." 

History. — -Andral  in  France,  in  1S21,  reported  cases  of  what  was  probably  tliis 
disease,  and  Channing  in  Boston  recognized  them  in  1832.  Pepper  and  Tyson 
showed  the  bone-marrow  changes  in  1875.  Sorenson,  in  1874,  made  the  first 
observations  as  to  the  number  of  the  red  cells,  reporting  cases  with  only  470,000 
corpuscles. 

Etiology. — The  etiology  is  still  unknown,  but  it  is  probable  that  certain  of  the 
causes  of  ordinary  secondary  anemia  may  antedate  pernicious  anemia.  Age 
has  no  great  influence.     Most  cases  appear  between  twenty  and  Forty  years  of 


ANEMIA  71 1 

age,  but  even  young  children  of  less  than  five  years  have  been  seen  with  the  malady. 
In  some  of  the  reported  cases  the  Ankylostomuia  duodenale,  the  Bothr'uiceyhalus 
latus,  or  tapeworm,  and  the  Oxyurw  venniciilaris  have  been  found.  The  first-named 
parasites  can  cause  grave  anemia,  but  it  is  doubtful  if  any  of  tiicm  alone  can  cause 
pernicious  anemia.  So,  too,  severe  hemorrhage,  syphilis,  and  pregnancy  have 
been  found  associated  with  the  development  of  the  disease.  They  are  not  the 
actual  cause,  but  rather  predisposing  causes.  The  various  fevers,  as  malaria  and 
typhoid  fever,  exert  only  an  indirect  eft'ect,  and  the  condition  of  the  gastro-intestinal 
tract,  at  one  time  thought  to  be  responsible,  has  been  proved  to  be  only  a  predis- 
posing or  secondary  condition.  Hunter  thinks  the  disease  is  due  to  bacterial 
infection  of  the  alimentary  canal  from  a  foul  mouth.  Some  cause,  or  causes,  which 
induce  hemolysis  is  responsible  for  the  condition,  so  while  pernicious  anemia  is 
classed  as  a  primary  anemia  it  may  be  justly  called  secondary. 

Morbid  Anatomy. — The  most  noteworthy  pathological  changes  are  the  alterations 
in  the  blood  and  in  the  bone-marrow.  Unlike  cases  of  chlorosis,  the  bluod  may 
be  difficult  to  obtain.  In  marked  cases  it  does  not  form  a  rounded  drop,  but  flows 
from  the  puncture  made  by  the  needle  or  scalpel  sometime  after  the  wound  is 
inflicted.  Coagulation  is  usually  delayed,  and  even  at  an  autopsy  made  many 
hours  after  death  the  blood  may  still  be  fluid.  The  red  cells  are  decreased  to 
2,000,000,  then  to  1,000,000,  and  sometimes  to  less  than  500,000  to  the  cubic 
millimeter.  A  great  proportion  of  the  remaining  cells  are  larger  than  normal 
(megalocytes),  and  some  are  smaller  (microcytes).  Many  of  the  red  cells  are 
misshapen  (poikilocytes),  and  the  amount  of  hemoglobin  in  most  of  the  red  cells 
is  considerably  increased,  although  some  of  them  may  be  poor  in  hemoglobin. 
Red  cells  possessing  nuclei  (erythroblasts)  are  also  present  in  considerable  number. 
Some  of  these  are  large  (megaloblasts)  and  others  of  normal  size  (normoblasts). 
Small  nucleated  red  cells  called  microblasts  are  also  present.  The  presence  of 
the  megaloblast  is  an  important  aid  in  reaching  a  positive  diagnosis.  These 
nucleated  cells,  both  large  and  small,  contain  a  great  amount  of  hemoglobin,  and 
some  of  them  differ  from  ordinary  red  cells  in  one  very  important  particular — 
namely,  they  possess  ameboid  movement — and,  further,  when  the  blood  is  examined, 
they  are  seen  to  form  rouleaux  as  do  ordinary  red  cells.  Basophilic  granulation 
also  occurs  in  the  red  cells. 

In  mild  cases  the  leukocytes  may  not  be  altered  in  number,  although  usually 
they  are  slightly  reduced.  Rarely  they  are  greatly  reduced  in  number  if  the  case 
is  severe.  As  a  rule,  but  few  myelocytes  occur  and  the  lymphocytes  may  be 
increased. 

The  hemoglobin  is  reduced,  the  average  being  25  to  30  per  cent.,  but  not  in 
proportion  to  the  red  cells,  hence  a  high  color-index,  often  above  1,  is  the  rule. 

When  the  bone-marrow  is  examined  very  marked  changes  are  manifest.  There 
is  an  excess  of  large  nucleated  red  cefls,  many  of  which  are  gigantoblasts.  The  bone- 
marrow  is  pale,  shows  lack  of  erythrocyte  formation,  and  may  undergo  lymphoid 
hyperplasia.  The  liver,  spleen,  lymph  glands,  and  particularly  the  liver,  are 
loaded  with  iron  derived  from  the  destroyed  red  blood  cells,  and  even  the  urine  con- 
tains pigment  from  this  source;  Hunter  denies  an  excess  of  iron  in  the  spleen.  Fatty 
degeneration  of  the  liver,  kidneys,  and  of  the  heart  muscle  are  often  present,  and 
because  of  similar  changes  in  the  walls  of  the  arteries  and  of  the  altered  character  of 
the  blood,  hemorrhages  into  the  retina  and  into  other  parts  may  occur.  In  some 
cases  marked  atrophy  of  the  gastric  tubules  is  found.  A  dift'use  degenerative  change 
occurs  in  the  posterior  and  lateral  columns  of  the  spinal  cord.  When  regenerative 
changes  in  the  bone  marrow  are  slight  or  lacking,  the  disease  assumes  the  form 
known  as  "aplastic  anemia."  The  blood  picture  dift'ers  from  that  of  the  ordinary 
type  in  that  the  color-index  is  lower  and  megaloblasts  are  absent.  (See  Aplastic 
Anemia.)     Leukopenia  is  present  and  accompanied  by  a  decided  lymphocytosis. 


712  DISEASES  OF  THE  BLOOD 

Symptoms. — A  patient  with  pernicious  anemia  usually  first  seeks  medical  advice 
because  he  is  feeling  weak  and  lacks  initiative.  Often  he  suft'crs  from  some  dyspnea 
on  exertion  and  has  a  throbbing  headache  or  attacks  of  vertigo.  His  tissues  are 
well  filled  with  fat  and  his  appearance  is  plump,  but  he  is  pallid  and  cheesy  looking. 
The  sclerotic  part  of  the  eyes  is  peculiarly  pearly  and  the  ///;.s-,  yuins,  and  tongue 
are  prone  to  be  very  pale  and  bloodless.  There  may  be  slight  puffiness  of  the  face 
on  the  dependent  side  if  the  patient  lies  on  his  side  in  bed.  A  purring  heinic  murmur 
is  often  heard  over  the  pulmonary  artery  at  the  third  left  costal  cartilage,  and 
the  arteries  of  the  neck  pulsate  and  throb  with  a  peculiar  jerking,  expansile  move- 
ment. An  irregular  fever  is  very  constantly  present.  AYhen  the  disease  is  far 
advanced  a  state  of  mental  torpor  with  muttering  delirium  may  occur. 

Diagnosis. — The  fact  that  the  patient  is  in  middle  life,  or  even  older,  serves  to 
separate  this  state  from  chlorosis,  which  has  its  greatest  frequency  at  the  eighteenth 
or  nineteenth  year.  Again,  pernicious  anemia  is  more  common  in  men,  chlorosis 
in  women.  The  skin  in  pernicious  anemia  is  prone  to  show  a  cheesy-yellow  hue 
in  distinction  from  the  greenish-yellow  of  chlorosis.  From  the  blood  of  the  chlorotic 
that  of  pernicious  anemia  differs  so  radically  that  a  diagnosis  is  readily  made  in 
typical  cases,  for  in  the  former  we  have  cells  poor  in  hemoglobin  and  here  we  have 
cells  rich  in  hemoglobin.  In  the  former  the  red  cells  are  not  greatly  decreased 
in  number,  here  they  are  markedly  diminished.  In  chlorosis  the  size  of  the  red 
cells  is  below  the  normal,  in  pernicious  anemia  the  average  is  above  the  normal. 
Again,  in  chlorosis  we  do  not  find,  to  the  same  degree,  nucleated  red  cells  or  cells 
with  mitotic  nuclei,  nor  red  cells  with  ameboid  movement.  The  color-index  in 
chlorosis  is  low  and  in  pernicious  anemia  high.  In  cases  of  gastric  cancer  there . 
is  present  ordinary  secondary  anemia  and  the  presence  of  gastric  symptoms  to 
aid  the  diagnosis.  Unless  the  blood  picture  is  typical  the  possibility  of  small 
repeated  hemorrhages  as  a  cause  of  profound  anemia,  such,  for  example,  as  bleeding 
from  hemorrhoids,  should  be  borne  in  mind.  In  other  words,  the  stools  should 
be  tested  for  occult  blood.  Finally,  Ewing  states  that  unless  at  least  32  per  cent, 
of  the  red  cells  are  oversized,  the  diagnosis  of  pernicious  anemia  must  be  made 
with  reserve. 

Prognosis  and  Treatment. — The  prognosis  of  true  pernicious  anemia  is  almost 
invariably  fatal,  athough  there  have  been  a  considerable  number  of  cases  in  which 
recovery  has  been  said  to  have  occurred.  Many  cases  have  periods  of  extraordinary 
improvement  in  all  the  symptoms  as  well  as  in  the  blood,  and  then  a  disheartening 
relapse  takes  place.  This  may  be  repeated  several  times.  ]\Iost  cases  die  within 
a  year  after  they  are  first  seen.  A  great  decrease  in  the  number  of  red  cells  and  a 
large  number  of  megaloblasts  are  bad  signs. 

The  prognosis  in  pernicious  anemia  depends  not  a  little  upon  the  quantities 
of  arsenic  which  the  patient  can  take  without  developing  disagreeable  symptoms 
from  its  use,  for  many  of  these  cases  are  markedly  benefited  if  they  can  take  what 
might  be  called  massive  doses  of  this  drug.  By  a  process  of  training  with  ascending 
doses  I  have  known  patients  to  take  as  much  as  30  minims  of  Fowler's  solution 
three  times  a  day  with  no  bad  results  except  some  exfoliation  of  the  skin  of  the 
hands  after  several  weeks'  treatment.  Arsenic  administered  in  this  manner  up 
to  the  point  of  tolerance  sometimes  produces  periods  of  remarkable  improvement 
in  this  disease,  the  patient's  symptoms  becoming  modified  and  the  number  of 
red  blood  cells  becoming  markedly  increased. 

Of  course,  all  measures  which  tend  to  increase  the  general  health  of  the  patient 
are  advantageous,  such  as  plenty  of  sunshine,  fresh  air,  and  good  food.  Small 
quantities  of  iron  may  be  given  from  time  to  time  with  advantage.  Diarrhea  is 
to  be  controlled  by  the  use  of  sulphuric  acid  or  one  of  the  vegetable  astringents, 
such  as  fluidextract  of  hematoxylon,  kino,  or  catechu.  Constipation,  if  present, 
is  to  be  relieved  by  the  use  of  cascara  sagrada  and  aloes.     In  some  instances  hypo- 


CHRONIC  SPLENOMEGALIC  POLYCYTHEMIA       '  713 

dermic  injections  of  cacodyiate  of  sodium  in  2  grain  doses  every  few  daj's  have 
been  resorted  to  with  asserted  advantage.  If  the  patient  is  very  anxious  to  carry 
out  a  plan  of  treatment  which  may  possibly  be  advantageous,  inhalations  of  oxj-gen 
may  be  suggested. 

In  the  treatment  of  pernicious  anemia  it  is  the  universal  experience  of  clinicians 
that  iron  is  by  no  means  as  beneficial  as  is  arsenic.  Indeed,  the  general  proposition 
may  be  stated  that  if  anemia  is  associated  with  diminution  in  the  number  of  red 
blood  cells,  arsenic  is  more  advantageous  than  iron;  whereas,  in  those  anemias 
which  are  characterized  by  a  low  color-index  or  a  diminution  in  hemoglobin,  iron 
is  more  useful  than  arsenic. 

In  certain  cases  the  direct  transfusion  of  blood  from  a  healthy  person  greatly 
improves  the  state  of  the  patient,  provided  it  is  found  beforehand  that  the  blood 
of  the  donor  does  not  hemolyze  that  of  the  recipient.  The  improvement  is  however 
only  temporary. 

Aplastic  Anemia  is  a  term  applied  to  a  form  of  anemia  characterized  by  retro- 
gressive changes  in  the  bone-marrow,  the  ordinary  red  marrow  ^becoming  fatty, 
the  spleen  presenting  at  autopsy  a  hyperplastic  appearance  such  as  is  seen  in 
pernicious  anemia.  It  is  possibly  of  the  class  of  secondary  anemias,  as  it  may 
follow  profuse  hemorrhage,  but  the  primary  lesion  is  in  the  marrow  and  not  in 
the  blood.  The  blood  picture  is  typical  and  pathognomonic.  There  is  a  profound 
anemia  as  to  red  cells  and  hemoglobin,  but  the  color-index  may  be  high  or  low, 
usually  high.  There  is  no  poikilocytosis  or  change  in  the  size  of  the  red  cells  and 
no  polychromatophilia.  Leukopenia  is  marked,  as  low  as  from  200  to  800  per  cubic 
miUimetre.  There  is,  however,  no  change  in  the  relative  number  of  the  white 
cells,  unless  it  be  a  slight  relative  lymphocytosis.  Some  clinicians  have  regarded 
it  as  a  severe  form  of  pernicious  anemia,  but  it  differs  in  several  important  respects 
from  that  disease,  namely,  there  is  no  excess  of  the  iron  pigment  in  the  liA"er  or 
spleen  and  the  bone-marrow  is  very  light  in  color  and  fatty  instead  of  red  as  is 
seen  in  pernicious  anemia.  The  disease  is  very  rare,  only  59  authenticated  cases 
having  been  recorded  (Musser).  It  was  first  described  by  Ehrlich  in  1888.  The 
disease  is  progressive  and  rapid  in  its  course,  the  patient  rarely  living  after  two 
months,  and  is  characterized  by  increasing  exhaustion,  subcutaneous  hemorrhages, 
and  bleedings  from  mucous  membranes. 

CHRONIC  SPLENOMEGAUC  POLYCYTHEMIA  (ERYTHREMIA). 

Definition. — A  chronic  condition  characterized,  as  its  name  indicates,  by  a  great 
increase  in  the  number  of  the  red  cells  with  enlargement  of  the  spleen  and  great 
fulness  of  the  entire  vacular  system,  arterial  and  venous.  Because  of  the  poly- 
cythemia and  vascular  turgescence  there  is  usually  cyanosis.  The  condition  is 
to  be  clearly  separated  from  the  polycythemia  occurring  after  hemorrhage  and 
that  found  in  cases  of  congenital  cardiac  disease. 

Etiology. — This  is  unknown.  The  disease  occurs  in  middle  life,  the  youngest 
patient  so  far  reported  being  twenty  years  of  age,  and  it  is  about  equally  frequent 
in  both  sexes.     A  large  proportion  of  the  cases  have  occurred  in  Jews. 

Morbid  Anatomy  and  Pathology. — The  spleen  is  always  enlarged  and  sometimes 
has  contained  tubercles.  Its  blood  spaces  are  engorged  with  blood  cells.  The 
liver  is  also  engorged,  but  presents  no  definite  lesions  neither  do  the  kidneys  present 
any  peculiar  lesions.  Occasionally  the  intestines,  which  share  in  the  congestion 
of  the  spleen  and  liver,  are  ulcerated.  The  increase  in  the  total  quantity  of  the 
blood  is  actual.  Haldane  estimated  the  total  amount  in  a  patient  of  Parkes  Weber 
and  found  it  to  be  nearly  double  the  normal  quantity.  The  red  cells  are  propor- 
tionately increased  by  the  abnormal  activity  of  the  red  bone-marrow.  There  is 
also  a  great  but  not  commensurate  destruction  of  red  cells,  for  the  spleen  contains  a 


714  DISEASES  OF  THE  BLOOD 

great  excess  of  broken-down  erythrocytes  and  the  urine  shows  an  excess  of  urobilin. 
I'olychromatojjliilia  is  present.  Tlie  leukocytes  are  materially  increased.  It  is 
noteworthy  that  the  enlargement  of  the  spleen  usually  antedates  the  polycythemia 
by  some  months  or  years.  There  is  no  poikilocytosis,  a  somewhat  diminished 
color-index,  and  very  rarely  nucleated  red  cells. 

Symptoms. — The  sym])toms  presented  by  the  patient  are  persi.stent  cyanosis, 
engorgement  of  the  bloodvessels,  large  and  small,  dyspnea  on  exertion,  progressive 
asthenia,  pigmentation  of  the  skin,  and  albuminuria.  The  red  blood  cells  when 
counted  may  amount  to  1.5,500,000  per  cubic  millimetre.  The  white  cells  may  or 
may  not  be  increased.  The  hemoglobin  may  be  increased  to  200  per  cent,  although 
such  an  excess  is  rare.  The  ophthalmoscope  reveals  very  great  engorgement  of  the 
retinal  veins  but  retinal  hemorrhages  have  not  been  recorded  although  hemorrhages 
from  mucous  membranes  may  occur. 

Treatment. — No  treatment  has  been  of  value.  Bleeding  has  been  resorted  to 
with  temporary  benefit,  and  stimulants  like  digitalis  may  be  used  for  the  laboring 
heart.  A  very  exhaustive  study  of  erythremia  has  been  contributed  to  the  ^Archives 
of  Internal  Medicine  for  December,  1912,  by  one  of  my  clinical  assistants,  Dr. 
Walter  Lucas,  who  reports  2  cases  from  my  wards. 

LEUKEMIA. 

Definition. — Leukemia  is  a  disease  in  which  the  blood  sufl'ers  an  extraordinary 
increase  of  leukocytes  with  associated  alterations  in  the  bone-marrow,  the  spleen, 
and  in  the  lymphatic  glands.  It  is  divided  into  two  types,  that  form  in  which  the 
spleen  and  bone-marrow  are  chiefly  affected,  and  that  in  which  the  lymphatic 
glands  are  chiefly  involved,  the  first  being  called  splenomedvUary  leukemia  and  the 
second  lymphatic  leukemia.  Because  of  the  important  role  played  by  the  bone- 
marrow  in  splenomedullary  type  it  is  sometimes  called  myelogenous  leukemia. 
Leukemia  is  also  sometimes  called  leukocythemia. 

Although  a  division  of  the  disease  into  two  types  is  to  some  extent  justified 
because  it  renders  the  study  of  leukemia  less  difficult,  and  because  changes  in 
certain  tissues  preponderate  in  one  instance  and  in  other  tissues  in  other  instances, 
it  is  not  to  be  forgotten  that  intermediate  cases  occur  in  which  both  types  of  the 
malady  are  represented,  or  at  least  inwhich  no  definite  dividing  line  can  be  drawn. 
Thus  cases  are  recorded  in  which  the  blood  cells  presented  the  picture  of  lymphatic 
leukemia,  the  lymphatic  glands  were  not  involved  but  the  bone-marrow  was 
altered.  Again,  it  has  been  thought,  in  times  past,  that  acute  and  rapidly  pro- 
gressive leukemia  was  usually  of  the  lymphatic  type,  and  that  the  subacute  or 
chronic  form  of  the  disease  was  commonly  of  the  splenomedullary  variety.  While 
this  view  still  holds  true,  we  have  been  forced  to  recognize  the  fact  that  acute 
cases  may  be  of  splenomedullary  type  and  that  some  of  the  chronic  cases  may  be 
lymphatic. 

History. — As  long  ago  as  ISOl  Bichat,  in  France,  noted  a  condition  of  the  blood 
which  was  probably  identical  with  leukemia  as  we  know  it  today.  Thirty  years 
later  because  of  the  peculiar  appearance  of  the  blood  it  was  called  "suppurative 
hematitis,"  and  in  1839  Donne  described  the  blood  in  these  cases  as  consisting 
largely  of  "white  or  mucous  globules."  Virchow,  about  the  middle  of  the  last 
century,  described  it  as  "  Weisses  Blut,"  and  showed  that  there  was  no  suppurative 
process  present.  Bennett  made  the  first  complete  study  of  the  disease  in  IS.51. 
Since  then  a  host  of  investigators  have  thrown  light  upon  its  characteristics. 

Etiology. — The  cause  of  leukemia  is  unknown.  It  may  occur  at  any  time  of 
life,  but  is  most  frequently  met  with  about  the  fourth  decade.  It  is  about  twice 
as  common  in  males  as  in  females.  A  very  large  number  of  conditions  have  been 
brought  forward  as  causes,  but  none  of  them  have  been  proved  to  exercise  a  deter- 


LEUKEMIA  715 

mining  influence.  Among  these  may  be  named  syphilis,  malaria,  and  intestinal 
intoxication.  The  view  has  been  advanced  that  leukemia  and  tuberculosis  are 
nearly  related  in  the  sense  that  the  latter  may  act  as  a  cause  of  the  former.  This 
view  is  incorrect.  Gowers  tells  us  that  the  appearances  of  the  lungs  in  one  or 
two  cases  have  been  those  of  tubercle,  that  extravasations  of  blood  into  the  lungs 
are  common,  and  that  these  organs  may  undergo  caseation  and  a  tuberculous 
process  may  be  simulated.  Cavities  may  result  from  lymphoid  infiltration.  This, 
however,  is  not  phthisis.  Susmann  has  been  able  to  collect  only  25  cases  from 
literature  in  which  tuberculosis  and  leukemia  were  even  associated.  Further, 
when  the  diseases  are  combined  there  is  a  tendency  to  a  decrease  in  the  number 
of  leukocytes.  A  number  of  observers  are  strongly  inclined  to  the  belief  that 
the  condition  is  due  to  an  infection  by  a  parasite,  but  careful  obser^•ation  and 
experimental  studies  have  afforded  no  conclusive  result.  Lowit  and  others  have 
sought  to  establish  a  protozoal  origin,  but  their  observations  are  inconclusive, 
and  bacteriology,  so  far,  has  yielded  no  promising  results. 

Pathology  and  Morbid  Anatomy. — ^Yhen  defining  the  disease  leukemia  it  was  stated 
that  it  is  a  malady  which  appears  in  two  forms,  and  that  these  forms  may  be  quite 
dissimilar  in  their  chief  features,  or  overlap  one  another,  according  to  the  degree 
to  which  the  lymphatic  system  and  the  bone-marrow  are  chiefly  aft'ected.  It  is 
probable  that  in  nearly  every  instance  the  bone-marrow  is  involved  in  the  disease 
process,  and  almost  never  are  the  lesions  situated  only  in  the  lymph  nodes  and 
other  lymphatic  tissues.  Further,  although  the  lymphocv-tes  of  a  person  in  good 
health  are  usuallj'  derived  from  the  lymphatic  system,  in  the  patient  suffering 
from  lymphatic  leukemia  they  are  derived,  to  a  large  extent,  from  the  bone-marrow 
as  well. 

Having  made  these  preliminary  remarks,  we  can  best  proceed  to  the  study  of 
two  forms  of  lei(keviia  by  considering  them  separately. 

Splenomedullary  Leukemia. — The  color  of  the  blood  may  be  normal  in  some 
cases,  but  if  the  disease  is  well  developed  it  is  much  paler  in  hue  because  of  the 
anemia  and  the  excess  of  white  cells.  The  coagulability  of  the  blood  is  greatly 
decreased  or  lost.  The  red  corpuscles  are  not  verj-  greatly  diminished  in  number 
until  the  disease  is  far  advanced,  and  sometimes  not  then.  They  rarely  fall  below 
3,000,000  to  the  cubic  millimetre,  but  they  may  drop  to  1,000,000.  Nucleated 
red  cells,  especially  normoblasts,  are  present  in  varying  numbers,  but  megaloblasts 
are  rarely  present  in  any  great  degree.  There  is  a  decrease  of  hemoglobin  so  that 
the  color-index  is  about  0.6  to  0.8. 

The  white  cells  show  remarkable  changes  as  to  number,  shape,  size,  and  variety. 
Even  in  cases  which  may  be  called  moderate  they  usually  amount  to  200,000  or 
more,  to  the  cubic  millimetre,  and  as  high  as  1,000,000  have  been  reported,  as 
against  a  normal  of  about  6000  to  8000.  Of  the  varieties  of  white  blood  cells 
we  find  a  form  which  never  appears  in  normal  blood,  and  which,  if  present  in  con- 
siderable numbers,  is  pathognomonic  of  the  disease,  namely,  large  mononuclear 
leukocj'tes  containing  neutrophile  granules.  These  cells  are  called  neutrophile 
myelocytes  and  appear  in  two  forms,  viz.,  the  smaller  myelocytes,  about  the  size 
of  the  polymorphonuclear  leukocyte,  possessing  a  central  nucleus  which  stains 
quite  deeply,  and  a  larger  cell,  which  has  a  pale  staining  nucleus  placed  at  one  side 
of  the  corpuscle.  Eosinophilic  and  basophilic  myelocytes  also  may  be  found.  The 
relative  percentage  of  polymorphonuclear  cells  is  decreased,  although  the  total 
number  of  these  corpuscles  far  exceeds  the  normal.  The  presence  of  the  myelocytes 
is  at  the  expense  of  the  polymorphonuclear  cells. 

The  eosinophile  cells,  leukocytes  the  granules  of  which  stain  intensely  with  eosin, 
are  generally  increased  in  myelemia,  although  they  are  never  as  numerous  as  are 
the  other  forms  already  named. 

The  number  of  lymphocytes,  both  large  and  small,  varies  within  wide  limits 


716  DISEASES  OF  THE  BLOOD 

in  cases  of  splenomediillary  leukemia,  and  at  diil'erent  times  in  the  same  case. 
Relatively  they  are  reduced  (as  low  as  2  per  cent.),  but  even  in  this  percentage  the 
blood  may  contain  more  mononuclears  to  the  cubic  millimetre  than  in  health. 
Very  large  mononuclear  leukocytes  with  faintly  staining  nuclei  arc  rarely  ci)nsj)icu- 
ous  by  their  number.  "Mast-cells"  are  usually  present,  not  infrequently  reaching 
5  or  10  per  cent.  When  present  in  large  numbers  they  are  second  to  myelocytes 
only  in  diagnostic  significance.  These  mast-cells  are  polynuclcar  cells  with  coarse 
basophile  granules. 

The  onset  of  any  one  of  the  acute  infections  may  completely  change  the  appear- 
ance of  the  blood  so  that  it  is  no  longer  characteristic  and  there  may  be  a  great 
increase  in  polymorphonuclear  cells. 

The  normal  red  bone-marrow  shows  marked  hyperplasia  and  the  fatty  marrow 
of  the  long  bones  undergoes  a  similar  transformation.  It  contains  nucleated  red 
cells  in  unusual  numbers,  and  is  crowded  with  leukocytes  which  are  ancestral  to 
those  found  in  the  blood,  including  all  forms,  but  particularly  myelocytes.  In 
some  cases,  however,  these  changes  appear  in  patches  rather  than  all  through  the 
bone  cavity.  At  certain  points  the  compact  portion  of  the  bone  may  atrophy 
before  the  hyperplastic  marrow,  and  new  subperiosteal  nodes  may  develop. 

The  spleen  is  very  much  enlarged,  sometimes  to  fifteen  times  its  normal  size. 
It  is  frequently  attached  to  adjacent  tissues.  Its  capsule  is  usually  thickened  and 
roughened,  and  the  consistency  of  the  organ  increased.  On  section  it  is  seen  to  be 
mottled  red  and  gray,  or  it  may  be  a  homogeneous  red.  The  trabecule;  may  be 
thickened  and  hemorrhagic  infarctions  may  be  present.  The  venous  system  is 
engorged  and  purulent-looking  clots  may  be  found  in  the  heart  and  vessels.  The 
liver  is  often  enlarged  and  leukemic  nodules  may  be  found  in  it  and  in  the  kidneys 
and  thymus  gland. 

Lymphatic  Leukemia. — The  conspicuous  blood  changes  in  this  disease  are  con- 
fined to  the  lymphocytes,  which  are  greatly  increased  in  number  so  that  they  may 
exceed  80  per  cent,  of  the  total  number  of  white  cells.  For  this  reason  the  condition 
is  sometimes  called  lymphemia.  Usually  most  of  the  cells  are  small  lymphocytes, 
but  the  large  form  may  predominate,  especially  in  the  acute  type  of  the  disease. 
The  total  increase  in  leukocytes  rarely  approaches  that  seen  in  the  splenomedullary 
form.     Nucleated  red  cells  are  rarely  encountered. 

The  lymphatic  glands,  particularly  those  which  are  deeply  situated,  are  enlarged, 
but  the  spleen  and  the  medulla  of  the  long  bones  are  not  greatly  altered.  Cases 
are  on  record  in  which  chronic  lymphatic  leukemia  has  occurred  without  any 
enlargement  of  the  lymph  nodes,  and  in  some  instances  there  is  an  actual  increase 
in  the  number  of  white  cells,  but  only  a  relative  lymphocytosis. 

Symptoms. — The  symptoms  of  splenomeduUary  Jcuhemia  are  at  first  those  of 
anemia,  the  patient  presenting  himself  because  of  dyspnea  on  exertion,  or  because 
of  lack  of  energy  and  poor  digestion.  Sometimes  the  sifoUe7i  spleen  first  calls  his 
attention  to  his  condition.  In  other  cases  nosebleed  or  gastric  hemorrhage  or  renal 
hemorrhage  comes  on  very  early  in  the  disease.  In  other  cases  there  is  pnrpvra 
hemorrhagica.  If  the  hand  is  placed  over  the  splenic  area  and  the  abdominal 
wall  moved  over  the  enlarged  spleen  a  creaking  sensation  may  sometimes  be  felt. 
Not  rarely  the  liver  is  greatly  enlarged,  and  ascites  may  be  present.  There  is 
dizziness  and  vertigo.  Occasionally  a  violent  diarrhea  develops.  The  urine  is 
normal,  save  that  it  contains  uric  acid  in  excess.  The  heart  sounds  are  normal, 
although  the  first  sound  may  be  feeble,  and  anemic  murmurs  can  occasionally  be 
heard.  Retinal  hemorrhages  may  cause  blindness.  Hemiplegia  with  coma,  the 
result  of  cerebral  hemorrhage,  may  occur.  A  moderate  but  varying  febrile  move- 
ment is  nearly  always  present.  Occasionally  persistent  priapism,  probably  due  to 
irritation  of  the  spinal  cells  by  anemia,  is  present.     Sudden  death  may  take  place. 

In  cases  of  lymphatic  leukemia  the  symptoms  complained  of  by  the  patient  are 


LEUKEMIA  717 

not  different  from  those  just  described,  but  the  spleen  is  not  so  much  enlarged. 
The  lymph  nodes  are,  however,  increased  in  size,  and  so  the  appearance  of  the 
patient  may  not  be  unlike  that  of  Hodgkin's  disease. 

It  is  important  to  recall  the  fact  that  in  both  of  these  states  an  irregular  febrile 
movement  may  be  present  and  give  rise  to  the  belief  that  some  one  of  the  acute 
or  chronic  infections  characterized  by  fever  are  present.  This  is  particularly 
true  in  certain  cases  of  acute  lymphatic  leukemia,  in  which  the  condition  of  the 
patient  may  be  so  like  that  of  typhoid  fever  that  an  examination  of  the  blood  is 
required  to  determine  the  e.xact  nature  of  the  illness.  The  condition  often  runs 
its  course  in  three  or  four  weeks;  fever  of  moderate  degree  is  present,  and  the  general 
state  is  asthenic.  Even  an  autopsy  may  not  reveal  the  real  cause  of  the  illness, 
because  the  lymph  nodes  in  the  solitary  and  agminated  glands  of  the  intestine 
are  infiltrated  as  in  typhoid  fever. 

Diagnosis. — The  pallor,  the  enlarged  spleen,  and  the  state  of  the  blood  are  all 
part  of  a  picture  which  cannot  be  mistaken  for  any  other  disease,  but  in  doubtful 
early  cases  repeated  blood  examinations  may  be  necessary  to  determine  the  diagno- 
sis positively. 

Prognosis. — The  prognosis  of  leukemia,  like  that  of  pernicious  anemia,  is,  in  the 
great  majority  of  cases,  fatal,  but  rare  instances  have  been  recorded  in  which 
recovery  has  taken  place.  Life  may  be  preserved  from  a  year  to  three  years. 
Unfavorable  prognostic  signs  are  marked  dyspnea,  an  excessive  number  of  leuko- 
cytes, a  tendency  to  exhausting  diarrhea  or  to  hemorrhages,  and  high  fever.  The 
lymphatic  type  usually  runs  a  more  rapidly  fatal  course  than  the  splenomedullary 
form.  When  death  occurs,  the  cause  is  usually  pulmonary  edema,  pneumonia,  or 
exhaustion. 

Treatment. — The  treatment  of  leukemia  in  both  its  forms  is  identical,  but,  unfor- 
tunately, it  is  by  no  means  successful,  for  the  disease  in  all  instances  proceeds  by  a 
more  or  less  rapid  course  to  a  fatal  ending.  There  can,  however,  be  no  doubt  that 
the  administration  of  arsenic  in  ascending  doses  until  the  point  of  intolerance  is 
reached  seems  to  exercise  a  favorable  influence  upon  the  malady,  at  least  in  so  far 
that  it  delays  its  advance.  Cases  of  leukemia  not  subjected  to  treatment  not 
infrequently  have  periods  of  remission,  in  which  temporary  improvement  maj^"  take 
place.  It  is,  therefore,  difficult  to  determine  how  much  credit  should  be  given  to 
arsenic  when  the  remissions  occur  under  its  use.  Those  members  of  the  profession 
who  have  had  the  most  experience  in  the  treatment  of  leukemia,  however,  regard 
arsenic  as  being  practically  the  only  remedy  of  any  value,  and  it  should  always 
be  tried,  preferably  in  the  form  of  Fowler's  solution.  The  beginning  doses  should 
be  3  drops  three  times  a  day,  rapidly  increased  until  the  patient  has  some  puffiness 
of  the  face  or  some  griping  of  the  bowels.  Recently  several  clinicians  have  reported 
"cures"  of  this  disease  by  exposing  the  long  bones  of  the  patient  to  the  Roentgen 
rays.  This  results  after  several  applications  in  a  diminution  in  the  size  of  the 
spleen  which  continues  as  the  treatment  is  continued.  After  this  organ  has  been 
materially  reduced  in  size  and  the  patient  generally  improved  the  spleen  itself 
is  exposed.  Not  rarely  such  exposure  is  followed  at  first  by  a  great  increase  in 
the  leukocytes.  The  main  effect,  a  notable  decrease  in  leukocytes  follows.  The 
treatment  requires  several  months  with  about  twenty  or  thirty  applications  a 
month.  The  plan  also  relieves  the  pain  in  the  long  bones.  As  well  sho\\Ti  by 
Warthin  in  his  exhaustive  discussion  of  this  subject  the  final  outcome  of  most  if 
not  all  of  the  cases  thus  treated  is  relapse  and  death  from  the  disease.  Warthin's 
experimental  studies  indicate  a  possible  danger  from  the  absorption  of  substances 
liberated  by  the  destruction  of  cells  brought  about  by  the  Roentgen-ray  exposures. 
Further  investigations  will  be  necessary  to  place  this  procedure  upon  a  sound 
therapeutic  basis,  as  it  deals  with  a  disease  that  is  notoriously  resistant  to  ordinary 
remedial  measures.     However,  the  question  is  one  that  merits  careful  study. 


718  DISEASES  OF  THE  HLOOD 

Recent  studies  by  Warthin  have  led  liini  to  tlie  following  conclusions  regarding 
the  efl'ect  of  this  treatment:  "Prolonged  irradiation  of  the  hematopoietic  organs 
in  leukemia  causes  first  a  degeneration  of  the  young  and  maternal  ceils,  leading 
to  a  great  decrease  in  the  output  of  leukocytes,  ])articuiarly  in  myckmia.  After 
this  destructive  efl'ect  there  follows  a  reaction  in  which  cells  of  a  more  resistant 
type  are  formed,  and  the  essential  leukemic  process  remains  unchecked,  although 
altered  in  character." 

Excellent  temporary  results  have  accrued  in  some  cases  by  the  use  of  5  to  10 
minims  of  benzole  (not  benzine)  three  times  a  day  given  in  capsule  after  food. 
The  best  cases  have  also  had  the  .r-rays  during  or  before  the  benzole  was  employed. 

Benzole  does  more  good  in  the  splenomedullary  type  than  in  the  lymphatic 
form  of  the  disease. 

CHLOROMA. 

Under  the  name  chloroma  is  recognized  a  condition  characterized  I)y  the  forma- 
tion of  greenish  lymphoid  tumors,  especially  in  the  cranial  bones  and  periosteum, 
and  the  occurrence  of  a  profound  anemia  which  Dock  and  Warthin  regard  as, 
in  some  if  not  all  cases,  a  malignant  type  of  leukemia.  Exophthalmos  and  lymphoid 
infiltration  of  the  cornea  and  of  the  conjunctiva  may  be  present.  Later  the  perios- 
teum of  the  bones  of  the  spinal  column  become  affected.  Localized  paralysis,  from 
pressure  exerted  by  these  growths  upon  nerve  trunks,  may  arise.  Another  char- 
acteristic of  chloroma  is  the  peculiar  green  hue  of  the  new  growths;  the  cause  of 
this  coloration  is  unknown. 

The  latest  study  of  this  remarkable  and  rare  disease  is  that  made  by  Dock  and 
Warthin.  These  investigators  conclude  that  the  disease  consists  in  a  neoplastic 
hyperplasia  of  the  parent  cells  of  the  leukocytes  which  develops  primarily  in  the 
red  bone-marrow  and  secondarily  affects  the  periosteum.  Typical  and  atypical 
leukocytes  are,  therefore,  developed,  set  free  in  the  blood,  and  nuiy  apjjear  as  large 
lymphocytes  or  as  neutrophiles  or  eosinophile  myelocytes.  On  the  other  hand,  it 
is  not  essential  for  the  diagnosis  of  chloroma  that  these  leukocytic  changes  be 
present,  for  sometimes  they  fail  to  appear.  Chloroma  may,  therefore,  be  regarded 
as  a  malady  lying  midway  between  leukemia  and  lymphosarcoma.  The  essential 
point  of  differentiation  is  the  development  of  the  green  masses  of  lymphoid  tissues 
which  are  distinctlv  neoplastic  in  character.  The  prognosis  of  chloroma  is  invari- 
ably fatal. 

ANEMIA  INFANTUM. 

Definition. — Untler  this  term  von  Jaksch  has  described  a  form  of  anemia  occurring 
in  children  under  four  years  of  age  and  resembling  leukemia  in  many  respects, 
in  that  there  is  great  enlargement  of  the  spleen,  marked  leukocytosis,  some  increase 
in  the  size  of  the  liver  and  of  the  lymph  nodes.  Aon  Jaksch  believes  that  this 
malady  separates  itself  from  a  true  leukemia  of  infancy  by  the  fact  that  the  increase 
in  the  white  cells  is  never  so  marked  as  in  true  leukemia,  that  children  often  recover, 
and  because  there  is  never  any  leukemic  infiltration  of  the  viscera.  The  cause  is 
not  known. 

The  red  cells  are  so  much  decreased  that  they  number  only  from  3,000,000  to 
1,500,000.  There  are  also  present  poikilocytes  and  usually  a  large  number  of 
nucleated  red  cells.  The  total  leukocytosis  rarely  exceeds  50,000,  the  chief  increase 
being  in  the  mononuclear  corpuscles.  Myelocytes  are  absent,  or  not  present  in 
sufficient  number  to  justify  a  diagnosis  of  leukemia.  The  li\cr  and  spleen  are 
enlarged.  The  condition  is  usually  met  with  in  rachitic  or  syphilitic  children  and 
in  those  sullVring  from  chronic  gastro-inte.stinal  catarrh. 

Treatment. — The  treatment  is  identical  with  that  of  leukemia. 


PURPURA  719 


PURPURA. 


Under  this  term  is  included  all  those  cases  in  which,  as  the  result  of  various 
causes,  extravasations  of  small  fjuantities  of  blood  take  place  into  the  skin.  These 
extravasations  are  multiple  and  often  very  widespread.  It  must  be  borne  in  mind 
that  under  no  condition  is  purpura  a  disease  in  itself.  It  is  a  symptom  or  mani- 
festation of  some  disturbance  in  the  nutrition  of  the  smaller  bloodvessels  or  of  the 
blood.  Thus,  it  occurs  as  a  manifestation  of  severe  infections,  such  as  profound 
septicemia,  scarlet  fever,  typhus  fever,  measles,  and  smallpox,  and  in  infections 
not  so  well  understood,  in  which  micro-organisms,  known  and  unknown,  are  mani- 
festly the  cause  of  the  condition.  Various  investigators  have  isolated  from  cases 
of  purpura  such  micro-organisms  as  the  Streptocomis  yyogenes,  the  Staphylococcvf 
pyogenes  aureus,  the  jmeumococais,  and  the  Bacillus  aerogenes  capsidatvs.  The 
Bacillus  coli  covimunis  has  also  been  obtained  from  the  blood.  Again,  certain 
poisons,  as  snake  venom  and  poisons  from  the  mineral  kingdom,  may  cause  purpura. 
A  large  number  of  cases  of  marked  purpura  have  de\'eloped  in  persons  who  have 
taken  iodide  of  potassium,  and  after  the  use  of  mercury,  copaiba,  and  the  chlorate 
of  potassium,  and  certain  acid  fruits  like  strawberries  or  grape  fruit,  and  foods 
like  shell  fish  may  induce  an  attack.  It  may  also  develop  as  the  result  of  some 
congenital  defect  in  the  blood,  as  in  hemophilia. 

Diseases  generally  called  diathetic,  such  as  scurvy,  tuberculosis,  Hodgkin's 
disease,  and  chronic  nephritis,  may  cause  this  symptom.  Purpuric  extravasations 
sometimes  develop  after  severe  neuralgic  seizures  in  locomotor  ataxia  and  along 
the  course  of  certain  nerves  in  hysterical  women.  It  is  evident,  therefore,  that 
while  the  exact  pathology  of  those  various  states  is  obscure  the  etiological  factor 
is  in  one  instance  an  infection,  in  another  a  toxemia,  endogenous  or  exogonous,  and 
in  the  third  class  due  to  some  inherative  or  congenital  state.  In  still  other  instances 
it  is  the  result  of  some  trophic  nervous  lesion. 

The  severity  of  the  lesions  may  vary  from  small  pin-head  spots,  at  first  bright 
red  and  copious  which  fade  to  a  dirty  yellow,  to  blebs  and  bullae  with  ulcerated 
bases.  In  other  cases  the  exudate  is  so  largely  serous  that  the  lesions  partake  of 
the  character  of  an  urticaria.  Such  cases  also  may  have  edema  of  the  glottis,  and 
sharp  attacks  of  abdominal  pain  which  preceding  the  appearance  of  erythematous 
patches,  urticarial  wheals,  or  true  purpuric  lesions  may  mislead  the  physician  into 
a  diagnosis  of  appendicitis,  gallstone  colic  or  ruptured  tubal  pregnancy.  Hema- 
temesis  may  be  free  and  give  rise  to  a  diagnosis  of  gastric  or  duodenal  ulcer,  par- 
ticularly in  those  instances  in  which  the  lesions  in  the  skin  and  mucous  membrane 
are  scanty  or  absent.  The  extravasation  of  blood  into  the  wall  of  the  bowel  may 
cause  intestinal  obstruction;  sometimes  extravasations  of  blood  or  serum  take 
place  in  the  eyeball  causing  blindness,  or  in  the  brain  inducing  a  hemiplegia  and 
unconsciousness. 

Under  the  name  "purpura  rheumatica,"  or  "peliosis  rheumatica,"  a  form  of 
purpura  develops  in  which  there  is  a  distribution  of  the  spots  chiefly  about  the 
large  joints,  particularlj;-  about  the  knees.  Associated  with  this  eruption  there  is 
swelling  of  the  tissues  about  the  joints  resembling  that  seen  in  rheiunatism.  There 
is  usually  no  fever  and  little  pain,  although  the  joints  appear  stiffened  at  times. 
It  was  this  arthritic  state  that  gave  the  name  "purpura  rheumatica"  to  the 
condition.  In  some  instances  the  joint  disorder  is  due  to  acute  rheumatism  but  in 
the  majority  it  is  some  other  form  of  infection. 

Under  the  name  of  "Schonlein's  disease"  a  very  much  more  severe  type  of  this 
condition  has  been  described.  Many  of  the  joints  are  affected,  so  that  the  patient 
is  bedridden,  and  the  extravasations  of  blood  into  the  submucous  tissues  and  into 
the  skin  are  so  copious  that  great  swelling  and  even  sloughing  may  result.  Some 
years  ago  I  saw,  in  consultation  with  Dr.  Wilson,  of  Woodbury,  New  Jersey,  another 


720  DISEASES  OF  THE  BLOOD 

physician  who  not  only  had  the  joints  of  the  extremities  greatly  affected,  but  the 
inferior  maxillary  joint  was  also  involved.  The  buccal  mucous  membrane  was  so 
infiltrated  that  we  feared  the  development  of  noma,  and  the  whole  face  was  much 
distorted  by  the  infiltration.  Notwithstanding  the  severity  of  the  lesions  and 
the  intense  prostration  of  the  patient,  recovery  u.sually  takes  place.  Care  must 
he  taken  that  this  form  of  purpura  is  not  confused  with  scurvy  or  scorbutus 
(which  see). 

"Henoch's  purpura"  describes  a  condition  characterized  by  lesions  in  the  skin 
which  may  be  a  combination  of  purpura  and  erythema  multiforma.  The  joints 
may  or  may  not  be  affected,  and  bleeding  from  the  gums  may  appear.  The  most 
distinctive  sjmptom,  which  is  not  present  in  all  cases,  but  wliich  may  be  present 
when  the  others  are  absent,  is  gastro-intestinal  crises,  in  which  the  child  is  seized 
with  pain,  diarrhea,  and  vomiting.  All  these  sjTnptoms  are  prone  to  recur  at 
irregular  intervals.  Recovery  usually  occurs,  except  in  those  eases  in  which  the 
hemorrhagic  state  affects  the  kidneys,  when  a  fatal  result  may  ensue. 

A  form  of  fulminating  purpura  sometimes  develops  in  young  girls  and  causes 
death  in  a  few  days,  the  patient  being  apparently  overwhelmed  by  some  unknown 
infection. 

There  are  three  hemorrhagic  affections  of  the  neichorn  that  occasionally  occur. 

In  children  with  inherited  syphilis,  hemorrhage  from  the  mucous  membranes 
and  from  the  navel,  with  intense  subcutaneous  extravasations,  may  occur  and  cause 
death.  The  autopsy  shows  hemorrhages  into  the  liver  and  kidneys,  and  signs  of 
inherited  syphilis  in  these  parts  as  well. 

Under  the  name  of  Winckel's  disease  a  condition  of  jaundice  develops  within  a 
week  of  birth,  followed  by  dyspnea,  hemoglobinuria,  and  deep  cyanosis.  I  saw  a 
case  some  years  ago  in  which  the  child  was  so  cyanotic  that  parts  of  its  body  were 
blue-black.  The  autopsy  in  such  a  case  shows  swelling  of  the  spleen  and  fatty 
degeneration  of  the  liver  and  kidneys. 

A  third  state  called  "morbus  maculosus  neonatorum"  develops  in  newborn 
infants,  and  consists  in  hemorrhages  from  the  stomach,  intestines,  or  from  the 
navel.     It  is  rarely  seen  in  private  practice,  and  is  probably  due  to  some  infection. 

Hayem  and  Bensaude  have  stated  that  in  purpura  hemorrhagica  the  blood, 
when  allowed  to  stand  in  a  vessel  for  twenty-four  hours,  slowly  clots,  but  the  clot 
does  not  contract  to  any  extent,  and  therefore  does  not  squeeze  out  the  serum  as  it 
does  in  normal  blood,  but  Howell  was  unable  to  find  that  the  blood  of  such  patients 
lacked  prothrombin  or  antithrombin. 

Treatment. — The  treatment  of  all  forms  of  purpura  is  based  upon  the  recollection 
of  two  facts,  viz.,  first,  that  the  condition  is  due  in  most  cases  to  an  infection  or  at 
least  to  a  cause  which  has  im])aired  the  health,  and  therefore  every  means  to  aid 
the  vital  resistance  of  the  body  must  be  resorted  to.  The  food  should  be  easily 
digested  and  nutritious;  the  patient,  if  able  to  travel,  should  be  removed  to  some 
j)lace  where  he  can  bask  all  day  in  the  sunshine.  Moderate  doses  of  tincture  of 
the  chloride  of  iron  should  be  given  each  day  to  combat  the  infection  and  the 
anemia. 

The  second  point  to  be  recalled  is  that  certain  drugs  may  be  employed  to  increase 
the  coagulability  of  the  blood.  Of  these,  the  only  ones  with  any  real  claim  to 
power  are  the  lactate  and  chloride  of  calcium,  which  may  be  given  in  the  dose  of 
20  grains  three  times  a  day  to  an  adult,  well  diluted  with  water.  Certain  cases 
seem  unable  to  absorb  calcium  salts  through  the  alimentary  canal  and  these  should 
be  treated  by  hypodermic  injection.  The  solution  should  not  be  stronger  than  1 
l)art  in  20  of  water  and  the  lactate  should  be  used  because  the  chloride  is  too 
irritating.  The  effect  of  one  day's  dose  of  60  grains  lasts  three  or  four  days,  and 
it  should  not  be  too  frequently  repeated,  since,  if  this  is  done,  coagulability  is 
decreased.      Turpentine,  oil  of  erigeron,  ergot,  and  sulphuric  acid  have  all  been 


IIEMOrilHJA  721 

used.  Their  employment  is  purely  empirical,  aiKJ  there  is  little  reason  to  rely  on 
them.  Plenty  of  nutritious  food,  fresh  air,  and  a  day  in  the  bright  sunlight  will 
do  more  good  in  this  .state  than  all  the  medicines  can  accomplish,  and  this,  too, 
without  damaging  the  .stomach.  The  use  of  these  remedies  in  this  state  is  putting 
"drugs  of  which  we  know  little  into  bodies  of  which  we  know  less." 


HEMOPHILIA. 

Definition. — Hemophilia  is  a  condition  of  the  body  in  which  there  is  an  inability 
to  arrest  hemorrhage  by  the  normal  coagulation  of  the  blood,  or  in  which  hem(jrrhage 
arises  apparently  without  cause  and  persists  without  any  attempt  being  made  by 
nature  to  arrest  it.  The  disease  is  essentially  hereditary  in  most  ca.ses,  and  it  is 
an  extraordinary  fact  that  the  hemorrhagic  tendency  is  transmitted  to  males  only 
through  the  female  parent,  although  the  mother  is  herself  usually  not  afflicted. 

Etiology. — Howell  has  shown  that  in  hemophilia  there  is  a  deficiency  of  pro- 
thrombin which  accounts  for  the  delay  in  coagulation. 

Pathology  and  Morbid  Anatomy. — ^lliere  are  no  changes  in  the  blood  cells  that 
account  for  this  condition.  An  examination  of  the  tissues  of  the  various  organs  is 
also  practically  negative,  save  that  if  the  hemorrhage  has  been  profuse  the  changes 
always  met  with  in  marked  anemia  are  present. 

Symptoms. — An  active  but  oozing  capillary  hemorrhage  is  the  form  in  which  the 
bleeding  usually  occurs,  and  it  follows  in  some  instances  very  slight  injury.  Thus 
the  mere  blowing  of  the  nose  may  be  sufficient  to  rupture  the  fine  vessels  of  the 
nasal  mucous  membrane  and  cause  a  dangerous  loss  of  blood,  and  epistaxis  is  the 
most  common  form  in  which  this  condition  manifests  itself.  Another  common 
source  of  the  blood  is  from  the  gum  after  tooth  extraction. 

In  some  cases  bloody  effusions  take  place  into  the  large  joints. 

Prognosis. — ^The  prognosis  depends  largely  upon  the  scA-erity  of  the  loss  of  blood 
and  upon  the  ability  of  the  patient  to  restore  the  cjuantity  lost  before  the  next 
bleeding  comes  on.  Fully  50  per  cent,  of  bleeders  die  before  the  seventh  year,  but 
some  live  to  old  age.  Although  girls  who  reach  puberty  menstruate  with  their 
entrance  upon  adult  life,  and  so  are  exposed  to  an  excessive  loss  of  blood,  their 
mortality  rate  in  this  disease  is  not  so  high  as  that  of  boys. 

Treatment. — ^The  treatment,  if  the  hemorrhage  is  acute,  consists  in  the  subcu- 
taneous injection  of  the  blood  serum  of  a  healthy  hiunan  being  or  of  "Coagulose" 
prepared  from  the  serum  of  the  horse.  In  hemophilia  neonatorum  this  is  the  only 
plan  which  will  save  life,  in  the  building  up  of  the  general  health  by  out-door  hfe 
and  exposure  to  sunshine,  and  in  the  use  of  small  tonic  doses  of  iron  and  arsenic 
if  anemia  is  present.  If  a  special  tendency  to  hemorrhage  exists  at  any  particular 
time,  calcium  lactate  or  chloride  should  be  given  in  doses  varying  from  10  to  20 
grains  three  or  four  times  a  day,  well  diluted,  to  increase  the  coagulability  of  the 
blood,  but  this  must  not  be  used  for  long  periods  without  intermission,  as  after  a 
certain  amount  is  taken  the  coagulability  of  the  blood  is  decreased  and  not  increased. 
The  local  treatment  consists  in  the  use  of  tampons  wet  with  blood  serum  derived 
from  a  healthy  animal  or  man,  or  with  coagulose  which  is  dried  horse  serum,  placed 
on  the  market  for  this  purpose,  with  adrenalin  chloride,  1 :  1000,  or  gelatin  solution 
of  the  consistency  of  thin  mucilage  may  be  used  for  the  same  purpose.  'When 
adrenalin  cannot  be  obtained,  peroxide  of  hj-drogen  may  be  applied  in  the  same 
manner  to  the  bleeding  spot.  When  the  hemorrhage  is  from  the  gum,  a  compress 
made  of  punk  may  be  used,  or  a  compress  wet  with  a  saturated  solution  of  alum, 
with  [Nlonsel's  solution,  or  with  adrenalin  chloride  solution,  1 :  1000, 


DISEASES  OF  NUTRITION. 


DIABETES  MELUTUS. 

Definition. — Diabetes  mellitus  is  a  disease  characterized  by  the  appearance  in  the 
urine  of  glucose,  and  the  development  of  polyuria,  thirst,  and  excessive  appetite 
with  impairment  of  nutrition,  and  in  some  cases  progressive  emaciation.  The 
mere  presence  of  glucose  in  the  urine  does  not  necessarily  indicate  that  diabetes 
is  present.  The  glycosuria  must  be  associated  with  other  morbid  processes  to 
present  the  symptom-complex  of  the  disease. 

Furthermore,  while  it  is  true  that  large  amounts  of  sugar  in  the  urine  are  in  a 
sense  of  greater  importance  than  small  amounts,  it  is  a  fact  that  the  amount  of  sugar 
is  not  the  real  index  of  gravity.  It  is  the  secondary  products  of  perverted  metab- 
olism, such  as,  |8-oxybutyric  acid  and  the  proportion  of  nitrogen  in  the  urine 
which  are  the  gauges  of  severity. 

History. — Diabetes  mellitus  has  been  known  since  the  time  of  Christ,  but  it 
was  not  till  the  latter  part  of  the  seventeenth  century  that  Willis,  in  England, 
noted  that  the  sweet  taste  of  the  urine  was  probably  due  to  sugar,  and  not  until 
1775  that  Dobson,  of  England,  actually  obtained  sugar  from  the  urine.  Since  that 
time  a  host  of  experimental  investigators  and  clinicians  have  studied  the  disease 
from  every  aspect  and  have  added  much  to  our  knowledge  of  it,  but  no  one  has 
as  yet  been  able  to  give  us  a  clear  conception  of  the  causes  of  the  malady.  Probably 
there  are  several  causes. 

Distribution  and  Frequency. — Diabetes  occurs  in  all  parts  of  the  civilized  world, 
but  is  much  more  common  in  Europe  than  in  the  United  States.  It  is  frequently 
met  with  in  France,  in  Sweden,  in  Italy,  in  India,  and  Ceylon,  but  is  comparatively 
rare  in  Russia,  Holland,  and  in  Brazil.  Negroes  rarely  suffer  from  it,  but  Hebrews 
are  so  frequently  affected  by  it  that  it  may  almost  be  said  to  be  the  prevalent 
disease  of  that  race.  Kulz,  of  Germany,  found  that  in  692  cases  of  diabetes  17.8 
per  cent,  occurred  in  Jews,  which  is  all  the  more  remarkable  when  we  consider  that 
Hebrews  constitute  only  1.2  per  cent,  of  the  population  of  that  country.  Frerichs 
found  102  Jews  in  400  diabetic  patients,  and  von  Noorden  252  Jews  in  650  patients 
suffering  from  this  disease. 

It  is  a  disease  of  adult  life,  as  a  rule,  but  very  young  children  suffer  from  it 
occasionally,  and  even  nurslings  have  from  time  to  time  been  reported  as  presenting 
well-developed  cases  of  the  malady.  To  emphasize  its  rarity  in  children.  Stern 
may  be  quoted  in  his  assertion  that  only  thirteen  deaths  have  been  reported  from 
this  malady  as  occurring  in  children  under  five  years  of  age  in  thirteen  years.  It 
is  more  common  in  males  than  in  females  in  the  proportion  of  3  to  2. 

The  statement  generally  made  that  diabetes  is  a  disease  of  cities  rather  than  of 
country  districts  is  not  altogether  true.  Some  years  ago  Purdy  showed  that,  as  a 
rule,  it  was  much  more  frequent  in  the  country  districts  than  in  cities.  In  the 
United  States  the  disease  is  much  less  frequent  in  the  Gulf  and  South  Atlantic 
States  than  anywhere  else. 

There  can  be  no  doubt  that  the  disease  is  becoming  very  much  more  frequent 
than  it  was  several  decades  ago.     I  showed  this  in  a  paper  published  some  years 

(723) 


724  DISEASES  OF  NUTRITION 

since,  based  upon  statistics  gathered  from  the  Jefferson  ^ledical  College  Hospital 
and  other  large  hospitals  here  and  abroad.  Since  then  additional  statistics  have 
been  collected  which  indicate  the  correctness  of  these  earlier  conclusions. 

According  to  the  mortality  statistics  of  the  United  States  Census  Reports  for 
six  decades,  the  proportion  of  deaths  from  diabetes  mellitus  in  100, 000  deaths  from 
all  known  causes  has  been  as  follows: 

From  1840  to  1850 72        From  1870  to  1880      ....     191 

"     1850  to  1860 98  "     1880  to  1890      ....     280 

"     1860  to  1870 170  "     1890  to  1900      ....     470 

It  seems  scarcely  credible  that  so  great  an  increase  could  have  occurred,  and  it 
is  possible  that  greater  care  in  examining  patients  and  in  regard  to  correct  death 
certificates  is  responsible  for  part  of  the  increase,  yet  the  records  of  the  Massachu- 
setts General  Hospital  from  1824  to  1898  showed  that  four  times  as  many  cases  of 
diabetes  were  admitted  to  the  hospital  during  the  last  thirteen  years  of  that  period 
as  during  the  first  fifteen  years.  On  the  other  hand,  it  is  only  fair  to  state  that  the 
statistics  of  L'Hotel  Dieu,  Lyons,  for  seventeen  years,  which  were  collected  by 
Alix,  for  Lepine,  who  attempted  to  ascertain  if  diabetes  was  increasing  in  a  certain 
district  of  France,  do  not  show  any  increase  in  the  disease. 

Etiology. — The  causes  of  diabetes  are  not  known,  although  it  is  a  well-recognized 
fact  that  lesions  in  certain  portions  of  the  nervous  system  are  followed  by  glycosuria, 
and  that  certain  alterations  in  the  islands  of  Langerhans  in  the  pancreas  and  in  the 
circulation  of  the  liver  are  also  followed  by  the  same  sjinptom.  (See  Pathology.) 
As  somewhat  indirect  causes  we  recognize  severe  nervous  strain  and  errors  in  diet, 
but  these  alone  are  not  sufRcient  to  cause  even  glycosuria,  much  less  true  diabetes, 
in  the  vast  majority  of  human  beings. 

Certain  factors  tend  to  produce  the  chain  of  disturbances  just  enumerated, 
and  all  these  agencies  may  cause  changes  which  may  be  mild  and  continue  so,  or, 
in  another  case,  become  severe  and  rapidly  fatal.  These  may  be  mentioned  as 
follows : 

1 .  Heredity.  It  is  well  recognized  that  a  diabetic  parent  often  hands  down  to  the 
offspring  certain  defects  which  interfere  with  the  proper  utilization  of  carbohydrates. 

2.  Errors  in  diet,  both  as  to  food  and  drink.  It  is  conceivable  that  errors  of  this 
character  can  so  pervert,  or  overwhelm,  the  processes  of  nutrition  or  elimination 
that  primary  glycosuria  followed  by  permanent  diabetes  may  ensue.  Thus,  the 
excessive  beer-drinkers  of  Bavaria  often  suffer  from  this  disease,  probably  because 
of  the  excess  of  fluid,  of  alcohol,  and  of  carbohydrate  which  they  ingest.  These 
factors  pervert  the  function  of  the  liver,  of  the  pancreas,  and  of  the  kidneys. 

3.  Projound  nervous  worry  and  mental  anxiety  are  undoubtedly  followed  by 
diabetes  in  some  persons  probably  because  the  nervous  mechanism  governing 
nutritional  processes  is  perverted  in  function  by  the  stress  and  strain. 

4.  Certain  injuries  to  the  central  nervous  system  may  so  result,  for  severe  trauma 
of  the  head  or  the  growth  of  an  intracranial  tumor  may  produce  glycosuria. 

5.  It  has  been  definitely  shown  tliat  injury  to,  or  a  qrouih  in,  but  not  destructio7i 
of  the  posterior  lobe  of  the  hypophysis  may  de\elop  glycosuria  with  i)olyuria 
without  any  associated  changes  in  the  islands  of  Langerhans  in  the  pancreas. 
This  deduction  is  supported  liy  the  fact  that  in  animals  which  have  been  subjected 
to  extirpation  of  the  infundibular  portion  of  the  gland  there  is  as  great  an  increase 
in  fat  and  as  extraordinary  tolerance  of  starches  and  sugars,  as  in  indivifluals  who 
have  complete  destruction  of  this  gland  by  disease. 

6.  Possibly  in  some  cases  excessive  secretion  of  the  suprarenal  glands  is  present. 
Such  an  abundance  of  adrenalin  in  the  blood  is  supposed  to  act  on  the  system  so 
that  glucose  cannot  be  stored  or  there  is  set  free  large  amounts  of  glucose  already 
in  storage. 


DIABETES  MELLITUS  725 

7.  Certain  infectious  diseases  may  produce  temporary  glycosuria,  which  disappears 
with  the  acute  disease,  or  persists  and  becomes  true  diabetes,  prol)ably  because  the 
acute  infection  has  damaged  beyond  repair  nervous  centres  or  glands  whose  function 
is  to  control  glycogenesis  and  the  utilization  of  glycogen. 

8.  Diathetic  diseases  such  as  gout  undoubtedly  cause,  or  predispose  to,  diabetes 
in  some  cases,  but  whether  this  influence  is  direct  or  simply  a  sign  of  genera!  jicrver- 
sion  of  metabolism  we  do  not  know. 

All  these  factors  are  predisposing  causes.  We  still  do  not  know  the  actual 
cause.  Hale  White  quotes  Sir  William  Gull  as  having  asked  "What  sin  did  Pavy 
or  his  fathers  before  him  commit  that  he  should  be  condemned  to  spend  his  whole 
life  seeking  the  cure  of  an  incurable  disease?"  To  which  White  adds  "Pavy, 
with  steadiness  of  purpose,  probably  unmatched,  worked  at  the  subject  from  the 
age  of  23  till  after  his  eighty-second  birthday,  but  neither  he  nor  the  many  hundreds 
of  others  who  have  tried  to  unravel  it  have  yet  succeeded  in  fully  explaining  why 
sugar  is  sometimes  found  in  urine,  nor  have  they  discovered  how  to  cure 
diabetes." 

Pathology. — Of  the  pathology,  or  morbid  physiology,  of  diabetes  we  are  very- 
ignorant,  although  an  immense  amount  of  skilled  research  has  been  devoted  to 
this  subject  for  years.  It  is  a  well-recognized  fact  that  in  all  human  beings  dextrose 
is  prepared  from  carbohydrate  foods,  and  even  from  proteids  and  fats,  and  deposited 
in  the  liver  and  in  the  muscles  as  glycogen  where  it  lies,  as  in  a  storehouse,  as  reserve 
food.  When  needed  for  nutritive  processes  it  is  reconverted  into  dextrose.  Dextrose 
also  circulates  in  the  healthy  blood  stream  in  the  proportion  of  about  1 :  1000,  and 
so  is  carried  to  various  parts  of  the  body  for  nutritional  purposes. 

There  are  many  conditions  which  produce  loss,  or  leakage,  of  this  substance 
in  the  form  of  glucose  in  the  urine.  Thus,  glycosuria,  or  the  mere  presence  of 
sugar  in  the  urine,  may  follow  the  ingestion  of  an  excess  of  either  cane-sugar  or 
grape-sugar  or  an  excess  of  carbohydrate  food.  Under  these  circumstances  it  is 
simply  an  overflow  of  material  which  the  system  cannot  utilize.  This  being  true, 
it  is  readily  conceivable  that  in  certain  states  of  disease  the  system  may  be  unable 
to  utilize  the  ordinary  amount  of  dextrose,  and  therefore  it  escapes  from  the  body. 
This  view  receives  support  from  the  theory  advanced  by  Loewi  and  Kolisch,  who 
believe  that  there  is  in  the  organism  a  body,  or  ferment,  or  agent,  which  binds  the 
glucose  in  the  tissues  in  such  a  form  that  it  does  not  appear  in  the  blood  in  excess. 
If  for  any  reason  this  binding  body  (Bindekorper)  is  diminished  in  power,  an  excess 
of  glucose  passes  to  the  kidneys  and  so  escapes  from  the  body.  This  view  explains 
a  considerable  number  of  cases  of  glycosuria,  but  by  no  means  all  of  them. 

It  is  a  well-known  fact  that  injury  or  disease  of  the  so-called  diabetic  centre  of 
Claude  Bernard  in  the  medulla  is  followed  by  glycosuria,  and  that  this  glycosuria 
is  directly  due  to  a  disorder  of  the  blood  supply  in  the  capillaries  of  the  liver.  This 
may  interfere  with  the  "binding"  of  the  glycogen  in  that  organ.  Again,  the  admin- 
istration of  phloridzin  will  produce  glycosuria,  but  this  condition  is  quite  different 
in  its  causation  from  ordinary  glycosuria,  in  that  the  drug  acts  upon  the  kidney 
structure  in  such  a  way  that  it  permits  a  leakage  of  the  normal  content  of  glucose 
from  the  blood.  In  other  words,  in  this  state  the  fault  does  not  lie  in  an  inability 
of  the  body  to  use  its  glycogen,  but  in  the  inability  of  the  kidneys  to  prevent  its 
escape  from  the  body. 

We  find,  therefore,  that  glycosuria  and  diabetes  mellitus  are  by  no  means  identical 
conditions  necessarily,  although  glycosuria  is  the  predominant  symptom  in  this 
disease.  There  may  be  a  loss  of  sugar  in  the  urine  for  many  years  without  any 
impairment  of  health,  or  the  glycosuria  may  not  be  constant,  but  recurrent  and 
appear  only  when  nutritional  process  are  for  any  reason  jarred  or  disturbed.  In 
true  diabetes  mellitus,  on  the  other  hand,  there  are  associated  with  the  glycosuria 
more  or  less  profound  impairment  of  nutrition,  with  wasting,  emaciation,  and  the 


726  DISEASES  OF  NUTRITION 

development  in  the  body  of  certain  poisons  wliicli  act  very  deleteriously  and  may 
cause  death. 

These  distinctions,  which  serve  to  separate  in  the  mind  of  the  student  glycosuria 
from  true  diabetes  mellitus,  however,  like  many  other  distinctions,  do  not  actually 
hold  true  in  all  cases,  for  we  frequently  see  persons  who  begin  with  the  leakage  of 
sugar  into  the  urine  and  end  with  true  diabetes;  and  we  meet  intermediate  cases 
in  which  the  degree  of  emaciation,  thirst,  and  polypliagia  is  so  mild  that  it  is  difficult 
to  tell  whether  the  patient  is  a  sufferer  from  an  inability  to  deal  witii  carbohydrate 
food  or  is  really  diabetic. 

The  question  of  the  pathology  of  this  disease,  as  far  as  we  know  it  today,  can 
perhaps  be  summed  up  in  the  following  words:  In  certain  individuals  there  exists, 
as  a  result  of  congenital  or  acquired  defect  in  the  metabolic  functions  of  the  body, 
an  inability  to  utilize  for  the  purpose  of  nutrition  all  the  carbohydrate  material 
which  is  taken  as  food.  Such  persons  suffer  from  smiple  glycosuria.  If  the  defect 
just  referred  to  becomes  more  marked  they  gradually  lose  the  power  to  retain 
and  utilize  any  noteworthy  quantity  of  the  carbohydates  ingested.  Given  an  indi- 
vidual who  is  unable  to  store,  or  retain,  glucose  in  his  body  we  ha^•e  before  us  one 
who  is  deprived  of  one  of  the  chief  elements  required  for  nutritional  balance  and 
he  is  continually  losing  a  most  important  source  of  energy  and  heat.  The  more 
carbohydrates  he  ingests  the  more  he  loses,  and  the  greater  his  polyuria  because 
the  glucose  stimulates  the  kidneys  to  secrete  urine  and  therefore  the  greater  becomes 
his  thirst.  Whenever  any  individual  is  deprived  of  food  for  a  length  of  time, 
whether  it  be  by  ordinary  starvation,  a  rigorously  inadequate  diet,  or  by  loss  of 
sugar  as  in  diabetes,  his  system  attempts  to  obtain  the  food  necessary  for  its 
existence  by  utilizing  its  deposits  of  fat  and  protein,  not  only  utilizing  these 
tissues  as  they  are  ordinarily  used  when  taken  as  food  but  it  also  forms  sugar 
from  fats  and  from  proteins  in  order  to  obtain  its  carbohydrate  quota.  In  this 
process  of  forming  sugar  from  fats  it  develops  a  poisonous  substance,  /3-oxy- 
butyric  acid.  If  the  metabolic  processes  are  not  seriously  disordered  the  body 
goes  one  step  further  and  oxidizes  this  acid  into  aceto-acetic  acid,  and  by  still 
another  step  changes  aceto-acetic  acid  into  acetone,  which  is  not  poisonous.  As 
another  means  of  protecting  itself  it  utilizes  the  alkalis  in  the  tissues  to  neutralize 
these  acid  substances  and  to  aid  in  their  elimination,  and  so  great  may  be  the 
demand  for  alkali  for  this  purpose  that  the  ammonia  produced  in  protein  metab- 
olism is  not  converted  into  urea  as  it  is  in  health.  The  urine  as  the  result 
of  protein  destruction  and  as  the  result  of  this  use  of  ammonia  may  therefore 
contain  an  excess  of  nitrogen  but  a  diminished  quantity  of  urea  (sec  Prognosis). 

The  result  of  these  processes  may  be  summed  up  as  follows:  (1)  The  patient 
is  starved  by  his  constant  loss  of  sugar.  (2)  He  is  wasted  by  the  destruction 
of  his  fats  and  proteins.  (3)  He  is  deprived  of  fluid  by  his  polyuria.  (4)  He  is 
robbed  of  the  normal  alkalies  in  his  tissues.     (5)  He  suffers  from  auto-intoxication.  . 

But  the  chain  of  evils  does  not  cease  here  for  his  vital  resistance  being  de- 
creased he  falls  a  ready  victim  to  all  pathogenic  germs.  Bad  as  it  may  be  to 
lose  glucose  in  the  urine  this  loss  is  only  the  first  evil  which  induces  infinitely 
worse  ones.  Indeed  it  may  occur  that  when  a  patient  is  passing  little  sugar, 
because  he  is  deprived  of  starch  as  a  food  and  has  largely  used  up  his  fats,  he  may, 
nevertheless,  be  in  an  infinitely  worse  condition  than  another  patient,  who  is  passing 
enormous  amounts  of  sugar.  The  fact  that  deprivation  of  carbohydrate  in  the  diet 
of  a  healthy  man  induces  acetonuria  indicates  why  it  is  dangerous  to  suddenly 
deprive  a  diabetic  patient  of  all  starchy  food  in  an  endeavor  to  decrease  his  sugar 
loss.     (See  Treatment.) 

Finally,  it  must  be  recalled  that  of  all  the  organs  of  the  body  the  liver  and  the 
pancreas  are  the  viscera  which  show  the  greatest  morbid  changes  in  true  diabetes. 
Not  (inly  is  the  liver  the  organ  which  is  chiefly  concerned  with  the  manufacture 


DIABETES  MELLITUS  727 

and  storing  of  glycogen,  but  the  pancreas  undoubtedly  exercises  a  very  powerful 
influence  upon  the  glycogenic  processes;  for  not  only  does  it  secrete  digestive 
ferments  which  act  in  the  intestine,  but  also  a  ferment  or  factor  which  enters 
the  blood  stream  and  is  intimately  concerned  with  the  utilization  of  glycogen. 
Thus,  if  the  pancreas  is  extirpated  glycosuria  is  at  once  developed,  and  the  same 
condition  ensues  if  the  gland  is  totally  destroyed  by  disease.  It  would  appear 
that  the  so-called  islands  of  Langerhans  are  the  portion  of  the  gland  which  exercises 
this  influence  upon  the  processes  connected  with  the  utilization  of  glycogen,  and 
in  many  cases  these  islands  are  found  to  be  distinctly  diseased.  ^Vhile  disease  of 
the  pancreas  is  responsible  for  the  development  of  diabetes  in  some  cases  of  the 
malady,  it  is  also  a  fact  that  in  many  cases  of  very  severe  diabetes  the  most  careful 
examination  of  the  pancreas  after  death  fails  to  discover  any  lesion  that  can  be 
considered  in  any  way  responsible  for  the  malady.  It  seems  evident,  therefore, 
that  many  causes  may  so  pervert  nutritional  processes  that  glycosuria  or  true 
diabetes  may  result,  and  in  this  sense  it  may  be  said  that  diabetes  is  not  a  primary 
disease,  but  rather  a  s\-mptom  complex  of  some  primary  lesion  which  we  do  not  at 
present  understand. 

Morbid  Anatomy. — The  changes  found  in  the  islands  of  Langerhans  are  various. 
In  some  cases  they  manifest  capillary  engorgement  or  hemorrhagic  extravasation. 
In  others  there  is  found  a  pericapillary  or  peri-insular  sclerosis,  an  atrophy,  a 
necrobiosis,  or  hyaline  degeneration.  The  latter  is  probably  always  primary,  and 
the  former  conditions  usually  secondary.  Aside  from  changes  of  the  islands  of 
Langerhans  in  the  pancreas,  the  most  notable  changes  presented  postmortem  in 
any  of  the  organs  of  the  body  are  found  in  the  liver.  This  organ  is  usually  markedly 
hyperemic  and  darker  in  color  than  in  diseases  which  do  not  affect  its  functions. 
INIicroscopically  it  is  found  that  its  capillaries  are  congested,  and  that  the  liver 
cells  are  enlarged  and  show  a  tendency  to  coalesce.  These  changes  are  not,  how- 
ever, peculiar  to  the  disease,  being  found  in  other  states;  and  it  is  a  fact  worthy 
of  consideration  that  when  death  results  in  cases  of  severe  disease  of  the  liver, 
glycosuria  is  rather  an  unusual  sjonptom.  There  is  however  a  form  of  diabetes, 
associated  with  hepatic  cirrhosis  and  bronzing  of  the  skin  called  ''bronzed 
diabetes,"  owing  to  the  color  of  the  skin.     (See  Bronzed  Diabetes.) 

The  structure  of  the  kidneys  is  diseased  in  a  very  large  number  of  diabetics. 
These  changes  are  not  in  any  way  a  part  of  the  disease  itself,  but  result  from 
the  increased  activity  of  these  organs  in  excreting  water  and  sugar,  and  by  reason 
of  the  effect  of  toxic  substances,  such  as  diacetic  acid  and  oxybutyric  acid, 
which,  as  they  are  eliminated,  damage  the  renal  tissues.  The  constancy  of  renal 
changes  in  diabetes  is  proved  by  the  frequency  with  which  these  organs  are  found 
diseased  at  autopsy  when  death  has  occurred  from  this  disease.  Out  of  121  autop- 
sies, reported  by  Griesinger,  Dickinson,  and  Seeger,  renal  changes  in  diabetes  were 
found  in  77  cases,  and  Elliott  has  collected  statistics  from  European  clinicians 
which  show  that  albuminuria  is  present  in  43.68  per  cent,  of  all  cases  of  diabetes. 
The  renal  lesions  may  be  divided  into  two  classes:  In  one  class,  which  is  usually 
met  with  in  chronic  cases,  an  ordinary  chronic.nephritis  develops  in  which  parenchy- 
matous and  interstitial  changes  both  occur.  In  the  second  form,  which  is  reallj' 
toxic  in  origin,  there  is  a  hyaline  degeneration  of  the  tubular  epithelium,  the  so-called 
"cellular  necrosis  of  Ebstein."  A  so-called  glycogen  degeneration  of  Henle's 
loop  and  of  the  straight  uriniferous  tubules  (Ehrlich's  lesion)  is  also  found,  but  it 
cannot  be  claimed  that  these  changes  are  pathognomonic. 

The  changes  in  the  nervous  system  are  usually  of  little  importance.  Peripheral 
neuritis  is  often  present.  Probably  this  is  purely  secondary.  Distinct  changes 
have,  however,  been  found  in  the  spinal  cord  in  cases  of  diabetes  mellitus,  notably 
by  Williamson.  Using  Van  Gieson's  method  this  clinician  found  an  increase  in 
connective  tissue  in  the  columns  of  Goll  in  the  cervical  area.     There  was  also  a 


72S  DISEASES  OF  NrTh'ITlOX 

diminution  in  size  of  tlic  ncrxc  fibres  in  these  columns,  and  tlic  myelin  slieaths  and 
axis  cylinders  were  also  diminished  in  size,  altliouf^h  a  few  of  the  myelin  sheaths 
were  distended.  When  ]\Iirrchi's  method  was  employed  dejienerated  fibres  were 
seen  in  Goll's  columns  in  the  cervical,  dorsal,  and  luml)ar  regions,  and  a  few  degen- 
erated fibres  were  present  in  Burdach's  columns.  So,  too,  degeneration  was  found 
in  the  intramedullary  course  of  the  posterior  nerve  roots,  between  the  posterior 
surface  of  the  cord  and  the  posterior  horn  of  gray  matter,  and  to  the  median  side 
of  the  po.sterior  horn.  These  latter  changes  were  most  marked  in  the  lumbar  and 
cervical  regions.  In  a  few  instances  degenerated  fibres  were  .seen  in  the  posterior 
roots  just  outside  the  pia  mater.  These  changes  are  probably  secondary  and  due 
to  the  altered  condition  of  the  blood  in  diabetes. 

The  blood  is  not  only  unduly  rich  in  glucose,  but  sometimes  contains  an  excess 
of  fat-globules  to  such  an  extent  that  it  may  form  a  cream-like  layer  on  the  clot 
when  it  stands  after  withdrawal.  Fraser  has  recorded  a  case  in  which  an  analysis 
of  the  blood  showed  that  it  contained  16.5  per  cent,  of  fat  and  the  pleural  fluid 
20  per  cent. 

The  blood  in  some  cases  of  diabetes  mellitus  is  of  a  pale  salmon  color  which  has 
been  thought  to  be  due  to  the  presence  of  fat,  and  for  this  reason  this  condition 
has  been  called  lipemia.  P\itcher,  however,  has  shown  that  this  appearance  is 
not  entirely  due  to  fat,  for  it  is  not  possible  to  remove  it  from  drawn  blood  by  the 
use  of  ether,  and  the  granules  do  not  stain  black  with  osmic  acid.  Pie  suggests 
that  these  granules  are  in  part  albuminous.  IMore  recently  Cole,  in  testing  the 
blood  in  a  case  for  Hale  White,  reached  the  conclusion  that  true  fat  is  not  present, 
but  that  the  foreign  material  seems  to  be  an  ester  of  cholesterin  with  one  of  the 
higher  fatty  acids.  Heyl  showed  in  1880  that  this  state  of  the  blood  could  be 
demonstrable  in  the  retinal  vessels,  and  Hale  W'hite  has  more  recently  recorded  a 
remarkable  case  of  this  character. 

The  lungs  are  often  found  to  contain  tuberculous  foci,  and  may  show  well-devel- 
oped bronchopneumonia  or  croupous  pneumonia,  but  these  are  the  result  of  ter- 
minal infections  and  not  part  of  the  primary  disease.  Arteriosclerosis  and  its 
train  of  associated  lesions  are  of  frequent  occurrence  in  diabetes  mellitus. 

Symptoms. — The  symptoms  of  diabetes  vary  very  greatly  in  their  severity  in 
different  cases,  so  greatly  that  it  is  almost  impossible  to  detail  any  array  of  symp- 
toms which  are  common  to  all  cases.  In  many  instances  the  gli/cosuria  exists  for 
a  considerable  period  of  time  before  the  patient  suffers  from  symptoms  which  lead 
him  to  think  he  is  not  well.  A  very  well-known  medical  writer  in  London,  some 
years  ago,  first  discovered  he  was  diabetic  by  observing  that  flies  were  unduly 
attracted  to  the  vessel  in  which  he  urinated,  and  later  by  noticing  that  a  few  drops 
of  urine  which  accidentally  fell  on  his  black  trousers  left  a  white  stain  on  drying. 
Later  on,  all  the  diabetic  manifestations  developed,  and  he  died  of  diabetic  gan- 
grene of  the  foot. 

As  a  rule,  as  the  disease  progresses  the  patient  notices  that  he  passes  water  more 
frequently  and  in  larger  quantiiy  than  is  normal,  he  develops  more  or  less  thirst, 
and  loses  sexual  desire  and  poicer.  Later  on  he  begins  to  feel  languid  and  inert; 
he  is  usually  constipated  because  of  his  polyuria,  and  he  may  develop  an  inordinate 
appetite  in  the  endeavor  to  compensate  for  the  loss  of  nutriment  through  his  urine. 
The  thirst,  the  pulyphagia,  and  the  loss  of  strength  and  flesh  are  usually  in  direct 
proportion  to  the  puh/iiria  and  the  quantity  of  sugar  excreted.  When  the  polyuria 
is  marked  the  tonqve  becomes  glazed,  dry  and  raw  in  appearance,  and  attacks  of 
stomatitis  or  thrush  ma>-  develop.  The  shin  is  also  dry  and  harsh,  and  the  hair 
lacks  lustre  and  is  brittle.  The  pulse  is  fcehle  and  the  temperature  sidmormal. 
Pruritus  ani  and  \  ulv;p  may  he  severe. 

Although  the  disease  is  often  characterized  by  excessive  emaeiaiiun,  this  symptom 
is  subject  to  extraordinary  variations  in  difierent  patients.     ^larked  loss  of  flesh 


DIABETES  MELLITUS  729 

is  almost  constant  in  all  persons  under  twenty-five  years  of  age,  but  after  tliis  time 
it  is  by  no  means  uncommon  to  meet  with  jjatients  who  maintain  their  weight  for 
years.  This  holds  true  in  direct  proportion  to  the  j^ears  of  age  and  the  degree  of 
polyuria  and  loss  of  sugar.  Where  the  tissues  are  freely  drained  of  fluid  or  .starved 
beyond  repair  the  weight  of  course  suffers.     (See  Complications,  j 

The  urine  in  diabetes  mellitus  is  not  only  abnormal  in  that  it  contains  sugar, 
but  it  not  uncommonly  contains  albumin  as  well.  (See  Complications.)  Its 
specific  gravity  is  high  and  ranges  from  1.025  to  1.045,  and  one  instance  of  1.074 
is  recorded  by  Trousseau.  Such  a  specific  gravity,  however,  is  exceedingly  rare. 
Notwithstanding  its  high  specific  gravity,  however,  the  urine  is  usually  exceedingly 
limpid  and  clear,  it  has  a  sweet  odor,  and  is  acid  in  reaction. 

The  quantity  of  sugar  present  varies  over  wide  ranges.  Sometimes  it  is  found 
in  as  small  an  amount  as  1  to  3  per  cent. ;  in  others  it  is  found  to  be  present  in  the 
proportion  of  10  per  cent.  The  total  quantity  passed  in  twenty-four  hours  may 
be  from  one  ounce,  or  less,  to  a  pound  and  a  half.  Very  rarely  even  more  escapes. 
Dickinson  reports  a  case  that  passed  the  incredible  amount  of  fifty  ounces  of  sugar 
a  day. 

The  quantity  of  urine  is  also  very  great  in  some  cases,  while  in  others  it  may 
not  be  much  above  the  normal  quantity.  As  much  as  six  to  twelve  pints  are  often 
passed  in  each  twenty-four  hours,  and  cases  are  recorded  in  which  as  much  as 
thirty  pints  were  passed  in  this  time. 

Complications  and  Sequelae. — The  complications  and  sequelae  of  diabetes  mellitus 
are  important,  and  are  so  constantly  present  that  they  may  aid  materially  in  the 
diagnosis  of  the  disease.  Many  of  them  are  dependent  upon  the  fact  that  the 
constant  loss  of  sugar  lowers  nutrition  and  so  decreases  vital  resistance  to  the 
various  infections,  or  they  result  from  perverted  metabolic  processes  closely 
associated  with  the  inability  of  the  body  to  properly  control  the  functions  govern- 
ing the  utilization  of  dextrose  in  the  economy. 

Sweet  has  demonstrated  that  for  certain  organisms  the  blood  loses  its  bactericidal 
power  in  diabetes. 

It  not  infrequently  happens  that  the  first  symptom  presented  by  a  diabetic 
patient  is  repeated  crops  of  boils  or  carbuncles.  When  the  urine  is  examined  sugar 
is  found,  and  it  becomes  evident  that  the  lowered  vitality  caused  by  diabetes 
mellitus  has  permitted  infection  of  the  skin  to  occur.  Sometimes  the  carbuncle 
becomes  malignant  and  speedily  destroys  the  patient.  In  still  other  instances, 
which  are  not  as  common  as  has  been  thought,  diabetic  gangrene  occurs,  the  primary 
lesion  being  some  break  in  the  skin  of  a  finger  or  of  a  toe  resulting  from  the  blister 
made  by  an  ill-fitting  shoe,  or  by  wounding  a  corn.  Through  this  lesion  infection 
takes  place,  and  vital  resistance  is  so  low  that  the  micro-organism  speedily  causes 
the  local  death  of  the  part,  and  almost  equally  rapidly  may  involve  the  blood  in 
a  diabetic  bacteremia.  In  such  cases  the  gangrene  is  moist.-  In  another  class  of 
cases,  which  depend  upon  secondary  vascular  changes  not  due  to  direct  infection, 
the  gangrene  is  dry  and  of  the  so-called  senile  type. 

Elliott's  statistics,  already  quoted,  show  that  albuminuria  is  present  in  about 
43.68  per  cent,  of  diabetics.  This  albuminuria  may  at  times  possess  grave  sig- 
nificance, and  is  worthy  of  careful  consideration.  It  may  be  said  to  arise  from  tfiree 
causes,  namely,  from  renal  congestion,  due  to  cardiac  feebleness  and  impairment  of 
the  circulation;  from  degeneration  of  the  kidneys,  due  to  true  nephritis,  and,  finally, 
to  severe  irritation  or  inflammation  of  the  renal  tissues  by  the  poisons  of  the  disease. 
The  first  type  can  usually  be  relieved  by  careful  treatment  of  the  heart,  and  the 
second  type,  with  casts  in  the  urine,  is  to  be  regarded  as  a  complicating  condition 
of  gravity  superimposed  upon  one  already  exceedingly  grave.  The  third  or  toxic 
type  is,  however,  the  form  which  presents  the  most  serious  and  alarming  aspect, 
for  its  onset  is  usually  acute;  it  comes  on  when  the  patient  is  already  profoundly 


730  DISEASES  OF  NUTRITION 

ill,  and  it  often  betokens  the  rapid  approach  of  diabetic  coma,  which  in  such  a  case 
may  be  said  to  be  partly  due  to  the  renal  lesions.  jVIany  clinicians  consider  that 
coma  never  comes  on  without  this  associated  sjTnptom.  The  kidney  condition 
is  therefore  to  be  studied  carefully  in  these  cases,  as  it  may  give  warning  of 
approaching  coma. 

Although  albuminuria  is  quite  a  common  symptom,  particularly  in  those  patients 
who  have  arteriosclerosis,  general  dropsy  is  rare,  notwithstanding  the  enfceblement 
of  the  heart  and  the  impaired  state  of  the  kidneys,  because  the  urinary  flow  is  so 
profuse  that  the  body  is  rapidly  drained  of  fluid. 

Dyspeptic  symptoms  are  often  very  annoying.  They  depend  upon  the  excessive 
eating  and  drinking,  to  which  many  diabetics  are  forced  by  their  thirst  and  hunger. 
Feebleness  of  the  digestion  arises  from  the  failure  in  vital  power,  or  to  perversion 
of  the  digestive  functions  by  the  toxemic  state  often  developed  as  the  disease 
advances.     Extreme  constipation  is  often  a  very  troublesome  symptom. 

Pulmonary  complications,  such  as  bronchopneumonia  or  tuberculosis,  are  very 
frequently  met  with  in  diabetics,  owing  to  the  lowered  vital  resistance  which  permits 
infection.  Such  complications  are  very  often  the  cause  of  death,  particularly 
tuberculosis. 

Callian  has  especially  studied  the  influence  of  diabetes  on  the  female  genitals; 
pruritus  vulvse  is  very  common;  menstrual  disturbances  are  common;  the  atrophy 
.  of  uterus  and  ovaries,  he  thinks,  depends  on  the  associated  sclerosis  of  their  nutritive 
vessels. 

The  nervous  complications  of  diabetes  mellitus  may  be  divided  into  the  acute  and 
chronic.  The  acute  complications  are  very  serious  from  a  prognostic  point  of 
view,  and  consist  chiefly  of  diabetic  coma.  Many  theories  have  been  advanced 
as  to  its  direct  cause.  It  is  undoubtedly  toxic  in  origin,  and  seems  to  be  chiefly 
associated  with  a  state  of  acidosis,  or  the  presence  of  one  or  more  abnormal  acids 
in  the  blood,  of  which  one  is  called  ;5'-oxybutyric  acid.  The  idea  that  acetone 
and  diacetic  acid  are  the  causes  has  been  cast  aside.  In  some  instances  the  onset 
of  the  coma  (sometimes  called  "Kussmaul's  coma")  is  sudden,  but  it  may  be  grad- 
ual, although,  even  in  the  gradual  cases,  it  is  a  matter  of  a  few  hours  at  the  most, 
as  a  rule. 

Diabetic  coma  may  be  said  to  appear  in  three  types :  The  first,  and  most  common, 
is  often  met  with  in  young  persons,  and  develops  with  suddenness  in  many  instances; 
that  is  to  say,  its  onset  lasts  but  a  few  hours  at  the  most.  The  early  symptoms 
are  those  of  disorders  of  digestion,  with  abdominal  pain,  vomiting,  muscular  weak- 
ness, and  drowsiness,  which  soon  ends  in  coma.  The  breathing  in  tiiis  coma  is 
often  slow  and  deep,  very  much  as  it  is  in  the  second  stage  of  opium  poisoning.  At 
other  times  it  is  sighing.  To  one  tj^e  of  the  respiratory  state  in  this  condition 
Ivussmaul  applied  the  descriptive  word  "Lufthunger."  The  second  form  often 
comes  on  after  fatigue,  particularly  in  elderly  persons,  and  the  symptoms  may  be 
those  of  profound  collai>se.  In  the  third  form  the  early  sjinptoms  are  those  of 
ataxia  and  confusion  of  speech. 

Sometimes  the  unconsciousness  is  preceded  by  great  restlessness  and  irritability, 
while  in  other  instances  the  onset  of  the  comatose  state  is  gentle. 

Of  the  ocular  complications,  cataract,  optic  nerve  atrophy,  and  diabetic  retinitis 
are  to  be  remembered.  Sudden  blindness  due  to  optic  nerve  or  retinal  changes 
occasionally  ensues  and  palsies  of  the  ocular  muscles  may  take  place. 

Diabetics  are  also  subject  to  apoplexy. 

Of  the  subacute  nervous  s\'mptoms  we  find  painful  neuritis,  and  not  infrequently 
a  pseudotabes  due  to  this  cause,  with  loss  of  knee-jerk,  Romberg's  sjinptom,  and 
even  the  Argyll-Robertson  pupil.     Sometimes  a  true  tabes  dorsalis  seems  to  develop. 

Diagnosis. — The  diagnosis  of  diabetes  mellitus  is  easily  made  if  the  physician 
will  cnrcfully  examine  the  urine  and  will  bear  in  mind  the  fact  that  he  is  not  justified 


DIABETES  MELLITUS  731 

in  deciding  that  the  well-developed  disease  is  present  unless  some  symptoms  which 
are  characteristic  are  associated  with  the  glycosuria.  It  may  be  said  that  he  who 
has  constant  glycosuria  is  in  the  early  stages  of  diabetes  mellitus,  and  this  is  par- 
ticularly true  if  this  symptom  be  constant  in  a  young  person.  On  the  other  hand, 
it  not  infrequently  happens  that  a  person  of  fifty-five  or  sixty  years  develops  a 
mild  glycosuria  which  lasts  for  years,  and  does  not  materially  impair  the  health 
for  a  long  period  of  time.  Even  these  cases,  however,  often  develoj)  into  the  true 
disease.  In  other  words,  we  may  say  that  while  glycosuria  is  not  diabetes,  it  is  a 
state  that  indicates  a  tendency  to  this  disease  or  the  presence  of  its  early  stages. 
The  separation  of  the  polyuria  of  diabetes  insipidus  from  that  of  diabetes  mellitus 
is  made  by  the  low  specific  gravity  of  the  urine  in  the  former  disease,  and  the  fact 
that  sugar  is  present  in  the  latter  malady.  A  more  or  less  constant  glycosuria 
is  met  with  in  some  cases  of  exophthalmic  goitre,  ultimately  disappearing  as  the 
disease  improves,  or  finally  developing  into  true  diabetes,  and  the  administration 
of  thyroid  gland  may  induce  glycosuria.  Glycosuria  is  sometimes  seen  in  women 
with  ovarian  cysts. 

It  not  infrequently  happens  that  diabetes  mellitus  is  overlooked  because  the 
patient  does  not  complain  either  of  thirst  or  of  excessive  urination,  and  the  physician 
fails  to  examine  the  urine  as  a  matter  of  routine.  But  these  patients  often  present 
symptoms  which,  while  not  distinctly  urinary,  should  at  once  call  the  attention 
of  the  physician  to  the  possibility  of  diabetes  being  present.  Thus,  any  patient 
who  suffers  from  marked  loss  of  flesh  and  increasing  weakness  should  always  be 
suspected  of  having  diabetes,  even  if  signs  of  tuberculosis  are  present,  for  not 
infrequently  the  tuberculosis  is  secondary  to  the  diabetes.  So,  too,  women  will 
sometimes  complain  of  pruritus  of  the  vulva  or  eczema  of  the  genitals,  or  men  will 
state  that  they  are  becoming  impotent,  in  all  of  which  cases  the  urine  should  be 
examined,  since  diabetes  often  produces  these  signs.  So,  too  defects  of  vision, 
due  to  diabetic  cataract,  or,  more  rarely,  to  retinal  changes,  may  be  the  first  symp- 
toms manifest  to  the  patient,  and  still  others  complain  of  numbness  or  tingling 
in  the  extremities  and  present  the  sjonptoms  of  locomotor  ataxia.  On  the  other 
hand,  as  already  pointed  out,  physicians  not  infrequently  are  so  careless  as  to 
examine  the  urine  only  once,  and  when  they  discover  sugar  consider  that  the  case 
is  one  of  diabetes;  or  they  obtain  a  reaction  with  Fehling's  test,  because  of  the 
presence  of  some  sugar-reducing  substance,  as  when  the  patient  is  taking  chloral; 
or,  again,  they  mistake  physiological  glycosuria  for  true  diabetes.  It  is  evident 
that  most  of  the  mistakes  in  the  diagnosis  of  diabetes  depend  upon  lack  of  urinary 
examination  or  imperfect  methods  of  testing  the  urine. 

As  an  illustration  of  how  necessary  it  is  to  examine  a  number  of  samples  of 
urine  before  determining  that  the  patient  has  or  has  not  diabetes,  it  may  be 
recalled  that  urine  passed  during  the  night  or  before  breakfast  is  often  free 
from  sugar;  while  that  passed  after  breakfast  and  during  the  day  may  contain 
much  of  it. 

The  condition  of  diabetic  coma  is  separated  from  the  unconsciousness  of  uremia 
by  the  cider-like  odor  of  the  breath,  the  presence  of  glycosuria  and  acetonuria, 
and  the  absence  of  the  high  arterial  tension  usually  met  with  in  renal  disease,  for 
in  this  state  the  pulse  is  feeble  and  of  low  tension.  At  the  same  time,  it  is  to  be 
recalled  that  uremia  may  complicate  diabetes.  The  patient  lies  in  a  condition 
which  resembles  profound  alcoholic  intoxication.  Deeply  unconscious,  with  half- 
opened  eyelids,  wandering  eyeballs,  and  dilated  pupils,  he  breathes  in  a  panting 
manner,  a  deep  inspiration  being  followed  by  a  quick  expiration.  The  respiratory 
rate  may  not  be  greatly  different  from  the  normal,  but  sometimes  it  is  hurried, 
and  then  forms  "diabetic  dyspnea,"  with  a  gradually  increasing  cyanosis.  The 
temperature  is  usually  normal  or  below  normal.  This  state  almost  invariably 
ends  in  death  in  from  one  to  two  days. 


732   ■  DISEASES  OF  XUTRITIOX 

Urinary  Tests. — For  many  years  tlic  most  jjoijiilar  tests  for  tlie  determination 
of  tlie  presence  of  sugar  in  the  urine  have  been  those  which  depend  ujjon  the  fact 
that  strongly  all-ialine  solutions  of  grajic-sugar  reduce  copjjer  oxide  to  lower  grades 
of  oxidation.  The  most  frequently  enij)loycd  of  these  tests  is  that  which  is  made 
by  means  of  Frlilinc/'s  dilution.     This  is  best  made  in  the  folk)\\ing  manner: 

Copper  sulphate,  34.(14  gm.,  with  water  enough  to  make  500  c.c.  Mix  and  keep 
in  a  bottle  by  itself.  Pure  Rochelle  salts,  173  gm.;  solution  of  sodium  hydrate, 
specific  gravity  1.330,  100  c.c,  and  water  enough  to  make  500  c.c.  For  use  mix 
equal  volumes  of  these  two  solutions,  thereby  forming  Fehling's  solution.  About 
one  drachm  of  this  solution  is  placed  in  an  ordinary  test-tube  and  boiled.  If  the 
solution  does  not  remain  clear,  it  is  unsuitable  for  use.  If,  on  the  other  hand,  it 
does  remain  clear  on  boiling  the  suspected  urine  is  to  be  added  to  it,  a  few  drops 
at  a  time,  and  the  boiling  continued,  when,  if  sugar  is  present,  the  solution  becomes 
opaque  and  yellow  in  hue,  and  soon  a  dense,  yellowish-red  sediment  falls  to  the 
bottom.  Should  the  quantity  of  sugar  present  be  exceedingly  small,  it  may  be 
necessary  to  add  urine  until  the  volume  of  urine  and  the  volume  of  Fehling's 
solution  are  equal.  But  the  volume  of  urine  must  never  exceed  that  of  the  Fehling 
solution. 

Trommer's  test  is  performed  in  the  following  manner: 

A  drachm  of  urine  is  placed  in  an  ordinary  test-tube,  and  is  treated  with  sufficient 
quantity  of  sulphate  of  copper  solution  to  render  the  fluid  a  light-green  color. 
An  equal  volume  of  liquor  potassie  is  then  added.  This  results  in  a  blue  precipitate 
of  hydrated  copper  protoxide,  which  dissolves  upon  shaking  the  tube,  so  that  a 
clear  blue  solution  remains.  If  the  test-tube  be  allowed  to  stand  for  some  time 
the  copper  is  gradually  reduced,  and  precipitation  of  the  yellowish-red  suboxide 
of  copper  occurs.  If  the  solution  is  heated,  the  tests  act  more  promptly.  Care 
must  be  taken  that  the  fluid  is  not  boiled  actively,  as  under  these  circumstances 
precipitation  may  take  place  without  sugar  being  present. 

It  is  hardly  necessary  to  add  that  in  making  these  tests  the  greatest  possible 
cleanliness  in  the  test-tube  and  bottles  should  be  maintained. 

It  is  of  vital  importance  to  remember  that  the  copper  tests  for  sugar  respond 
to  other  agents  in  the  urine.  These  reducing  agents  are  glycuronic  acid,  maltose 
in  nursing  women,  lactose,  and  alcaptone. 

Occasionally  the  urine  in  cases  of  diabetes  mellitus  contains  acetone  in  excess 
and  diacetic  and  oxybutyric  acids.  The  appearance  of  acetone  in  amounts  greater 
than  normal  (0.008  to  0.027)  is  always  to  be  considered  a  signal  of  danger  of  diabetic 
coma.  The  test  for  the  presence  of  acetone  consists  in  distilling  the  urine  and 
adding  to  .several  cubic  centimetres  of  the  distillate  a  few  drojjs  of  liquor  potassne, 
to  render  it  alkaline.  Several  drops  of  Lugol's  solution  are  now  added,  when,  if 
acetone  is  present,  the  fluid  becomes  turbid,  and  iodoform  is  precijMtated  in  crystals. 
If  this  fluid  is  now  heated,  the  odor  of  iodoform  is  noticeable. 

Gerhardt's  test  consists  in  adding  an  aqueous  solution  of  chloride  of  iron  to  the 
urine,  when,  if  diacetic  acid  is  present  in  large  amount,  the  fluid  becomes  a  deep 
red;  but  this  test  is  fallacious  if  the  salicylates  have  been  ingested. 

Prognosis. — The  prognosis  of  diabetes  is  largely  influenced  by  a  number  of  factors. 
In  the  first  place,  as  a  rule,  but  by  no  means  always,  the  outlook  is  favorable  for 
long  life  in  direct  proportion  to  the  age  of  the  patient.  Thus,  it  not  infrequently 
hap])ens  that  men  and  women  who  develop  the  disease  after  fifty  or  sixty  years  of 
age  live  the  full  length  of  years  usually  credited  to  human  beings  of  that  age.  Even 
in  these  cases,  however,  the  possibility  of  some  intercurrent  infection,  like  pneu- 
monia, is  to  be  borne  in  mind  as  a  constant  threat  against  life.  Conversely,  the 
disease  is  ra])idly  fatal  in  proportion  to  the  youth  of  the  patient.  In  young  persons 
it  runs  a  rajiid  course  and  may  destroy  life  in  a  few  weeks.  Great  emaciation 
usually  develoj)s  in  these  cases;  whereas,  older  persons  may  maintain  their  weight. 


DIABETES  MELLITUS  733 

The  mere  presence  of  glycosuria  is  not  justification  for  as  grave  a  prognosis,  even 
if  the  amount  of  sugar  be  marked,  as  is  the  presence  of  glycosuria  with  associated 
thirst,  hunger,  and  loss  of  flesh.  For  the  first  state  is  a  leakage,  while  the  second 
shows  that  nutritional  changes  are  marked,  and  that  true  complete  diabetes  mellitus 
is  present. 

The  prognosis  also  depends  somewhat  upon  the  manner  in  which  the  patient 
responds  to  the  regulation  of  his  diet.  Thus,  if  on  the  partial  withdrawal  of  carbo- 
hydrates and  the  use  of  ordinary  amounts  of  proteid  and  fatty  food  the  sugar  is  no 
longer  found  in  the  urine,  and  the  urine  gives  no  reaction  with  perchloride  of  iron 
for  acetone,  the  condition  may  be  considered  as  a  mild  form  of  the  disease.  If,  on 
the  other  hand,  the  quantity  of  sugar  diminishes,  but  does  not  disappear,  and  the 
urine  gives  reaction  with  perchloride  of  iron,  the  case  should  be  considered  as  one 
of  moderate  severitj'.  Again,  if  the  gradual  decrease  in  starchy  foods,  until  the 
patient  is  taking  no  carbohydrates,  fails  to  diminish  the  sugar  excretion  and  if  a 
perchloride  of  iron  test  gives  a  Burgundy  or  port-wine  coloration,  showing  the 
presence  of  acetone  in  excess,  then  the  disease  is  to  be  considered  as  severe. 

The  degree  to  which  the  fats  are  being  broken  down,  and  the  danger  of  acid 
intoxication,  are  important  to  determine.  The  presence  of  acetone  is  not  as  grave 
an  indication  as  the  presence  of  diacetic  acid  nor  is  diacetic  acid  as  grave  as 
/3-oxybutyric  acid,  since  the  latter  when  present  shows  that  the  body  cannot  oxidize 
it  into  diacetic  acid  much  less  into  acetone.  The  quantitative  estimation  of  these 
bodies  is  so  complicated  that  it  is  much  better  to  study  the  relative  and  absolute 
output  of  ammonia  which  is  easy  to  do  and  is  an  accurate  gauge  of  the  degree  of 
their  presence,  because  these  acids  would  rob  the  body  of  alkali  were  it  not  that 
the  organism  produces  an  excess  of  ammonia  to  save  the  normal  alkalies.  A 
patient  in  health  excretes  daily  about  0.7  gram  of  ammonia,  but  in  diabetes  it 
may  be  so  enormously  increased  as  to  equal  8  or  even  14  grams  a  day.  As  much  as 
5  grams  per  day  in  a  diabetic  are  indicative  of  grave  diabetes  which  may  cause 
death  in  a  year.  Brown  of  the  United  States  Navy  recommends  the  following 
simple  method  for  ammonia  estimation: 

"About  60  c.c.  of  filtered  urine  are  treated  with  3  gm.  of  basic  lead  acetate,  well 
stirred,  allowed  to  stand  a  few  minutes  and  filtered.  The  filtrate  is  treated  with 
2  gm.  of  neutral  potassium  oxalate,  again  well  stirred  and  filtered.  Ten  c.c.  of 
the  clear  filtrate  are  diluted  to  about  50  c.c.  with  distilled  water  and  a  few  drops 
of  1  per  cent,  phenophthalein  added.  The  fluid  will  be  slightly  alkaline  or  acid, 
more  frequently  the  latter.  Fifteen  gm.  of  neutral  potassium  oxalate  are  added, 
thoroughly  stirred,  and  the  specimen  exactly  neutralized  with  one-tenth  normal 
sodium  hydroxid  or  sulphuric  acid;  20  c.c.  of  20  per  cent,  commercial  formalin, 
previously  made  neutral,  are  added  and  the  solution  again  titrated  with  one-tenth 
decinormal  sodium  hydroxid.  Every  cubic  centimeter  of  one-tenth  normal  sodium 
hydroxid  corresponds  to  0.0017  gm.  ammonia.  The  burette  reading  of  the  second 
titration  multiplied  by  this  factor  represents  the  amount  of  ammonia  in  10  c.c. 
of  urine.  The  quantity  is  then  calculated  on  the  basis  of  the  twenty-four  hour 
volume." 

It  is  also  desirable  to  determine  the  degree  to  which  the  patient  is  splitting  up 
his  protein  molecule  to  form  sugar  and  ammonia.  This  can  be  theoretically  esti- 
mated by  determining  the  quantity  of  urinary  nitrogen,  since  physiological  chemists 
have  found  that  each  gram  of  nitrogen  represents  the  destruction  of  6.25  grams  of 
protein.  In  a  patient  who  is  so  far  advanced  in  the  disease  that  he  is  absolutely  in- 
tolerant of  carbohydrates  and  is  starved  of  carbohydrates  until  he  is  carbohydrate- 
free,  it  has  been  found  that  the  ratio  of  dextrose  to  nitrogen  is  2.8:1  and  this  has 
been  called  the  dextrose  and  nitrogen  ratio.  That  is  to  say,  if  he  has  no  carbohydrate 
from  which  to  make  dextrose,  he  is  now  making  2.8  grams  of  sugar  out  of  each 
6.25  grams  of  protein,  as  represented  by  the  1  gram  of  nitrogen  found  in  the  urine. 


734  DISEASES  OF  NUTRITION 

As  coni])aratively  few  diabetifs  arc  al)S()liitely  intolerant  of  carbohydrate  and  as  it 
is  often  unwise  to  make  them  carbohydrate-free  by  stravation,  this  method  of 
estimation  is  not  clinically  feasible,  because  of  its  danger,  and  it  would  further 
require  that  the  jirotein  intake  should  be  estimated,  but  if  this  ratio  of  2.8:1  is 
found  it  is  indicative  of  an  advanced  form  of  the  disease. 

Mandel  and  Lusk  have  stated  the  following  proposition  as  to  prognosis:  That 
if  a  diabetic  be  put  on  a  meat-fat  diet  (rich  cream,  meat,  butter,  and  eggs),  and 
the  twenty-four-hour  urine  of  the  second  day  be  properly  collected,'  the  discovery 
of  3.65  grams  of  dextrose  to  1  gram  of  nitrogen  signifies  a  complete  intolerance 
for  carbohydrates,  and  probably  a  quickly  fatal  outcome.  They  have  called  this 
the  fatal  ratio. 

The  cause  of  death  in  diabetes  mellitus  is  usually  one  of  the  acute  infections, 
such  as  pneumonia,  tuberculosis,  or  septicemia,  with  or  without  carbuncle.  Dia- 
betic coma  is  another  common  cause  of  death.  Frerichs  found  that  150  out  of 
250  deaths  in  diabetes  were  caused  by  coma.  Of  43  fatal  cases  observed  by  Taylor, 
death  resulted  from  coma  in  20.  ^lackenzie  found  19  deaths  from  coma  in  S7 
fatal  cases. 

It  may  be  laid  down  as  a  rule,  that  true  diabetes  mellitus  never  gets  well,  but 
that  temporary  glycosuria  often  does  so  under  proper  treatment.  Diabetes  may, 
however,  be  controlled  and  life  prolonged  very  materially  by  resort  to  suitable  diet 
and  remedial  agents. 

Treatment. — By  treatment  much  can  be  done  for  the  control  of  this  disease. 
As  already  stated,  simple  glycosuria  can  usually  be  entirely  relieved  by  proper 
attention  to  exercise,  the  regulation  of  the  diet,  so  that  the  patient  does  not  overeat 
or  overdrink,  and  particularly  by  the  limitation  of  the  amount  of  carbohydrate 
food  which  he  ingests.  In  these  cases  the  appearance  of  sugar  in  the  urine  is  to  be 
regarded  as  e^'idence  of  the  inability  of  the  patient  to  properly  utilize  these  sub- 
stances in  the  body.  If  there  is  reason  to  believe  that  he  is  too  sedentary  in  his 
habits,  it  sometimes  happens  that  a  moderate  amount  of  exercise  causes  a  dis- 
appearance of  the  glucose.  Again,  if  he  is  a  thin,  spare  individual,  who  naturally 
worries  much  about  business  or  professional  duties,  absolute  rest  from  these  causes 
of  stress  must  be  insisted  upon,  in  order  that  the  nervous  system  may  recover  its 
equipoise. 

When  true  diabetes  mellitus  is  present,  it  is  even  more  essential  that  these  etio- 
logical factors  should  be  controlled.  Indeed,  it  may  be  well  said  that  to  attempt 
treatment  by  a  diet  and  drugs  is  useless  in  a  case  of  diabetes  mellitus,  unless  the 
patient  can  be  properly  controlled  in  regard  to  his  manner  of  life,  provided  that 
manner  of  life  is  deleterious.  In  other  words,  it  is  futile,  in  the  majority  of  in- 
stances, to  regulate  the  diet  and  to  give  drugs  if  the  patient  is  to  be  continually 
exposed  to  causes  which  are  more  potent  for  evil  than  the  remedies  are  for  good. 

There  can  be  no  doubt  that  the  dietetic  treatment  of  diabetes  is  far  more  im- 
portant than  that  by  drugs,  and  it  is  essential  that  this  fact  be  borne  in  mind,  since 
physicians  are  often  careless  in  regard  to  the  question  of  dietetics,  and  patients 
are  still  more  so,  even  after  the  importance  of  a  proper  diet  has  been  conveyed  to 
them.  Quite  frequently  they  follow  the  directions  of  the  physician  for  a  short 
time,  and  then,  wearying  of  being  deprived  of  favorite  articles  of  food,  take  these 
articles  surreptitiously,  or  openly  declare  that  whether  it  does  them  harm  or  good 
they  do  not  intend  to  be  deprived  of  things  of  which  they  are  fond.  For  these 
reasons  the  dietetic  treatment  of  diabetes  is  much  the  more  difficult  part  of  the 
care  of  these  cases. 

'  "Tlie  urine  should  be  collected  so  that  an  early  morning  hour  (before  breakfast)  terminates  the  period 
for  one  day.  Tliis  is  necessary,  because  the  sugar  formed  from  eaten  protcid  is  eliminated  before  the 
nitrogen  belonging  to  the  same.  The  long  period  between  the  evening  meal  and  breakfast  allows  for 
the  elimination  of  both  constituents." 


DIABETES  MELLITUS  735 

As  diabetes  is  a  condition  in  which  the  body  is  unable  to  properly  utilize  car- 
bohydrates and  their  educts,  it  is  manifest  at  once  that  an  excess  of  carbohydrates 
must  be  forbidden;  but  what  is  an  excess  to  one  individual  may  not  be  an  excess 
for  another,  for  an  excess  is  that  quantity  which  is  more  than  the  body  can  use. 
For  this  reason  it  is  usually  wise,  when  placing  a  patient  upon  an  antidiabetic 
diet,  to  diminish  the  quantity  of  carbohydrates  which  he  receives,  by  a  very  gradual 
process,  and  to  watch  the  quantity  of  sugar  in  the  urine  from  day  to  day,  since  by 
this  means  the  quantity  of  carbohydrate  material  which  he  can  utilize  may  perhaps 
be  approximated.  A  second  reason  for  carrying  out  this  gradual  diminution  in 
the  quantity  of  starchy  food  lies  in  the  important  fact  that  not  infrequently  cases 
of  diabetes  are  plunged  into  diabetic  coma  by  the  institution  of  a  diet  practically 
free  from  carbohydrates,  perhaps  because  the  sj'stem  is  in  such  a  condition  that 
no  sudden  variation  in  the  character  of  the  food  can  be  permitted,  and  also  because 
in  such  cases  the  organism  immediately  splits  up  its  own  fats  and  forms  poisons. 
Not  only  is  it  a  clinical  fact  that  coma  may  be  precipitated  in  this  manner,  but  we 
also  know  that  the  quantity  of  acetone  in  the  urine  is  greatly  increased  by  severe 
restrictions  of  carbohydrates.  For  this  reason  the  physician,  when  restricting 
diet,  should  always  examine  the  urine,  not  only  as  to  its  content  of  sugar,  but  as  to 
content  of  acetone  as  well,  and  if  this  latter  ingredient  is  present  in  an  amount 
in  excess  of  that  which  may  be  considered  normal,  for  a  minute  trace  is  sometimes 
present  in  non-diabetic  persons,  it  is  absolutely  essential  that  he  shall  at  once 
restore  the  full  carbohydrate  diet,  since  by  so  doing  the  quantity  of  acetone  is 
diminished  and  the  condition  of  acidosis  which  produces  coma  is  diminished. 
This  is  more  important  if  the  urine  contains,  as  it  often  does,  diacetic  acid  and 
i8-oxybutyric  acid,  particularly  the  latter,  since  its  presence  indicates  that  the 
patient  cannot  convert  /3-oxybutyric  acid  into  diacetic  acid  or  diacetic  acid  into 
acetone.  (See  Treatment  of  Coma.)  The  elimination  of  more  than  one  gram  of 
acetone  in  twenty-four  hours  is  to  be  considered  an  excess. 

Patients  will  often  resent  the  total  removal  of  carbohydrates  from  their  diet 
list,  and  yet  yield  to  their  gradual  removal.  On  the  other  hand,  it  is  not  to 
be  forgotten  that  in  some  diabetics  a  certain  amount  of  carbohydrate  food  seems 
to  be  essential,  in  order  that  thej'may  not  manufacture  dextrose  from  other  articles 
of  food,  or  from  the  fat  of  their  own  bodies,  and  in  order  that  acidosis  be  not 
produced.  That  is  to  say,  the  administration  of  starch  in  moderate  quantity  may 
compensate  for  their  loss  of  dextrose. 

Sugars  should  always  be  excluded.  They  are  unnecessary  articles  of  diet,  and, 
aside  from  the  fact  that  the  body  is  unable  to  utilize  them,  they  are  apt  to  disturb 
digestion. 

Because  carbohydrate  food  cannot  be  utilized,  it  has  come  to  be  well  recognized 
that  the  patient  must  subsist  largely  upon  the  different  forms  of  meat,  both  salt 
and  fresh,  excepting  liver,  which  contains  glycogen,  and  which,  therefore,  ought 
not  to  be  given.  It  has  come  to  be  a  generally  accepted  fact,  however,  that  more 
than  a  very  moderate  ration  of  animal  proteid  is  disadvantageous.  Eggs  are  more 
desirable  than  meat  and  vegetable  albiunen  more  permissible  than  eggs  or  meat. 
So,  too,  butter,  cheese,  and  the  various  oils  and  fats  may  be  used. 

It  has  already  been  pointed  out  that  diabetic  patients  whose  supply  of  car- 
bohydrate material  has  been  cut  down  should  be  provided  with  an  amount  of  fat 
over  and  above  that  usually  ingested,  provided,  of  course,  that  the  individual  can 
digest  and  assimilate  fats.  It  is  evident,  however,  from  a  series  of  investigations 
made  by  von  Noorden  and  others,  that  butter,  when  taken  in  excess  of  five  ounces 
a  day,  may  cause  an  increase  in  the  quantity  of  oxybutyric  acid  in  the  blood.  Von 
Noorden  has  pointed  out,  however,  that  this  deleterious  effect  of  large  amounts 
of  butter  can  be  diminished  if  the  butter  is  first  washed  with  cold  water  in  a  most 
thorough  manner,  since  by  this  means  we  remove  the  lower  fatty  acids  which  are 


736  DISEASES  OF  NUTRITION 

chiefly  concerned  in  the  production  of  acidiosis.  Under  these  circumstances, 
von  Noordcn  tells  us  that  as  much  as  seven  ounces  of  butter  can  be  tai<en  daily 
without  difficulty. 

IMost  of  the  shell-fish  are  useful,  but  oysters  contain  too  much  fjlycogen. 

In  the  way  of  fresh  vegetables,  the  patient  may  receive  the  various  greens,  such 
as  lettuce,  sj)inach,  dandelion,  cabbage,  cauliflower,  Brussels  sprouts,  string  beans 
celery,  watercress,  tomatoes,  onions,  cucumbers,  olives,  and  the  various  kinds  of 
pickles,  and  practically  all  of  the  nuts  which  are  commonly  employed  as  foods, 
except  chestnuts,  whicla  contain  too  large  a  proportion  of  starch. 

Not  rarely  the  patient  does  best  when  he  is  placed  upon  a  diet  which  varies  in 
carbohydrates  from  week  to  week;  that  is  to  say,  he  is  given  a  very  small  quantity 
of  carbohydrate  one  week,  and  a  fairly  large  quantity  of  it  the  next. 

In  those  instances  in  which  the  acetone  reaction  persists  in  the  urine,  whether 
carbohydrates  are  removed  or  allowed,  vonNoorden  has  strongly  recommended  what 
he  calls  "  the  oatmeal  cure."  In  this  cure  the  patient  eats  nothing  but  oatmeal  gruel 
for  from  one  to  two  weeks,  save  that  in  addition  to  the  eight  ounces  of  oatmeal  he  is 
given  a  similar  quantity  of  butter  and  some  vegetable  albumin.  Often  this  mixture 
is  administered  as  frequently  as  every  two  hours.  Von  Xoorden  asserts  that 
on  this  diet  the  excretion  of  sugar  falls  to  a  point  far  below  that  excreted  on  a  mixed 
diet  from  which  all  carbohydrate  has  been  remoA'ed.  At  the  end  of  a  week  or  two 
it  is  always  necessary  to  return  to  other  foods  temporarily,  as  otherwise  the  patient 
rebels  against  the  pursuance  of  a  pure  oatmeal  diet;  but  even  with  these  frequent 
returns  to  an  ordinary  diet,  excellent  results  are  reached. 

For  some  reason,  no  better  understood  than  the  tolerance  of  oatmeal,  potato 
starch  is  often  well  utilized  when  other  starches  are  not. 

The  ability  of  the  patient  to  utilize  carbohydrates  can  be  at  times  distinctly 
increased  by  subjecting  him  to  a  "starvation  day."  This  consists  in  giving  little 
or  no  protein  and  no  starch  whatever  on  one  day  and  in  allaying  his  sense  of  hunger 
by  feeding  "greens"  such  as  spinach,  celery,  lettuce,  etc. 

Tea,  coft'ee,  and  cocoa  may  be  employed,  provided  they  are  not  sweetened  by 
cane-sugar,  but  by  saccharin.  Dry  wines  which  contain  little  sugar  may  be  given 
to  those  who  are  accustomed  to  alcoholic  drinks,  although  Scotch  whiskey,  rye 
whiskey,  and  dry  gin  are  better  than  most  wines.  The  various  simple  mineral 
waters  may  also  be  given,  and  of  these  both  the  natural  and  artificial  Vichy  waters 
are  excellent,  because  of  the  quantity  of  bicarbonate  of  sodium  which  they  contain. 
The  old  idea  that  because  the  patient  urinates  in  excess  he  .should  be  deprived  of 
water  is  no  longer  followed.  These  patients  should  be  allowed  water  freely,  in 
order  that  the  system  may  be  flushed  of  toxic  materials.  When  constipation  is 
present,  the  mild  saline  purgative  waters  may  be  given,  varying  from  Apenta, 
Carlsbad,  and  Hathorn  water,  to  the  more  powerful  saline  purges. 

Theoretically,  gluten  provides  a  source  of  nourishment  for  diabetic  patients, 
but  practically  it  is  almost  impossible  to  obtain  a  satisfactory  gluten  bread  which 
does  not  contain  a  very  considerable  ciuantity  of  starch.  There  are  upon  the 
market  a  few  samples  of  biscuits  made  from  gluten  flour  which  contain  a  very 
small  percentage  of  starch,  and  these  may  be  freely  given  to  these  patients.  The 
difficulty  in  the  majority  of  instances  is  that  patients  get  exceedingly  tired  of 
a  diet  from  which  all  forms  of  bread  are  excluded,  and  for  this  reason  it  may  be 
impossible  to  entirely  exclude  bread  from  the  diet  list.  Most  of  the  biscuits  which 
are  made  from  substitutes  for  wheat  flour,  such  as  that  of  the  soya  bean,  are  so 
oily  that  patients  find  it  difficult  to  digest  them.  Almond  meal,  which  also  contains 
a  very  large  percentage  of  oil  and  no  starch,  may  be  given.  But  here,  again,  the 
difliculty  in  digesting  the  fats  it  contains  is  often  marked.  Perhaps  the  most 
satisfactory  bread  is  that  which  is  known  as  aleuronat,  and  which  has  been  highly 
recommended  by  von  Noorden.     Williamson  gives  the  following  formula  for  its 


DIABETES  MELLITUS  7:57 

preparation:  Mix  2  ounces  (62  gm.)  of  desiccated  cocoanut  powder  with  a  little 
water  containing  a  small  quantity  of  German  yeast.  ]\Iake  the  mass  into  a  sort 
of  paste,  and  put  in  a  warm  place  for  half  an  hour  or  longer.  The  small  amount 
of  sugar  contained  in  the  cocoanut  is  almost  entirely  decomposed  by  the  fermenta- 
tion produced  by  the  yeast,  and  the  cocoanut  paste  becomes  spongy.  Add  2 
ounces  (62  gm.)  of  aleuronat,  1  beaten  egg,  and  a  small  quantity  of  water,  in 
which  a  little  saccharin  has  been  dissoh'ed,  and  mix  well  until  a  dough  is  formed. 
Divide  into  cakes  and  bake  in  a  moderate  oven  for  twenty  or  thirty  minutes.  The 
great  difficulty  is  to  obtain  cocoanut  fibres  sufficiently  desiccated  and  powdered. 

Among  the  articles  which  are  to  be  carefully  avoided  are  all  the  sweet  fruits, 
such  as  melons,  grapes,  peaches,  and  those  vegetables  which  contain  a  very  large 
amount  of  starch  and  sugar,  such  as  sweet  potatoes,  beets,  beans,  peas,  and 
carrots. 

The  medicinal  treatment  of  diabetes  mellitus  has  narrow  limits.  It  is  true  that 
a  host  of  drugs  have  been  recommended  by  various  clinicians  at  various  times,  the 
statement  being  made  that  they  were  capable  of  materially  decreasing  the  quantity 
of  sugar  which  was  lost  in  the  urine,  biit  further  experience  has  almost  universally 
proved  that  they  possess  little  power.  Furthermore,  very  few  of  them  have  been 
shown  to  possess  any  influence  upon  the  symptoms  associated  with  the  glycosuria. 
In  other  words,  at  the  best  they  affect  only  the  one  s>-mptom  of  loss  of  sugar,  and 
in  no  way  correct  the  underlying  cause  of  the  malady. 

Without  doubt  opium  is  the  most  valuable  drug  in  the  treatment  of  diabetes 
mellitus  in  the  majority  of  cases,  for  it  exercises  a  more  potent  influence  in  diminish- 
ing the  elimination  of  sugar  in  the  urine  than  any  other  drug.  Its  alkaloids, 
morphine  and  codeine,  are  also  exceedingly  valuable,  and  may  be  employed  when 
they  prove  capable  of  controlling  the  glycosuria  and  when  the  opium  increases  the 
constipation,  but  neither  of  these  alkaloids  is  the  equal  of  the  crude  drug. 

There  are  several  important  points  in  regard  to  the  employment  of  opium,  or 
its  derivatives,  in  diabetes:  First,  patients  of  all  ages  seem  to  be  able  to  take  large 
quantities  of  opiimi  in  this  disease  without  developing  the  evil  manifestations  of 
the  opium  habit.  Second,  these  patients  usually  have  to  take  ascending  doses 
of  the  drug  until  they  reach  a  dose  which  controls  the  glycosuria  more  or  less 
completely.  Third,  opiates  possess  the  advantage  that  they  diminish  to  a  large 
extent  nervous  irritation  and  stress.  Not  only  do  they  protect  the  nervous  system 
from  external  causes  of  irritation,  but  by  producing  mental  quiet  and  diminishing 
worry  they  indirectly  cause  good  results.  An  endeavor  should  be  made  from  time 
to  time  to  diminish,  at  least  temporarily,  the  quantity  of  the  drug  which  is  taken. 
Ordinarily  denarcotized  opiiun  is  the  best  preparation.  Patients  may  start  on  J 
grain  once,  tw'ice,  or  thrice  a  day,  and  gradually  increase  it,  if  necessary.  Or, 
I  to  J  grain  of  morphine  may  be  given  at  these  intervals.  In  other  instances  |  to  1 
grain  of  codeine  may  be  used  as  a  beginning  dose.  Some  patients  get  so  much 
comfort  and  such  a  diminution  of  glycosuria  under  moderate  doses  of  these  drugs 
that  the  size  of  the  dose  does  not  have  to  be  increased.  Thus,  I  have  had  under 
my  care  for  nearly  tw-elve  years  a  woman  who  has  taken  but  3  grains  of  codeine 
a  day  during  all  that  time.  She  has  never  had  any  desire  to  increase  the  dose 
beyond  this  amount,  and  it  has  kept  her  glycosuria  within  bounds,  besides  giving 
her  a  great  deal  of  comfort. 

In  cases  which  do  not  possess  marked  nervous  symptoms,  but  which  are  rather 
phlegmatic  in  type,  and  have  a  gouty  tendency,  the  salicylate  of  sodium  or  salicylate 
of  strontium  may  be  given  in  full  doses  varying  from  10  to  20  grains  three  or  four 
times  a  day;  or,  in  their  place,  we  may  employ  some  of  the  new  coal-tar  products, 
such  as  antipyrin,  acetanilid,  and  phenacetin.  These  drugs,  however,  must  be 
given  in  full  doses  to  have  any  effect,  and  they  so  greatly  increase  the  susceptibility 
of  the  patient  to  cold  that  they  must  be  used  with  great  caution.  In  cases  which 
47 


738  DISEASES  OF  NUTRITION 

have  a  syphilitic  history,  or  which  seem  to  be  gouty,  the  iodide  of  i)otassium,  in 
the  dose  of  10  to  30  grains  or  more  three  or  four  times  a  day,  often  does  good. 
When  the  patient  can  digest  it,  cod-liver  oil  is  an  exceedingly  valuable  alterative 
and  nutrient. 

With  the  idea  that  the  alkalies  aid  oxidation  processes  in  the  body  and  so  neu- 
tralize acid  poisons,  various  alkalies,  as  the  potassium  and  sodium  salts,  have  been 
largely  employed.  Thus,  potassium  or  sodium  bicarbonate  may  be  given  in  30, 
40,  or  60  grain  doses  three  or  four  times  a  day.  They  aid,  too,  in  the  elimination 
of  acids. 

Another  remedy  which  is  of  value  in  some  cases,  particularly  if  anemia  is  present, 
is  Fowler's  solution  in  doses  varying  from  1  to  3  minims  three  times  a  day.  With 
some  clinicians  it  has  a  great  reputation  in  this  disease. 

In  the  treatment  of  the  various  complications  of  diabetes  we  must  first  consider 
diabetic  coma.  After  coma  is  once  established,  we  have  no  method  of  treat- 
ment which  promises  permanent  recovery.  I  have  repeatedly  seen  a  temporary 
return  to  consciousness  follow  the  intravenous  injection  of  one  quart  of  normal 
saline  solution,  and  Continental  clinicians  have  employed  and  strongly  recom- 
mended the  injection  of  carbonate  of  sodium  in  solution.     (See  below.) 

When  the  presence  of  an  excess  of  acetone  or  diacetic  acid  or  oxybutyric  acid 
in  the  urine,  or  of  the  early  symiptoms  of  intoxication,  indicate  that  diabetic  coma 
is  not  far  distant,  two  plans  of  treatment  should  be  promptly  instituted.  One  of 
these  is  directed  to  the  prevention  of  the  further  formation  of  acidosis.  The 
other  is  designed  to  deprive  these  substances  of  their  poisonous  properties.  As 
already  pointed  out,  the  addition  of  liberal  amounts  of  starchy  foods  to  the 
diet  results  in  the  decrease  or  disappearance  of  acetone  from  the  urine — acetone 
being  the  symbol  of  intoxication.  This  may  increase  the  glycosuria  but  this  is 
nothing  as  compared  to  the  danger  of  coma.  If  this  cannot  be  done  by  the  use  of 
remedies  by  the  mouth,  because  the  stomach  is  unfit  to  deal  with  food,  then  one  of 
the  monosaccharids,  such  as  levulose  or  dextrose,  should  be  dissolved  in  sterile  salt 
solution  and  injected  subcutaneously  or  into  a  vein.  Ordinary  sugars  (disaccharids) 
cannot  be  used  in  this  way,  because  they  require  the  action  of  the  digestive  juices  to 
be  disintegrated.  The  quantity  of  fluid  used  should  be  a  quart  with  10  per  cent, 
of  dextrose.  Not  less  than  50  to  100  grams  of  levulose  a  day  should  be  given  by 
the  mouth.  A  5  per  cent,  solution  of  glucose  may  be  given  by  the  rectum,  using 
Murphy's  drop  method.  If  neither  of  these  can  be  had,  glycerin  may  be  given 
by  the  mouth.  Another  point  of  importance  is  to  cut  down  tlie  fats  given  to  these 
patients,  who  before  the  onset  of  these  sjonptoms  have  been  subsisting  largely 
upon  fats  and  proteids,  because  the  poisons  of  coma  are  derived  from  fats  and 
fatty  acids. 

For  the  diminution  of  the  poisonous  properties  of  the  toxic  substances  already 
formed  everyone  is  in  accord  that  alkalies  should  be  freely  administered.  Vichy 
water  should  be  taken  in  large  quantities,  and  60  or  120  grains  of  bicarbonate  of 
sodium  may  be  given  every  two  or  three  hours  dissolved  in  Vichy  water,  thereby 
fortifying  it.  Water  to  the  extent  of  5  quarts  in  twenty-four  hours  should  be 
given  to  help  in  the  elimination  of  poisons  and,  to  avoid  gastric  distention,  the 
amounts  given  each  time  should  not  be  too  large.  Salt  solution  may  be  used 
by  hypodermoclysis.  Stadelmann  has  advised  the  intravenous  injection  of  car- 
bonate of  sodium  in  order  that  it  may  combine  with  the  acids  in  the  tissues, 
and  aid  in  their  elimination.  The  quantity  of  acetone  in  the  urine  may  be 
temporarily  increased  by  this  plan  of  treatment.  Naunyn  uses  35  to  40  grams 
of  carbonate  of  sodiima  (not  bicarbonate)  dissolved  in  a  quart  of  water.  This 
must  be  given  very  slowly  by  intravenous  injection.  Even  this  plan,  if  insti- 
tuted after  coma  is  present,  rarely  does  more  than  restore  consciousness  tem- 
porarily.    If  the  bowels  are  confined  they  should  be  opened  by  some  saline  purge. 


DIABETES  INSIPIDUS  ■  739 

but  active  purgation  should  not  be  resorted  to,  since  by  this  means  concentration 
of  the  poison  may  take  place  if  the  bowel  is  not  active  in  the  process  of  eliminating 
poisons  from  the  blood. 

BRONZED  DIABETES. 

Bronzed  diabetes  is  characterized  by  cirrhosis  of  the  liver,  a  peculiar  pigmen- 
tation of  the  skin  and  viscera  (see  Hemochromatosis),  fibroid  changes  in  the 
pancreas  and  constant  glycosuria.  The  term  "bronzed"  is  probably  an  unfor- 
tunate one  as  the  pigments  of  the  skin  are  more  earthy  or  leaden  in  hue.  The 
color  is  most  marked  upon  the  parts  exposed  to  light,  as  the  face,  hands,  and  neck, 
and  it  is  very  unevenly  distributed.  Occasionally  there  is  considerable  somnolence, 
not  due  to  diabetic  coma,  with  great  emaciation  and  feebleness.  It  is  held  by 
some  that  iron  which  is  deposited  in  the  tissues  and  which  is  responsible  for  the 
pigmentation  is  not  derived  from  the  breaking  down  of  red  blood  cells  but  from  a 
failure  to  excrete  iron  taken  in  the  food  or  set  free  by  the  breaking  down  of  iron- 
containing  tissues.  The  prognosis  is  hopeless,  and  aside  from  measures  directed 
against  the  conditions  which  are  common  to  this  rare  malady  and  ordinary 
diabetes  mellitus,  there  is  no  efficient  treatment  known.  (See  Hepatic  Hj-per- 
trophic  Cirrhosis.) 

DIABETES  INSIPIDUS. 

Definition. — Diabetes  insipidus  is  a  condition  in  which  a  person  passes  excessive 
quantities  of  urine  containing  no  abnormal  constituents  and  of  a  low  specific  gravity. 
This  term  is  sometimes  applied  erroneously  to  a  fleeting  attack  of  polyuria  due  to 
nervousness  or  fright  and  to  profuse  diuresis  following  the  ingestion  of  excessive 
amounts  of  water.  It  is  also  to  be  separated  from  the  inconstant  polyuria  some- 
times seen  in  hysterical  women. 

Etiology. — Diabetes  insipidus  is  most  commonly  met  with  in  persons  under 
thirty  years  of  age  and  may  occur  in  early  childhood.  It  is  more  common  in  males 
than  in  females.  Very  rarely  it  is  definiteh'  hereditary,  and  occasionally  there  is 
in  the  history  of  the  patient  a  statement  that  it  developed  after  some  severe  injury, 
as  a  railroad  accident  or  fall.  It  has  also  followed  sunstroke  and  prolonged  fevers 
of  an  infectious  tj^pe,  and  it  has  been  met  with  as  a  symptom  in  cases  of  brain 
tumor,  particularly  if  it  involves  the  fourth  ventricle.  Within  the  last  few  years 
a  number  of  investigations  have  shown  that  irritation  of  the  posterior  lobe  of 
the  hypophysis,  either  reflexly  through  the  nervous  system  or  directly  in  operations, 
causes  a  very  marked  polyuria  and  this  perhaps  explains  this  condition  in  nervous 
and  hysterical  persons.  It  is  increasingly  evident  that  a  large  proportion  of  these 
cases  are  due  to  dyspituitarism,  since  polyuria  often  results  from  injury  to  the 
pituitary  body  in  operations  on  animals  and  man.  Furthermore,  an  increasing 
number  of  cases  of  polyuria  are  being  reported  in  which  lesions  of  the  pituitary 
body  have  been  found  at  autopsy.  In  every  case  associated  with  any  signs  of 
dyspituitarism  (see  Dyspituitarism)  or  of  brain  tumor,  as  choked  disk  or  hemi- 
anopsia, the  sella  turcica  should  be  studied  by  the  aid  of  the  x-rays. 

Morbid  Anatomy. — Aside  from  changes  in  the  hypophysis  no  distinct  lesions 
have  been  found  at  autopsy.  Sometimes  the  kidneys  are  found  to  be  swollen 
and  congested. 

Symptoms. — The  dominant  symptom  of  diabetes  insipidus  is,  of  course,  a  ■profuse 
urinary  fioio.  Next  to  this  symptom  is  the  constant  thirst  suffered  by  the  patient, 
who  no  sooner  provides  his  system  with  fluid  by  drinking  than  it  escapes  from  the 
kidneys.  The  third  symptom  of  importance  is  the  annoyance  caused  by  the  neces- 
sity of  emptying  the  bladder  many  times  a  day  and  the  loss  of  rest  at  night  by 
reason  of  the  same  condition.  Closely  related  to  these  symptoms  in  its  causation 
is  dryness  of  the  mouth  and  excessive  dryness  of  the  shin.     Partly  because  of  the  fact 


740  DISEASES  OF  NUTRITIOS 

that  the  condition  develops  usually  in  nervous  patients,  or  in  those  whose  nerves 
have  been  shattered  by  accident,  persons  suffering  from  diabetes  insipidus  are 
often  very  irritable  and  peevish,  an  irritability  wliich  is  maintained  I)y  the  necessity 
of  frequent  micturition.  The  body  temj^erature  may  be  normal  or  subnormal. 
Tyson  states  that  some  cases  can  take  inordinate  quantities  of  alcohol  without 
intoxication,  but  that  others  are  unduly  susceptible  to  the  cerebral  efl'ects  of  this 
drug. 

The  quantity  of  urine  passed  by  some  cases  of  diabetes  insipidus  quite  equals 
that  passed  by  well-advanced  cases  of  diabetes  mellitus  with  free  ])()lyuria.  As 
much  as  eighty  and  ninety  pints  a  day  have  been  excreted  but  the  usual  quantity 
is  rarely  above  ten  or  twelve  pints.  The  specific  gravity  is  almost  as  low  as  ordinary 
water,  and  rarely  exceeds  1.00.3  or  1.005,  owing  to  the  fact  that  the  normal  urinary 
solids  are  dissolved  in  such  an  exceedingly  large  quantity  of  fluid.  At  times  the 
total  urea  is  greatly  in  excess  of  that  normally  excreted.  Albumin  is  rarely  present 
except  in  very  small  amount. 

Diagnosis. — Before  deciding  that  a  patient  has  true  diabetes  insipidus  it  must 
be  determined  that  the  condition  is  not  a  fleeting  polyuria,  Init  a  constant  state. 
Tests  as  to  specific  gravity  of  the  urine  and  for  sugar  will  reveal  diabetes  mellitus. 
The  state  of  the  cardiovascular  system  and  the  eye-grounds  may  re\'eal  ciironic 
contracted  kidney. 

Prognosis. — Prognosis  so  far  as  life  is  concerned  is  good.  Recovery  is  by  no 
means  rare,  and  even  if  it  does  not  take  place  death  from  the  malady  rarely,  if 
ever,  occurs.  The  celebrated  case  of  Willis  lived  fifty  years  with  this  condition 
present.  It  is  only  when  the  diabetes  insipidus  depends  upon  a  serious  nervous 
lesion  that  the  prognosis  is  bad,  and  then  because  of  the  lesion  and  not  because  of 
the  polyuria. 

Treatment. — No  treatment  for  diabetes  insipidus  which  has  yet  been  instituted 
has  proved  satisfactory.  It  is  quite  true  that  a  large  number  of  remedies  have 
been  spoken  of  in  terms  of  praise  by  various  practitioners,  hut  the  very  number  of 
them  indicates  that  no  one  of  them  gives  results  which  are  definitely  curative.  The 
use  of  vegetable  astringents,  such  as  gallic  acid,  with  the  idea  that  by  this  means  a 
diminution  in  the  secretion  of  urine  may  be  brought  about,  sometimes  produces 
favorable  results.  The  dose  must  be  large,  from  5  to  20  grains  three  or  four  times 
a  day;  but  even  when  such  large  doses  are  used  as  to  disorder  the  stomach,  it  not 
infrequently  happens  that  no  decrease  in  the  quantity  of  urine  is  brought  about. 
In  other  instances  good  results  are  said  to  accrue  from  the  employment  of  an  active 
fluidcxtract  of  ergot  given  in  the  dose  of  20  to  150  minims  three  or  four  times  a  day, 
alone  or  with  the  bromide  of  sodium  in  the  dose  of  20  grains.  The  ergot  is  supposed 
to  act  by  contracting  the  capillaries  in  the  INIalpighian  tufts.  When  the  polyuria 
causes  much  restlessness  and  insomnia,  the  remedies  already  named  may  be  aided 
by  the  simultaneous  administration  of  codeine,  which  will  probaljly  not  decrease 
the  quantity  t)f  urine,  but  which  usually  acts  as  a  nervous  sedative  with  sufficient 
power  to  prevent  the  bladder  from  waking  the  patient  more  frequently  than  is 
absolutely  necessary.  The  bromides  may  also  be  used  for  this  purj)ose.  In  those 
cases  which  are  associated  with  neurasthenia  or  which  follow  prolonged  nervous 
strain,  the  "rest  cure"  or  a  vacation  where  the  patient  is  not  annoyed  by  business 
or  family  cares  will  probably  give  better  results  than  will  drugs. 

GOUT. 

Definition. — Gout  is  a  disease  which  depends  for  its  existence  upon  a  disorder 
of  metabolism,  as  a  result  of  which  deposits  of  biuratc  of  sodium  take  place  in  the 
joints  and  in  the  fibrous  tissues  surrounding  them.  It  is  characterized  by  associated 
changes  of  a  fibroid  and  calcareous  character  in  other  parts  of  the  body  in  many 


GOUT  741 

instances,  and  in  its  acute  exacerbations  it  frequently  causes  severe  inflammation 
and  pain  in  one  or  more  joints.  The  joint  of  the  big  toe  is  very  commonly  the 
chief  seat  of  the  articular  disorder.     Gout  is  sometimes  called  "podagra." 

Etiology. — The  precise  cause  of  gout  is  unknown,  but  certain  etiological  factors 
in  its  development  are  universally  recognized  as  being  active.  The  first  of  these  is 
undoubtedly  heredity,  but  while  it  is  true  that  the  tendency  to  the  di.sease  is  often 
inherited  it  is  also  true  that  the  descendants  of  gouty  persons  often  fail  to  develop 
the  disease,  and  that  other  persons  who  have  no  gout  in  their  family  history  suffer 
from  the  malady.  It  is  interesting  in  this  connection  to  note  that  younger  children 
of  gouty  persons  more  frequently  fall  victims  to  gout  than  the  children  of  their 
earlier  years,  probably  because  the  gouty  diathesis  is  better  developed  in  advanced 
years  in  the  parents  than  in  youth. 

A  second  factor  in  the  production  of  gout  is  mode  of  life  as  to  exercise  and  mental 
labor.  There  is  universal  accord  that  great  mental  and  nervous  stress  with  little 
physical  exercise  frequently  produces  a  gouty  diathesis  and  often  precipitates  an 
acute  attack  of  the  malady  in  those  already  gouty.  Duckworth  states  that  political 
life  in  England  is  notoriously  conducive  to  gout,  and  that  lawyers  are  ^'ery  prone 
to  it.  In  the  case  of  the  country  squire  who  is  so  often  gouty,  high  living  and  drink- 
ing, with  a  long  heritage  of  dietetic  indiscretion,  probably  overcomes  all  the  good 
effects  of  an  active  out-door  existence.  In  those  who  live  chiefly  out-of-doors,  as 
farmers,  soldiers,  and  sailors,  the  disease  is  rare. 

A  third  factor  of  some  importance  is  age.  While  cases  of  well-developed  gout 
are  met  with  in  young  children  and,  very  rarely,  even  in  infancy,  the  malady  com- 
monly does  not  develop  till  after  the  thirtieth  year,  but  rarely  waits  till  the  fifth 
decade  of  life  before  at  least  beginning  its  early  manifestations. 

A  fourth  factor  is  the  abuse  of  alcohol,  not  in  the  sense  of  going  on  sprees,  but 
in  such  a  manner  that  the  system  is  all  the  time  engaged  in  oxidizing  or  destroying 
this  drug.  Ales  and  beers — that  is,  malt  liquors — are  more  prone  to  cause  gout 
than  are  whiskies  and  other  distilled  liquors.  Sweet  and  sour  wines  are  also  provo- 
cative of  this  disorder,  particularly  champagnes. 

A  fifth  lactor  is  overeating.  There  is  an  increasing  number  of  persons  in  America 
who  do  not  eat  to  live,  but  live  to  eat,  and  who  stimulate  the  digestive  organs  to 
greater  activity  by  the  use  of  highly  seasoned  dishes,  with  the  result  that  they 
ingest  and  absorb  more  food  than  the  system  can  use,  stifling  oxidation  and  clogging 
elimination. 

Finally,  a  very  powerful  factor  in  producing  gout,  in  those  who  are  exposed  to 
the  metal,  is  lead  poisoning  of  the  chronic  type. 

We  find,  then,  that  the  chief  causes  of  gout  are  heredity,  lack  of  exercise,  nervous 
stress,  and  the  ingestion  of  more  food  or  drink  than  the  body  can  properly  deal  wdth. 

Frequency. — True  gout  in  its  frank  forms  is  far  less  common  in  England  than 
it  was  in  the  early  part  of  the  last  century  or  in  the  eighteenth  century.  In  America 
it  is  certainly  very  rare.  On  the  other  hand,  both  in  England  and  in  this  country 
"lurking,"  "lateral,"  or  masked  gout  is  certainly  greatly  on  the  increase.  The 
disease  is  more  common  in  men  than  in  women. 

Pathology. — When  we  come  to  a  study  of  this  disease  from  the  standpoint  of 
perverted  physiology  or  pathology,  we  encounter  a  task  over  which  the  profession 
has  toiled  unceasingly  year  after  year  with  little  advance  in  our  understanding  of 
gout,  but  great  advance  in  our  knowledge  of  the  metabolic  changes  in  the  body. 
When  Sydenham  wrote,  after  being  a  sufferer  from  gout  for  years,  that  it  is  due  to 
"the  impaired  concoction  of  matters  both  in  the  parts  and  juices  of  the  body," 
he  expressed  himself  as  clearly  and  correctly  as  do  many  modern  writers  on  this 
subject.  So  late  as  October  1913,  Walker  Hall  concludes  a  paper  on  this  subject 
in  the.se  words:  "It  is  a  slow  progress  along  the  zigzag  which  leads  to  the  centre 
of  the  gouty  maze,  but  the  researches  of  the  last  decade  have  opened  up  many 


742  DISEASES  OF  NUTRITION 

new  and  possible  pathways  thereto.  Further  advances,  however,  wait  for  progress 
in  chemistry  and  physics,  especially  in  connection  with  fermentative  processes." 

The  pages  of  a  text-book  are  not  suitable  for  a  discourse  in  whicli  a  multitude 
of  researches  are  analyzed  and  judged,  yet  it  is  i)r()|)er  to  take  note  of  several  theories 
as  to  the  cause  of  gout  that  have  been  strongly  advocated  by  one  or  more  investiga- 
tors, with  some  basis  for  their  views. 

One  theory  is  that  when  the  blood  and  lymph  are  saturated  with  uric  acid  the 
urates  are  precipitated  by  a  slight  lowering  of  the  temperature,  such  as  is  apt  to 
occur  in  an  exposed  joint.  This  theory  is  not  adequate  to  explain  the  disease, 
because  it  has  been  proved  that  the  fluids  are  not  saturated  with  uric  acid  or  urates 
in  cases  of  gout,  and  the  disease  affects  parts  which  are  not  chilled. 

Again,  Kolisch  advanced  the  view  that  the  so-called  xanthin  bases  are  the  cause 
of  gout.  This  investigator  believes  that  the  nucleinic  bodies  are  broken  up  into 
xanthin  and  hypoxanthin,  and  that  in  the  healthy  kidneys  these  are  in  turn  changed 
into  uric  acid.  In  gout  he  thinks  that  the  kidneys  fail  to  perform  tlieir  function 
properly,  that  the  xanthins  are  not  transformed  into  uric  acid,  and  that  this  results 
in  the  retention  of  xanthins,  which  straightway  proceed  to  cause  gout.  This  view 
has  been  impaired  by  the  fact  that  his  methods  of  research  were  faulty  and  by  the 
fact  that  other  investigators,  using  more  accurate  methods,  get  different  results. 

His  believes  that  the  uric  acid  of  the  gouty  is  a  product  of  the  disease,  and  that 
it  is  capable  of  causing  evil  effects  in  the  body.  It  is  not  the  prime  factor,  in  other 
words,  but  a  secondary  factor,  just  as  the  bacillus  of  diphtheria  is  the  prime  factor, 
and  the  toxins  which  it  produces  cause  widespread  lesions  as  secondary  factors. 
In  the  normal  body  uric  acid  is  in  large  part  destroyed;  whereas,  in  gout  it  is  per- 
mitted to  exist  and  induce  secondary  evil  effects.  Any  cause  which  prevents  the 
destruction  of  uric  acid  predisposes  the  patient  to  its  deleterious  influences,  and 
these  causes  may  be  inherited,  acquired,  or  due  to  poisons,  such  as  lead.  Here, 
again,  we  are  met  by  the  contradictory  fact  that  in  a  number  of  diseases  an  excess 
of  uric  acid  develops  without  any  signs  of  gout  appearing.  Thus,  in  leukemia, 
pneumonia,  and  chronic  kidney  disease  this  acid  circulates  in  the  blood  in  excess 
but  no  gout  is  produced. 

The  view  of  Ebstein  is  that  there  is  a  primary  nutritional  disturbance  in  the 
affected  joints,  and  in  other  tissues,  which  results  in  tissue  death  within  those  parts, 
and  that  in  these  devitalized  areas  urates  are  deposited.  Finally,  von  Noorden 
believes  that  a  special  ferment  acts  to  produce  these  local  nutritional  changes  and 
that  the  deposit  of  urates  then  ensues. 

The  most  popular  theory  as  to  the  cause  of  the  symptoms  has  been  that  there 
is  present  in  the  body  an  excess  of  uric  acid.  This  is  the  theory  of  Garrod,  and 
in  more  recent  times  has  had  its  most  enthusiastic  advocate  in  Ilaig.  Garrod's 
theory  that  the  decrease  of  uric  acid  in  the  urine  at  the  time  of  an  attack  is  due 
to  its  retention  in  the  body,  and  that  this  retention  causes  an  outbreak,  is  now  held 
to  be  erroneous,  or  at  least  is  regarded  with  grave  doubt,  as  is  also  his  Aiew  that  a 
decreased  alkalinity  of  the  blood  causes  a  precipitation  of  the  urates,  for  ^lagnus- 
Levy,  Luff,  and  W.  His,  Jr.,  have  all  proved  that  the  quantity  of  uric  acid  in  the 
blood  is  not  increased  during  or  before  an  attack,  nor  is  the  alkalinity  of  the  blood 
decreased.  Still  others  have  shown  that  the  decrease  in  the  excretion  of  uric  acid 
just  before  an  attack  of  gout  is  due,  in  part  at  least,  to  a  decreased  ingestion  of  food. 
These  researches  do  not  prove,  however,  that  uric  acid-producing  substances  are 
not  present  in  excess,  and  it  is  entirely  possible  that  the  scanty  elimination  of  uric 
acid  in  many  of  these  patients  in  the  interval  between  attacks  is  due  to  the  failure 
of  the  body  to  change  these  substances  into  uric  acid,  with  the  result  that  they 
cause  an  attack,  at  which  time  the  percentage  of  uric  acid  excreted  often  tempor- 
arily rises.     I  confess  that  this  view  seems  the  more  attractive. 

When  we  consider  that  the  injection  of  uric  acid  into  tlie  blood  docs  not  cause 


GOUT  743 

gout,  that  it  is  present  in  leukemia,  pneumonia,  and  nephritis  without  causing 
gout,  and  that  no  excess  of  uric  acid  is  found  in  the  blood  in  gout,  it  is  hard  to 
believe  that  uric  acid  causes  gout.  While  Kolisch's  theory  may  be  imperfect  in 
detail,  and  while  the  kidney  may  not  transform  xanthin  into  uric  acid,  it  is  entirely 
possible  that  an  excess  of  xanthin  may  be  present  in  gout.  This  view  is  supported 
by  several  facts,  which  indicate  that  uric  acid  is  an  end-product  derived  from 
nuclein  breakdown,  and  that  it  is  not  this  healthy  end-product,  but  by-products 
which  are  morbid  in  effect.  From  nuclein  we  can  obtain  albumin  and  nucleinic 
acid;  from  neucleinic  acid  we  can  obtain  phosphoric  acid  and  a  substance  which 
in  turn  may  be  split  up  into  xanthin  bases  and  uric  acid.  If  oxidation  is  complete, 
uric  acid  is  the  chief  end-product,  if  it  is  incomplete,  then  xanthin  is  the  chief 
product.  Bain  and  Futcher  have  both  shown  that  when  there  is  an  increase  in 
uric  acid  excretion  there  is  an  increase  in  phosphoric  acid  secretion,  and  they  believe 
that  this  throws  a  side  light  upon  the  relation  of  uric  acid  and  xanthin  to  gout. 
Thus,  in  one  of  Futcher's  cases  there  was  a  marked  fall  in  both  phosphoric  acid  and 
uric  acid  immediately  before  an  attack,  followed  by  a  very  great  increase  at  the 
time  of  the  attack,  and  this  again  by  a  fall.  The  phosphoric  acid  curve  was  far 
greater  than  the  uric  acid  curve. 

It  would  seem,  therefore,  that  the  destruction  of  nucleinic  bodies  may  be  per- 
verted in  gout,  and  this  is  what  Futcher's  study  proves,  namely,  that  as  phos- 
phoric acid  and  uric  acid  are  both  derived  from  nuclein,  and  as  they  are  greatly 
disturbed  in  amount  in  relation  to  the  attack,  it  is  fair  to  assume  that  some  relation 
exists  between  nucleinic  bodies,  their  derivatives,  and  gout. 

At  the  present  time  it  would  seem  probable  that  we  may  divide  this  question 
of  the  pathology  of  gout  into  two  sub-questions,  viz. : 

1.  Is  there  present  in  the  body  at  the  time  of  an  attack  of  gout  an  excess  of 
uric  acid,  or,  rather,  of  material  capable  of  producing  lu-ic  acid?  The  answer  is 
"Yes." 

2.  What  is  the  reason  that  this  condition  develops?  The  answer  is  that  we  do 
not  know,  but  that  it  is  dependent  upon  a  perversion  of  metabolism  not  yet  under- 
stood, whereby  in  health  uric  acid,  a  primarily  harmless  body,  is  produced,  and 
in  disease  a  by-product  is  found,  which  causes  an  attack,  before,  or  during,  which 
urate  of  sodium  is  deposited  in  the  tissues. 

Morbid  Anatomy. — Gout  may  produce  morbid  changes  in  every  tissue  of  the 
body,  even  to  the  hair  and  nails,  but  the  parts  which  are  most  frequently  impaired 
by  its  existence  are  the  heart  and  the  bloodvessels,  the  kidneys  and  the  joints. 
From  the  standpoint  of  outward  manifestations  and  early  discomfort,  the  joint 
changes  are,  of  course,  the  most  important,  but  from  the  standpoint  of  the  physician, 
whose  duty  it  is  to  prolong  life,  the  cardiovascular  and  renal  changes  are  the  factors 
which  deserve  most  attention.  Because  of  the  wide  distribution  of  gout  in  the  body, 
Sydenham  wrote:  "Totiun  corpus  est  podagra." 

The  lesions  in  the  joints  are  characteristic;  the  ligaments,  tendons,  and  bursse 
all  become  affected,  and  even  the  articular  cartilages  are  involved.  In  all  these 
tissues  deposits  of  biurate  of  sodium  take  place,  and  they  may  be  so  copious  that 
the  parts  are  deformed  and  incapacitated  by  roughening  of  the  cartilaginous  sur- 
faces, or  by  thickening  of  the  sheaths  of  the  tendons  and  joints.  In  tj-pical  cases 
the  disease  first  attacks  the  joint  of  the  big  toe,  then  the  finger-joints,  after  this 
the  metacarpal  and  metatarsal  joints,  and  still  later,  but  much  more  rarelj^  the 
large  joints.  When  these  are  affected,  the  wrist,  elbow,  and  knee  are  the  parts 
usually  involved.  The  ball-and-socket  joints  (hip  and  shoulder)  are  very  rarely 
involved  in  gout,  and  the  upper  extremities  are  much  less  frequently  affected  than 
the  lower  ones.  When  the  disease  is  well  advanced  there  is  so  great  a  deposit  of 
biurate  of  sodium  that  it  lies  under  the  skin  in  a  white  knob,  or  pea-shaped  mass, 
which  looks  white  and  chalky.     If  the  skin  covering  such  a  deposit  is  injured,  it 


744 


DISEASES  OF  XtriHTloX 


not  rarely  undergoes  necrosis,  and  Ijiurate  of  sodium  exudates  from  the  part,  looking 
like  wet  chalk.  Sometimes  f)n  the  fingers,  near  the  hase  ol'  tlie  finger-nails,  or 
about  the  first  ])lialangeal  joint,  there  develop  small,  hard,  uratic  masses  called 
"crab's  eyes."  It  is  a  remarkable  fact  that  these  deposits  often  take  i)lace  without 
any  other  manifestation  of  gout  being  present  and  without  any  pain,  so  that  atten- 
tion may  be  called  to  them  only  by  reason  of  the  disfiguration  produced.  Gouty 
deposits  about  the  base  of  the  finger  or  at  the  second  joint  are,  however,  usually 
part  of  a  general  gouty  outbreak. 

When  the  articulating  cartilages  arc  affected  two  conditions  may  be  presented. 
If  no  injury  has  occurred,  and  if  no  cause  of  irritation  has  existed  other  than  the 
gout,  the  articulating  surface  is  seen  to  be  smeared  or  plastered,  to  use  Duckworth's 
expression,  with  a  uratic  deposit  looking  as  white  and  smooth  as  fresh  white  lead 
(Fig.  125).  When  irritation  has  been  present  the  articular  cartilage  may  be 
eroded.     In  this  latter  form  there  is  often  overgrowth  of  connective  or  fibrous 


ShowinK  urate  of  socliii 


tissue  in  the  surrounding  parts  along  with  the  dejjosit  of  urates,  as  already  described, 
and  stiffening  or  distortion  of  the  joint.  The  changes  in  the  bursa  are  often  note- 
worthy. I  have  a  case  now  under  treatment  in  which  there  is  a  bursa  swollen  to 
the  size  of  a  bantam's  egg  on  the  heel  at  the  insertion  of  the  tendo  Achillis.  It  is  a 
very  dusky  red  and  is  exquisitely  sensitive,  but  contains  nothing  but  fluid.  It  has 
often  developed  before,  and  under  active  treatment  for  gout  has  alwa>s  disap])eared 
and  left  no  trace  behind  it. 

The  cardiovascular  changes  caused  by  gout  do  not  result  from  the  dejwsition 
of  biurate  of  sodium  in  the  heart-valves  or  in  the  bloodvessel  walls.  Indeed, 
it  is  rare  for  such  deposits  to  be  found,  although  cases  are  recorded  in  which  the 
cardiac  valves  and  the  intima  of  the  aorta  have  contained  the  biurate  of  sodium. 
But  while  it  is  true  that  biurate  of  sodium  is  not  deposited  in  the  vascular  system, 
as  it  is  in  the  joints,  it  is  also  true  that  gout  causes  first  arterial  spasm,  then  arterio- 
capillary  fibrosis,  and,  finally,  advanced  calcareous  changes  in  the  vessels.  The 
result  of  this  is  cardiac  hypertrophy  on  the  left  side  of  the  heart  in  particular. 


GOVT  745 

The  endocardium  is  never  the  seat  of  acute  endocarditis  as  a  result  of  true  gout. 
The  only  endocardial  changes  are  those  common  to  ordinary  cases  of  general 
atheromatous  degeneration,  in  that  sclerotic  changes  take  place  in  the  valves, 
particularly  those  guarding  the  aortic  and  mitral  orifices.  The  chordae  tendinese 
are  also  shortened  by  a  similar  process  and  rendered  inelastic. 

The  pericardium  is  very  rarely  affected. 

The  venous  system  is  prone  to  varicosities  and  calcareous  plates  may  be  present 
in  the  walls  of  the  veins.     These  in  turn  may  result  in  thrombosis  and  phlebitis. 

Gout,  cardiovascular  disease,  and  angina  pectoris  are  a  wicked  trio  that  bring 
many  a  noble  man  to  death. 

Whatever  the  gouty  poison  may  be  which  causes  changes  in  the  general  vascular 
system,  that  poison  also  damages  the  renal  tissues  as  well.  The  bloodvessels  of 
the  kidneys  are,  of  course,  involved  in  the  general  vascular  fibrosis,  andVe  have 
the  small,  contracted  kidney  sometimes  called  a  "gouty  kidney,"  because  it  is  often 
the  result  of  gout.  Many  years  ago  Ord  and  Greenfield  showed  that  in  two-thirds 
of  all  cases  examined  at  autopsy  in  which  there  was  gout  in  the  great  toe  there 
was  chronic  granular  kidney,  and  in  the  remaining  one-third  a  condition  allied 
to  it.  While  it  is  quite  true  that  deposits  of  biurate  of  sodium  are  sometimes 
found  in  the  kidney  structure  in  the  region  of  the  papilla?,  and  extending  outward 
along  the  pyramids  toward  the  periphery  of  the  organ  in  whitish  streaks,  such  cases 
are  very  rare  when  we  consider  the  number  of  cases  of  gout  and  the  number  of 
cases  of  renal  disease  complicating  its  existence. 

Symptoms. — These  are  best  studied  in  three  dimsiom:  the  acuie,  the  chronic, 
and  the  aberrant  types. 

Acute  Gout. — In  this  form  the  fully  developed  sjTnptoms  are  often  preceded 
by  several  hours  or  days  of  nervoxis  irritability,  of  insovmia,  or  of  general  wretchedness 
not  easily  described.  In  some  cases  pruritus  ani  is  present,  or  itching  elsewhere 
may  annoy  the  patient  and  keep  him  restless  at  night.  The  urinary  secretion  is 
often  scanty  and  the  bladder  may  be  irritable.  In  other  cases  these  symptoms  are 
entirely  absent  and  the  patient  will  recall,  during  his  hours  of  suffering,  that  he 
has  seldom  felt  as  well  as  he  felt  for  a  day  or  two  before  the  attack  came  on. 

The  attack  itself  usually  consists  in  the  sudden  onset  of  sharp  pain  and  inflam- 
mation in  the  ball  of  the  great  toe.  The  pain  is  very  severe  and  stabbing  in  char- 
acter, often  extending  upward  into  the  foot.  A  swelling  develops  with  surprising 
rapidity  and  the  skin  over  it  is  red,  hot,  and  burnished.  In  addition,  the  part 
affected  is  exquisitely  sensitive,  so  that  the  pressure  of  the  bedclothes,  much  less 
that  of  a  shoe,  is  insupportable.  Not  rarely  a  distinct  febrile  condition  is  present, 
the  temperature  reaching  102°  or  more.  After  a  few  hours  the  agony  diminishes, 
the  swelling  decreases,  and  the  patient  is  more  comfortable,  but  within  the  next 
twenty-four  hours  the  malady  may  return  with  fresh  severity.  This  may  persist 
for  several  days,  but  at  the  end  of  that  time  the  patient  is  not  only  soon  on  the  road 
to  recovery,  but  feels  better  than  for  a  considerable  time  before  the  attack,  although 
the  ball  of  the  toe  may  be  swollen  and  inflamed  for  some  days  longer. 

There  are  three  noteworthy  peculiarities  about  these  seizures,  namely,  that 
they  usually  develop  after  midnight,  waking  the  patient  from  sleep;  that  although 
the  inflammatory  process  in  and  about  the  joint  seems  furious  in  its  severity,  the 
part  never  goes  on  to  suppuration,  and  the  onset  and  disappearance  of  the  attack 
is  followed  by  little  if  any  disability  in  the  affected  part.  Only  when  repeated 
attacks  take  place  is  there  developed  much  deformity  of  the  area  involved  in  the 
gouty  manifestation. 

Acute  gout  is  nearly  always  recurrent.  Sometimes  it  attacks  the  patient  every 
few  weeks,  in  other  cases  every  few  months,  and  in  others  every  few  years. 

This  form  of  gout  is  very  rare  in  the  United  States,  but  frequent  in  England, 
although  less  so  than  it  was  many  years  ago. 


746  DISEASES  OF  NUTRITION 

Chronic  Gout. — Chronic  gout  as  a  distinct  condition  from  acute  gout  does 
not  really  exist;  that  is  to  say,  no  sharp  line  separates  this  type  from  the  acute 
form.  Two  types  of  it  may  be  recognized.  In  one,  repeated  attacks  of  acute 
gout  are  connected  with  one  another  by  modified  gouty  manifestations,  such  as 
stifFness  and  soreness  in  various  parts,  as  in  the  wrists  and  elbows,  or  the  main- 
tenance of  a  certain  degree  of  loio-grade  inflammaiion  in  the  joint  of  the  big  toe. 
In  the  other  form  there  are  no  acute  outbreaks  such  as  have  just  been  described, 
but  a  gradual  process  of  gouty  thickening  of  fibrous  tissues  and  an  equally  gradual 
deposition  of  hhirate  of  sodium  about  the  tendons,  the  joints,  and  in  the  articular 
cartilages.  Similar  deposits  called  tophi  are  found  in  the  edges  of  the  ears,  and 
the  "crab's  eye"  formations  in  the  fingers  already  referred  to  are  found. 

The  urine  is  scanty,  the  arterial  tension  is  usually  high,  and  the  aortic  .second 
sound  accentuated.     (See  Morbid  Anatomy.) 

In  some  instances  sudden  inflammatory  attacks  of  moderate  severity,  as  com- 
pared to  the  acute  attacks  in  the  big  toe,  develop  in  one  or  several  of  the  large 
joints,  as  the  elbow  and  knee,  and  may  give  rise  to  the  belief  that  acute  articular 
rheumatism  is  present,  particularly  as  a  rise  of  two  or  three  degrees  of  fever  may 
take  place.  I  have  seen  a  patient  with  severe  nodular  gout  of  the  hands  develop 
an  attack  of  universal  articular  gout  after  having  his  hands  baked  in  a  hot-air 
apparatus,  probably  because  the  treatment  caused  the  distribution  of  a  mass  of 
gouty  material  in  his  body.  The  alterations  in  the  appearance  of  the  joints  in 
these  attacks  has  already  been  described  when  writing  of  the  morbid  anatomy  of 
this  disease.  They  may  resemble  very  closely  that  malady  called  arthritis  deformans. 

After  this  type  of  gout  continues  for  years  the  patient  comes  to  his  death  as  a 
result  of  renal  or  cardiovascular  disease,  or  by  some  acute  infection,  such  as  pneu- 
monia, which  finds  a  ready  victim  in  one  whose  vital  organs  are  already  impaired. 
In  other  words,  death  is  due  to  a  terminal  infection. 

Not  rarely  patients  with  this  type  of  gout  are  intellectually  brilliant  up  to  the 
moment  of  their  final  illness.  The  presence  of  the  disease  seems  to  be  a  spur  to 
mental  activity. 

Irregular  Gout. — Without  this  division  of  gout  some  modern  physicians 
would  be  sadly  at  sea  in  diagnosis.  It  affords  a  loophole  of  escape  when  a  patient 
insists  on  a  diagnosis,  and  however  much  Haig  is  in  error  as  to  facts  he  deserves 
the  gratitude  of  many  practitioners  for  having  popularized  the  idea  of  "uric  acid 
as  a  factor  in  disease."  There  can  be  no  doubt  that  many  patients  do  present 
symptoms  of  aberrant  or  modified  gout,  but  they  are  by  no  means  as  numerous 
as  they  are  thought  to  be.  The  gouty  poison  is  capable  of  producing  almost  as 
many  sjinptoms  and  ailments  as  is  hysteria,  but  not  all  the  sjTnptoms  which  are 
credited  to  it,  and  it  is  unfortunate  that  "uric  acid"  is  so  often  a  cloak  to 
ignorance  which  so  pacifies  the  physician  and  patient  that  a  search  for  a  true 
cause  is  discontinued.  Uric  acid  is,  as  already  stated,  in  all  probability  not  the 
cause  even  in  the  true  gouty  cases  of  many  of  the  symptoms  presented,  but  rather 
the  result  of  the  metabolic  disorders  underlying  the  illness. 

There  can  be  no  doubt,  on  the  other  hand,  that  gout  really  is  responsible  in 
many  cases  for  the  presence  of  a  very  large  nimiber  of  disorders  in  widely  ditt'crent 
organs  of  the  body,  such  as  eczema  and  other  forms  of  inflammatory  or  irritative 
changes  in  the  skin,  notably  pruritus.  Duckworth  speaks  of  a  painful  induration 
of  the  ala  of  the  nose  in  some  gouty  persons.  In  the  circulatory  system  the  changes 
caused  by  gout,  even  in  those  who  have  no  outward  manifestation  of  the  disease, 
may  be  very  notable,  as  already  pointed  out. 

In  the  article  on  gonorrheal  infection  it  has  already  been  stated  that  a  snppuratire 
urethritis  may  be  due  to  gout,  and  irritability  of  the  bladder  and  renal  stone  may 
arise  from  this  cause.  So,  too,  it  is  not  infrequent  for  diabetes  mellitus  to  develop 
in  gouty  persons  and  to  be  modified  in  its  course  by  antigout  remedies. 


GOUT  747 

Albuminuria  is  also  frequently  present  as  a  result  of  the  high  arterial  tension 
or  of  the  nephritis  produced  by  the  gouty  poison. 

Gouty  persons  often  suffer  from  sudden  and  severe  attacks  of  acute  -pharyngitis 
or  laryngitis,  and  from  acid  dyspepsia,  and  ophthalmologists  constantly  meet  with 
iritis,  conjunctivitis,  and  other  inflammatory  processes  in  the  eye  due  to  this  cause. 
So,  too,  it  often  happens  that  a  thickening  of  the  tympanic  membrane,  which 
causes  deafness,  has  its  origin  in  this  malady. 

Finally,  and  by  no  means  least  important,  gout  or  gouty  tendencies  often  cause 
furious  attacks  of  neuralgia  and  of  migraine.  Not  rarely  after  such  a  seizure  of 
pain  the  patient  feels  unusually  well,  just  as  he  does  after  a  frank  attack  of 
gout. 

Retrocedent  gout  is  a  condition  in  which  the  gouty  process  suddenly  leaves  the 
toe  or  other  joint  and  attacks  some  one  of  the  internal  viscera,  producing,  it  may 
be,  violent  purging  and  vomiting,  or  precipitating  an  attack  of  angina  pectoris. 
In  other  cases  the  patient  suffers  from  an  asthmatic  seizure.  Sometimes  a  sudden 
uremia  makes  it  appear  that  a  retrocedent  gout  has  gone  to  the  brain.  As  a  matter 
of  fact  retrocedent  gout  is  not  often  seen.  A  letter  of  inquiry  sent  by  me  to  several 
eminent  English  physicians  brought  replies  that  they  had  rarely  seen  this  accident 
occur,  although  they  have  frequently  met  with  cases,  as  we  all  have,  in  which  a  man 
subject  to  acute  gout  of  the  toe  has  had  a  gouty  angina  pectoris  after  prolonged 
freedom  from  trouble  in  the  toe. 

Diagnosis. — The  diagnosis  of  gout  when  it  affects  the  big  toe  is  a  simple  matter. 
When  present  in  the  form  of  dermal,  ocular,  otic,  or  muscular  gout,  the  history  of 
the  patient  and  the  character  of  the  attack  render  a  diagnosis  possible;  but  when 
the  polyarticular  form  of  gout  with  fever  develops,  only  careful  study  and  the 
absence  of  heart  changes  will  enable  us  to  separate  the  conditions  if  we  can  find 
no  gouty  history  and  no  gouty  signs,  as  in  tophi  in  the  ears.  Again,  there  may  be 
some  hesitancy  in  separating  gout  from  chalky  deposits  and  fixation  of  joints  of 
arthritis  deformans  in  which  the  articular  process  is  somewhat  inflammatory  and 
painful,  and  in  which  fibroid  changes  in  the  connective  tissues  about  a  joint  are 
present.  Arthritis  deformans  is,  however,  a  more  surely  progressive  malady; 
it  causes  greater  crippling  of  the  patient;  it  is  not  characterized  by  chalky  "crab's 
eyes"  and  tophi  in  the  ears,  nor  by  inflammatory  attacks  in  the  eyes  or  the  great 
toe,  nor  in  the  tendons  and  bursse. 

Many  of  the  cases  of  masked  gout  can  only  be  diagnosticated  by  the  improvement 
which  is  produced  by  proper  dietetic  measures  and  the  use  of  therapeutic  measxires 
known  to  be  beneficial  to  gouty  persons. 

As  stated  at  the  beginning  of  the  discussion  of  irregular  gout,  remarkably  various 
sjTnptoms  can  be  caused  by  this  malady,  but  all  curious  symptoms  should  not  be 
credited  to  it.  As  Duckworth  well  says:  "Without  doubt  many  morbid  states 
have  often  been  flippantly  or  erroneously  set  down  to  irregular  gout  which  owned 
no  such  designation,  and  thus  a  cloak  for  ignorance  has  always  been  at  hand  to 
throw  over  careless  observation,  ignorance,  or  wilful  misinterpretation  of  sjTuptoms. 
As  a  consequence  of  such  errors,  some  have  come  to  regard  even  truly  gouty  mani- 
festations, when  not  articular,  as  actually  non-existant,  and  to  deny  the  dependence 
of  such  upon  a  gouty  habit.  The  latter  error  is  no  more  to  be  condoned  than  the 
former,  and  it  may  be  fraught  with  mischief  to  the  sufferer." 

Prognosis. — ^The  prognosis  of  gout  is  better  when  it  develops  after  forty'  than 
if  it  appears  after  thirty  years  of  age.  In  many  cases  of  frank  gout  the  prognosis 
as  to  life  is  better  than  in  the  insidious  form,  for  the  latter  often  attacks  the  circu- 
latory and  renal  tissues.  Much  depends  upon  the  vascular  system.  If  it  is  fibroid 
the  outlook  is  bad,  and  if  it  is  not  the  mere  existence  of  gout  need  not  shorten  life 
unless  alcohol  is  abused.  Gouty  persons,  however,  are  not  good  "risks"  in  life 
insurance,  as  has  been  proved  by  several  sets  of  statistics. 


748  DISEASES  OF  Xl'TRITIOX 

Treatment. — The  treatment  of  gout  is  hygienic,  dietetic,  and  mcdicinah  A 
further  suhdivision  of  the  subject  may  be  made  into  tiiat  which  is  devoted  to  tlie 
treatment  of  an  acute  attack  and  into  those  measures  whieli  are  tai<cn  for  the 
relief  of  the  more  subacute  or  irregular  manifcstatic^ns.  The  iiygienie  measures 
which  are  to  be  employed  in  the  treatment  of  a  person  suHering  from  either  gout 
with  acute  exacerbations,  or  suppressed  gout,  consist  in  such  exercise  as  can  be 
taken  in  the  open  air  without  at  any  time  j)rodueing  more  than  healthy  fatigue. 
Exercise  taken  to  the  point  of  exhaustion  is  of  course  always  deleterious,  and  par- 
ticularly in  those  who  are  gouty,  as  it  is  prone  to  produce  an  acute  attack  or  reduce 
vital  resistance  to  such  a  degree  that  intercurrent  maladies  may  develop.  Golf, 
horseback  exercise,  and  similar  out-door  pursuits  are  therefore  exceedingly  advan- 
tageous, but  are  not  to  be  carried  to  an  excess.  These  patients  should  also  be 
directed  to  drink  water  in  as  large  a  quantity  as  may  be  taken  without  overloading 
the  stomach  at  any  one  time.  INIany  persons  can  take  half  a  glass  of  water  every 
hour  without  ])roducing  gastric  discomfort  or  interfering  with  digestion;  whereas, 
if  they  are  content  to  drink  only  at  meal  times,  but  small  quantities  of  liquid  may 
be  ingested.  Water  aids  in  producing  a  profuse  urinary  flow,  and  so  helps  to 
eliminate  impurities  from  the  body.  If  the  heart  is  not  feeble,  hot  baths  or  hot 
Turkish  baths  may  be  taken  two  or  three  times  a  week  with  advantage.  Often 
such  patients  are  greatly  benefited  by  going  to  some  of  the  health  resorts  where 
hot  springs  exist. 

The  dietetic  treatment  of  gout  consists  in  the  exclusion  of  all  sweet  wines  and 
of  fatty  or  rich  foods,  and  in  the  ingestion  of  meals  which  are  sufficiently  varied 
in  character  to  maintain  the  appetite  and  adequate  to  maintain  nutrition.  The 
patient  should,  however,  be  particularly  warned  against  an  excessive  quantity  of 
food.  In  many  instances  gouty  persons  will  be  found  to  take  quantities  of  food 
which  are  far  in  excess  of  those  which  are  required  to  provide  the  patient  with  the 
2.500  to  3000  calories  per  day  which  he  requires  for  healthy  existence.  All  wines 
and  beers  are  also  disadvantageous  for  this  class  of  patients,  and  sweet  and  sour 
wines  and  champagnes  are  peculiarly  so.  In  regard  to  individual  articles  of  food, 
it  has  been  held  in  the  past  that  red  meats  were  distinctly  more  harmful  than  white 
meats;  but,  as  has  been  pointed  out  in  discussing  the  dietetics  of  Bright 's  disease, 
this  view  of  the  relative  harmfulness  of  red  and  white  meat  is  becoming  obsolete. 
Chemical  analysis  fails  to  reveal  any  material  difference  between  them.  The 
point  of  importance  is  that  the  patient  shall  not  eat  an  excessive  quantity  of  meat, 
or  meats,  which  is  prepared  in  such  a  way  that  it  is  difficult  of  digestion,  as,  for 
example,  larded  game  birds  or  larded  beef.  Of  the  various  beverages  cocoa  is 
perhaps  the  best,  but  rich  chocolates  are  harmful.  Coffee  is  usually  considered 
much  better  than  tea.  Indeed,  Dr.  Haig  is  quite  confident  that  tea  is  an  abomina- 
tion for  the  gouty. 

In  the  way  of  treatment  by  drugs,  there  are  only  three  which  can  be  considered 
as  exercising  an  approximately  specific  influence,  namely,  colchicum,  iodine  in  its 
various  forms,  and  the  salicylates.  Of  these  the  iodides  and  salicylates  are  most 
useful  for  the  subacute  or  irregular  forms  of  gout,  while  the  colchicum  is  of  most 
value  for  the  purpose  of  combating  an  acute  paroxysm.  Most  patients  with  con- 
stant, irregular,  gouty  manifestations  do  well  if  they  take  continuously,  over  a  long 
period  of  time,  10  to  15  grains  of  salicylate  of  strontium  three  or  four  times  a  day, 
or  5  to  10  grains  of  iodide  of  potash  or  iodide  of  sodium  at  similar  intervals.  By 
this  means  gouty  sore  throat,  gouty  iritis  and  conjunctivitis,  gouty  stift'ness  of  the 
various  muscles,  and  gouty  neuralgia  and  migraine  may  be  modified  or  entirely 
relieved.  If  there  is  any  tendency  to  acidity  of  the  urine  full  doses  of  citrate  or 
acetate  of  potash,  10  or  15  grains  three  times  a  day,  should  be  given,  well  diluted 
with  water.  In  some  in.stances  the  urine  is  alkaline,  and  when  it  is  so  the  patient 
feels  lu'a\y  and  dcjircssed.     These  sjTnptoms  can  often  be  modified  by  the  use 


ARTHRITIC  DEFORMANS  749 

of  10  to  20  grains  of  benzoate  of  sodium  in  capsule  tiiree  or  four  times  a  day.  Com- 
paratively recently  novatophan  has  become  a  popular  remedy  in  the  dose  of  about 
7  grains  four  or  five  times  a  day,  given  in  tablet  form. 

Acute  paroxysms  of  gout  are  to  be  treated  by  the  administration  of  full  do.ses 
of  the  wine  of  colchicum  seeds,  repeated  in  from  six  to  twelve  hours,  the  dose  varying 
from  20  to  40  minims,  according  to  the  irritability  of  the  stomach  and  the  idio.syn- 
crasies  of  the  patient  to  the  drug.  Not  infrequently  much  better  results  will  be 
obtained  if  before  the  colchicum  a  moderate  dose  of  the  compound  extract  of 
colocynth,  such  as  10  to  20  grains  with  1  or  2  grains  of  extract  of  hyoscyamus,  is 
given  to  unload  the  bowels.  Colocynth  is  chosen  because  experience  has  shown 
that  it  seems  to  exercise  a  more  beneficial  influence  in  gout  than  any  other  purgative, 
and  the  hyocyamus  is  used  because  it  prevents  the  colocynth  from  producing 
griping  pain.  Not  infrequently  some  relief  may  be  obtained  if  the  inflamed  joint 
is  wrapped  with  lint  laden  with  a  50  per  cent,  ichthyol  ointment.  Luff  has  strongly 
recommended  the  following  application  for  the  same  purpose:  The  entire  foot  is 
surrounded  by  a  warm  pack  consisting  of  cotton-wool  saturated  with  the  soothing 
lotion,  and  then  lightly  covered  with  oiled  silk. 

^ — Sodii  bioarbonatis 5iv. 

Linimenti  belladonnae     .  .      .      .  fSiv. 

Tinctura3  opii fgiss. 

AquEe  destillatte f  Sviij. 

Equal  portions  of  this  lotion  and  hot  water  should  be  used  to  saturate  the  wool 
which  has  been  rolled  around  the  joint,  and  the  dressing  should  be  changed  every 
four  hours. 

It  is  important  to  remember  that  no  local  depleting  measures  are  to  be  instituted 
under  any  circiunstances.  Blisters,  leeches,  and  other  forms  of  bloodletting  are 
not  only  valueless,  but  dangerous,  as  they  afford  opportunities  for  infection. 

Many  cases  of  acute  and  chronic  gout  are  also  benefited  if  from  time  to  time 
they  receive  moderate  doses  of  calomel  or  blue  pill,  such  as  3  or  4  grains  of  blue 
mass  or  a  grain  of  calomel  in  broken  doses.  Many  physicians  at  the  present  time 
also  prefer  the  active  principle  of  colchiciun,  colchicine,  to  the  wine  of  colchicum 
root.  It  may  be  given  in  the  dose  of  y^y-  to  2V  of  a  grain  every  two  or  three  hours 
in  a  case  of  acute  gout,  or  four  or  five  times  a  day  in  the  subacute  varieties. 

Although  the  various  salts  of  lithium  are  largely  employed  by  some  practitioners 
for  the  purposes  of  combating  the  various  aberrant  forms  of  gout,  it  is  to  be  remem- 
bered that  the  popularity  of  these  salts  depends  more  upon  the  skilful  advertising 
of  tablet  manufacturers  than  upon  the  actual  experience  of  the  profession.  Those 
who  know  most  about  these  salts  have  found  that  the  lithium  preparations  do 
not  act  as  well  in  gout  as  do  the  salicylates  of  sodium  or  potassium,  and  the  idea 
that  lithium  has  a  peculiar  affinity  for  the  uric  acid  is,  to  a  large  extent,  blasted 
by  the  knowledge  that  lithium  has  a  greater  affinity  for  the  acid  sodium  phosphate 
in  the  blood  than  it  has  for  uric  acid ;  beautiful  test-tube  experiments  to  the  contrary 
notwithstanding. 

ARTHRITIS  DEFORMANS. 

Dej&nition. — Arthritis  deformans  is  a  chronic  disease  affecting  the  joints,  and 
characterized  by  trophic  disturbances  in  their  cartilages,  in  the  ends  of  the  bones, 
and  in  the  synovial  membranes.  It  is  to  be  distinctly  separated  from  acute  rheu- 
matism and  from  true  gout,  although  in  some  cases  it  appears  to  be  a  sec^uel  of 
acute  rheumatic  infection.  Sometimes  arthritis  deformans  is  called  "rheumatoid 
arthritis,"  or  "osteo-arthritis." 

Etiology. — Much  discussion  has  arisen  as  to  the  cause  of  this  malady,  some 
adhering  to  the  view  that  it  is  due  to  nervous  lesions  which  result  in  changes  in 


750  DISEASES  OF  NUTRITION 

the  joints,  and  others  asserting  that  it  is  the  result  of  an  infection.  Within  recent 
years  the  former  view  has  lost  in  popularity  and  the  latter  opinion  is  now  in  the 
ascendant,  although  as  yet  no  one  has  succeeded  in  isolating  a  specific  micro- 
organism. It  is  probably  produced  by  any  one  of  several  micro-organisms  and 
the  phj'sician  should  search  for  a  source  of  infection,  however  remote,  and  endeavor 
to  isolate  the  micro-organisms  there  and  in  the  joints  (see  Treatment).  The  infect- 
ing organisms  probably  enter  by  the  upper  respiratory  passages  or  j)harynx  and 
the  intestines.. 

Those  who  argue  in  favor  of  the  infectious  nature  of  the  malady  ])oint  to  the 
fact  that  the  nearby  lymph  nodes  are  often  enlarged,  as  if  combating  infection; 
that  infection  of  the  joints  by  various  micro-organisms  is  the  usual  cause  of  arthritis, 
and  that  a  considerable  portion  of  the  cases  of  arthritis  defonnans  have  had  at 
some  previous  time  gonorrhea  or  other  disease  which  is  prone  to  cause  secondary 
arthritic  lesions.  In  support  of  the  nervous  theory  we  find  that  trophic  changes 
take  place  not  alone  in  the  joints,  but  in  the  muscles  and  skin  near  the  joints  affected; 
that  pain  is  often  present  in  the  nerve  trunks,  as  in  neuritis,  and  that  diseases  of 
the  central  nervous  system  not  rarely  produce  lesions  in  the  joints  which  resemble 
those  found  in  arthritis  deformans.  Certain  French  clinicians  have  claimed  that 
definite  lesions  are  demonstrable  in  the  spinal  cord,  in  the  columns  of  GoU  in  the 
cervical  level,  and  in  the  posterior  nerve  roots  as  well.  The  difficulty  in  accepting 
the  neural  theory  is  that  there  is  no  proof  that  these  changes  are  primary  and  not 
secondary,  for  it  is  well  known  that  many  joint  affections  are  followed  by  similar 
lesions,  at  least  in  the  nerves,  skin,  and  muscles. 

Most  clinicians  divide  the  cases  of  this  disease  into  two  classes:  the  primary, 
in  which  the  arthritic  state  develops  without  any  preceding  joint  affection,  and 
the  secondary,  in  which  there  is  a  history  of  such  an  infection.  The  primary 
cases  are  those  in  which  the  disease  develops  after  a  prolonged  nervous  stress  or 
severe  physical  strain,  as  in  frequent  childbearing.  The  secondary  form  follows 
acute  articular  rheumatism  and  occasionally  develops  after  injury  to  a  single 
joint,  although  in  this  case  the  relationship  of  cause  and  effect  is  very  doubtful. 
Even  in  the  cases  in  which  acute  rheumatism  has  preceded  the  malady  this 
relationship  is  in  doubt,  and  there  is  nothing  to  prove  that  there  exists  any  closer 
tie  between  them  than  sequence  by  coincidence.  I  have  seen  it  develop  in  cases 
of  bronchiectasis. 

Statistics  as  to  the  frerjuency  of  arthritis  deformans  in  the  two  sexes  differ  greatly. 
In  Garrod's  statistics  the  disease  affected  411  women  out  of  500  cases.  Stewart 
has  recorded  40  cases,  of  which  20  were  in  women;  and  more  recently  ]McCrae 
has  reported  110  cases,  of  which  55  were  women  and  55  were  men.  ]\Iy  own 
experience  at  the  Jefferson  Medical  College  Hospital  has  been  that  nearly  all  are 
women. 

The  greatest  prevalence  of  the  disease  is  between  twenty  and  fifty  years  of  age, 
but  Moncorvo  has  collected  48  cases  of  polyarthritis  deformans  in  patients  under 
fourteen  years. 

The  disease  is  very  rare  in  the  negro  race.  In  a  clinic  rich  in  negroes  ^NlcCrae 
met  with  this  disease  in  negroes  only  four  times  in  110  cases,  which  is  all  the  more 
noteworthy  because  negroes  are  peculiarly  subject  to  other  arthritic  changes. 

Morbid  Anatomy. — What  the  changes  are  in  the  early  stages  of  this  malady  is 
not  known,  because  patients  rarely  come  to  autopsy  until  after  the  disease  has 
existed  for  a  long  period.  What  little  information  we  have  indicates  that  the 
process  is  primarily  inflammatory,  in  that  the  synovial  membranes  are  injected 
and  hypcremic.  This  is  followed  by  the  development  of  fibrous  tissue,  and  this 
again  by  the  absorption  of  the  cartilaginous  coverings  at  the  ends  of  the  bones. 
By  these  means  cartilages  become  eroded  and  the  ends  of  the  bones  become  ebur- 
nated.     Finally,  there  develops  from  the  periosteum  covering  the  ends  of  the  bones. 


ARTHRiriS  DEFORMANS  751 

bony  growths  or  knobs  which  lock  the  joints  and  because  of  the  thickened  mem- 
branes and  roughened  cartilages  increase  the  tendency  to  immobility  already 
present.  These  osteophytes  are  called  "Haygarth's  nodosities."  Associated 
with  these  changes  there  is  marked  wasting  of  the  muscles  which  govern  the  move- 
ments of  the  joint,  a  wasting  not  rarely  met  with  in  all  serious  joint  affections,  a 
glossiness  of  the  skin  covering  the  affected  joints  due  to  atrophy  of  the  glands  in 
its  deeper  layers  and  to  changes  in  the  epiderm,  and  not  infrequently  trophic 
changes  in  the  nails  which  may  be  greatly  thinned,  ridged,  or  very  brittle. 

The  changes  in  the  vertebrae  consist  in  overgrowth  of  the  articular  cartilages, 
followed  by  ossification.  The  ligaments  also  become  thickened  or  atrophied. 
Bony  formations  may  appear  on  the  edges  of  the  vertebrae,  particularly  on  their 
anterior  surfaces,  and  finally  in  this  way  the  whole  vertebral  column  becomes  an 
inflexible  pillar  composed  of  vertebral  bodies  welded  together. 

Symptoms. — The  symptoms  vary  considerably  in  the  manner  of  their  onset  and 
in  the  course  of  the  disease  in  different  cases.  The  mode  of  onsef  may  take  two 
forms:  the  slow  progressive  or  gradual  type  and  that  type  in  which  a  series  of  attacks 
of  articular  distress  occur  which  leave  behind  them  more  and  more  chronic  change 
in  the  joints.  In  some  patients  the  first  complaint  consists  in  a  sensation  of  rough- 
ness in  the  knee-joint;  the  part  feels  stiff  after  it  has  been  in  one  position  for  any 
length  of  time,  and  "cracks"  when  it  is  moved.  Not  rarely  this  is  first  noticed 
in  going  up  or  down  stairs  or  in  rising  from  a  chair.  If  the  joint  is  flexed  by  the 
physician  who  holds  the  limb,  the  cracking  can  be  felt  by  him.  The  sensation  is 
one  of  distress  more  than  of  pain. 

The  tissues  about  the  joint  are  often  swollen,  but  rarely  if  ever  reddened.  Usually 
after  one  joint  is  affected  another  becomes  involved,  and,  as  the  process  gradually 
develops,  the  patient  becomes  more  and  more  incapacitated  owing  to  the  advancing 
changes  in  the  joints  and  the  new  areas  affected. 

The  atrophy  of  the  muscles  also  increases  the  inability  to  move  about  with 
ease. 

Finally,  the  disease  involves  all  the  articulations,  large  and  small,  even  the 
vertebral  joints  being  ail'ected,  and  the  patient  is  as  completely  paralyzed  from 
fixation  as  if  suffering  from  a  widespread  multiple  neuritis.  Such  a  result,  however, 
does  not  occur  in  most  instances,  the  malady  being  less  widely  distributed. 

It  is  a  noteworthy  fact,  for  which  patients  with  this  disease  have  cause  to  be 
devoutly  thankful,  that  in  the  cases  with  greatest  fixation  of  the  large  joints  the 
small  joints  of  the  hand  often  escape,  and  when  the  hands  are  severely  affected  it 
often  happens  that  the  large  joints  are  not  involved.  In  still  other  cases  the 
disease  after  incapacitating  one  part  ceases  to  be  progressive.  The  frequency 
with  which  pain  occurs  in  these  cases  is  very  variable.  In  some  there  is  none,  in 
others  it  appears  only  when  the  parts  are  used,  as  in  piano-playing,  and  in  others 
the  pain  is  severe  and  like  that  of  neuritis. 

Free  sweating  of  the  palms  of  the  hands  and  finger-tips  often  is  present. 

Because  of  the  fact  that  the  manifestations  of  the  disease  are  often  limited  to 
one  part  of  the  body  or  to  one  kind  of  joints,  it  has  been  customary  to  divide  the 
cases  into  those  with  only  one  joint  affected,  the  mono-articular  form;  those  in 
which  several  joints  are  chiefly  affected,  the  polyarticular  type;  and  those  in  which 
the  spinal  column  is  the  chief  seat  of  the  disease,  the  so-called  spondjditis  type. 
When  the  joints  of  the  fingers  are  chiefly  affected,  so  that  they  are  locked  by  the 
growth  of  small,  bony  knobs  on  the  sides,  these  growths  are  called  "Heberden's 
nodes."  An  important  difference  between  these  nodes  and  those  due  to  the  deposit 
of  urates,  as  in  cases  of  gout,  is  that  they  are  true  bony  growths,  and  not  due  that 
the  deposition  of  urate  of  sodium  in  the  fibrous  tissues.  It  is  easy  to  see  that  this 
classification  is  purely  one  of  convenience,  and  has  no  real  pathological  reason  for 
its  existence. 


752  DISEASES  OF  N VTR IT/OX 

\\\wu  the  large  joints  are  involved,  with  associated  fixation  of  the  spine,  the 
patient  lies  in  bed  heljjless,  with  the  knees  flexed  and  the  back  so  stiff  that  it  has 
been  called  "poker  back." 

Under  the  name  of  xpondijlitis  drjarmans  von  Bechtcrcw  has  described  a  state 
of  spinal  fixation  in  which  there  is  ])ain,  compression  of  the  spinal  nerve  roots, 
and  nuisciiiar  atr()i)hy.  Ascending  spinal-cord  degeneration  is  also  jtrescnt.  It 
is  questionable  if  this  can  be  considered  a  part  of  true  arthritis  deformans.  So, 
too,  under  the  name  spondyJUis  rhizo7)ielique,  otherwise  known  as  the  Stnim])ell- 
Marie  type  of  spinal  fixation,  the  muscles  of  the  shoulder  and  hip-joints  are  invohed, 
but  severe  nervous  lesions  such  as  those  just  detailed  do  not  develop.  Osier 
believes  that  both  of  these  affections  are  forms  of  arthritis  deformans.  This  may 
be  a  correct  \'iew,  but,  if  so,  they  do  not  present  any  symptoms  common  to  arthritis 
deformans  as  it  is  generally  met  with. 

A  form  of  general  arthritis  without  exostosis,  but  with  considerable  swelling 
of  the  joints,  is  sometimes  met  with  in  children.  The  lymphatic  glands  are  dis- 
tinctly enlarged,  the  mobility  of  the  joints  greatly  impaired,  and  the  atrojihy  of 
the  muscles  well  marked.  Not  only  the  lymph  nodes  nearest  the  joints,  but  all 
the  lymphatics  may  be  swollen.  Anemia  is  marked.  To  this  condition  the  name 
"Still's  disease"  has  been  applied,  because  it  has  been  carefully  studied  by  Dr. 
Still.  Children  may  also  have  the  polyarticular  form  of  arthritis  deformans  as 
it  occurs  in  adults. 

Attention  must  be  called  to  that  type  of  arthritis  deformans  in  which  the  vertebra? 
suffer  alone.  In  such  instances  the  spine  is  fixed  and  immovable,  the  ankylosis 
producing  so  much  rigidity  that  the  patient  in  stooping  can  only  bend  at  the  hips. 
When  in  addition  to  fixation  deformity  takes  place,  the  spinal  column  may  be 
deflected  laterally  or  posteriorly,  and  the  arching  of  the  back  may  be  so  great  that 
the  head  is  bowed  till  the  chin  nearly  touches  the  chest  and  the  patient  can  only 
see  a  short  distance  ahead  by  rotating  the  eyes  upward.  Lateral  rotation  of  the 
head  in  such  a  case  is  often  impossible.  Associated  with  this  form  of  vertebral 
arthritis  there  is  often  a  good  deal  of  pain,  which  may  be  felt  not  only  in  the  back, 
but  in  the  hips  and  even  down  the  course  of  the  sciatic  nerves.  In  those  cases  in 
which  the  disease  is  limited  to  a  small  portion  of  the  spinal  column  the  case  may 
be  considered  as  one  of  tuberculous  disease,  and  the  only  means  by  which  a  positive 
diagnosis  can  be  reached  is  by  the  use  of  tuberculin,  if  no  changes  in  other  joints 
point  to  the  malady  now  under  consideration. 

Diagnosis. — When  a  well-developed,  bedridden  case  of  arthritis  deformans  is 
met  with,  the  patient  being  "fixed,"  and  the  bony  knobs  locking  the  joints,  the 
diagnosis  is  not  difficult.  The  difficulty  lies  in  the  cases  which  are  in  the  early 
stages  of  the  malady.  This  is  particularly  true  of  the  cases  which  are  of  the  acute 
or  subacute  type,  and  which  are  ushered  in  by  a  somewhat  abrui)t  onset,  with 
soreness,  stiffness,  and  pain  in  the  aft'ected  parts.  The  differentiation  of  such  cases 
in  the  first  attack  from  a  subacute  form  of  true  articular  rheumatism  may  be 
practically  imjiossible.  If  an  endocarditis  develops,  the  disease  is  proliably  rheu- 
matism, for  the  endocardium  usually  escapes  in  rheumatoid  arthritis.  Another 
point  of  differentiation  lies  in  the  fact  that  acute  articular  rheumatism  passes 
from  joint  to  joint,  often  diminishing  in  the  first  joints  as  the  others  are  involved. 
This  is  also  true  of  arthritis  deformans,  save  that  the  joints  first  affected  do  not 
get  well.  The  pain  of  rheumatism  is  greater  and  the  parts  affected  are  more  tender 
to  touch.  Finally,  if  the  articular  difficulty  persists  week  after  week,  in  the  face 
of  the  salicylates  freely  given,  if  the  temperature  creeps  along  at  about  99°,  and 
if  there  is  crackling  in  the  joints  on  fiexion,  the  diagnosis  of  arthritis  deformans  is 
probably  correct. 

Rheumatoid  arthritis  also  must  be  differentiated  from  the  arthritic  changes 
due  to  gonorrlual  infection  and  those  of  locomotor  ataxia. 


CHRONIC  RHEUMATISM  lh?> 

Prognosis. — A  well-developed  case  of  arthritis  deformans  is  absolutely  incurable 
and  the  outlook  is  gloomy  as  to  freedom  of  movement.  The  fact  that  the  disease 
is  often  characterized  by  very  slow  progress  and  by  periods  of  arrest  is  the  most 
encouraging  feature  of  these  cases. 

Treatment. — From  the  stage  of  onset  the  treatment  consists  in  the  use  of  gentle 
massage  of  the  joints  with  .50  per  cent,  ichthyol  ointment,  this  ointment  being 
also  thickly  smeared  over  the  part  between  the  times  at  which  the  rubbing  occurs. 
If  pain  is  present  acetanilid  or  antipyrin  may  be  used.  If  much  stiffness  is  present 
the  joint  should  be  baked  in  a  hot-air  apparatus  every  day  or  two.  Luff  advises 
the  persistent  use  of  guaiacol,  5  to  20  grains,  three  times  a  day  for  months.  The 
iodides  may  also  be  used. 

It  is  a  vital  mistake  to  give  these  joints  rest  as  a  part  of  treatment.  Barring 
use  to  the  point  of  fatigue  the  patient  should  be  told  to  move  the  affected  parts 
as  frequently  as  possible. 

Fresh  air  and  sunshine  are  essential  factors  in  controlling  the  anemia  often 
present.  If  a  septic  focus  can  be  found,  as  in  diseased  tonsils,  it  should  be  removed 
and  an  autogenous  vaccine  employed,  or  if  the  infection  is  mixed,  a  mixed  vaccine 
or  mixed  phylacogen.  The  patient  should  be  well  fed  to  aid  him  in  combating 
the  infectious  process.  A  valuable  remedy,  one  of  the  best  we  have,  is  syrup  of 
the  iodide  of  iron  in  30  or  60  drop  doses  three  or  four  times  a  day  well  diluted  with 
water  and  taken  two  hours  after  meals. 

When  deformity  which  interferes  with  movement  is  present  it  may  be  wise  to  cut 
contracted  tendons,  but  this  does  not  increase  mobility  of  the  joint,  for  obvious 
reasons. 

Many  patients  resort  to  hot  springs  and  hydrotherapeutic  institutes  for  relief 
from  this  disease.  Such  a  plan  of  treatment  is  good  for  the  general  health  and 
may  seem  to  arrest  the  process,  but  it  cannot  cause  a  cure,  and  if  the  patient's 
means  are  limited  it  is  useless  to  let  him  waste  them  in  such  a  futile  search  for  health. 

CHRONIC  RHEUMATISM. 

Definition. — Chronic  rheumatism  is  a  condition  characterized  by  a  chronic 
low-grade  inflammatory  process  in  the  synovial  membranes  and  fibrous  tissues 
about  the  larger  joints  which  results  in  stiffness,  soreness,  and  disability.  It 
may  or  may  not  be  a  sequence  of  acute  articular  rheumatism. 

Etiology. — The  causes  of  this  state  are  unknown.  In  many  cases  it  seems  to 
be  part  of  the  general  fibrous  changes  which  occur  in  other  parts  of  the  body  due 
to  old  age.  Exposure  to  cold  and  wet,  as  in  the  case  of  soldiers,  firemen,  and 
policemen,  seems  to  be  productive  of  the  affection.  The  malady  is  very  common 
among  old  negroes.     It  often  causes  great  crippling. 

Morbid  Anatomy. — The  chief  change  consists  in  thickening  of  the  fibrous  tissues 
about  the  joints,  but  there  is  little  effusion,  as  a  rule,  and  no  deformity  aside  from 
immobility  or  fixation  in  an  awkward  position  until  secondary  muscular  atrophy 
ensues,  as  it  usually  does  in  all  chronic  joint  affections.  Occasionally  the  articular 
cartilages  undergo  changes  and  some  crepitus  can  be  felt  on  motion. 

Symptoms. — Stiffness  and  inability  to  move  readily  are  the  chief  symptoms 
complained  of.  These  are  worse  when  there  is  a  threatened  change  of  weather. 
If  sudden  movement  is  attempted  pain  is  caused.  Rest  increases  the  stiffness 
and  exercise  greatly  decreases  it,  but,  on  the  other  hand,  sufficient  exercise  to 
limber  the  joints  is  often  very  painful,  either  at  once  or  because  of  the  exaggerated 
degree  of  stiffness  that  may  follow.  Occasionally  these  patients,  particularly 
if  they  be  women,  become  exceedingly  obese. 

Treatment. — Unlike  arthritis  deformans,  this  malady  gives  us  the  best  therapeutic 
results,  in  manv  cases,  if  the  patient  can  be  subjected  to  the  salutary  influence  of 
48 


754  DISEASES  OF  NUTRiriON 

tlie  Hot  Sitriiigs  of  Arkansas,  \'irginia,  South  Dakota,  IJaiilV,  in  Canada,  or  at 
Bath,  in  P^nghind.  The  various  sulphur  springs  are  useful  in  many  cases.  When 
these  springs  cannot  be  resorted  to  the  patient  should  have  the  affected  joints 
baked  in  a  hot-air  apparatus,  or  should  take  a  Turkish  bath  several  times 
weekly.  A  well-constructed  Turkish  bath  cabinet,  such  as  is  widely  sold  at 
present,  may  be  used  at  home.  A  50  per  cent,  ichthyol  ointment  should  be  well 
rubbed  into  the  joints  twice  a  day.  This  may  be  alternated  with  chloroform 
liniment  containing  4  drachms  of  tincture  of  belladonna  and  2  drachms  of  tincture 
of  aconite  in  S  ounces.  In  other  instances  iodine  ointment  diluted  one-half  with 
lanolin  may  be  used. 

The  use  of  drugs  internally  is  not  very  satisfactory  as  to  results.  Pain  may  be 
decreased  by  acetanilid  or  antipyrin.  The  salicylates  are  rarely  useful,  but  the 
iodides  often  cause  great  improvement.  There  is  little  use  in  dieting  these  jjatients. 
If  they  eat  and  drink  .sensible  things  the  ordinary  diet  of  health  is  the  best.  Alcohol 
should  of  course  be  used  but  little,  if  at  all. 

Warm  flannel  should  be  kept  next  the  skin,  and  cold  winds  avoided  if  possible 
by  residence  in  a  balmy  climate  in  the  winter  months. 

MUSCULAR  RHEUMATISM. 

Under  the  name  of  muscular  rheumatism  there  exists  a  condition  in  which  a 
patient  experiences  pain  and  stifl'ness  when  attempting  to  move  certain  muscles. 
This  condition  is  most  frequently  met  with  in  patients  who  become  chilled  after 
severe  exercise.  It  sometimes  develops  when  certain  portions  of  the  body  have 
been  exposed  to  cold  and  wet,  as,  for  example,  the  stiff'  neck  which  follows  sitting 
in  a  draught  of  cool  air  or  the  lumbago  which  follows  exposure  to  a  storm. 

The  exact  cause  of  muscular  rheumatism  is  not  well  understood.  It  has  been 
claimed  by  some  persons  that  the  liquids  of  the  body  contain  so  large  a  quantity 
of  toxic  materials,  produced  by  perverted  metabolism,  that  when  a  part  is  exposed 
to  cold  precipitation  of  these  toxic  materials  takes  place,  either  in  crystalline  or 
amorphous  form,  and  this  causes  stiffness  and  pain.  The  findings  of  Rosenow 
(see  Acute  Rheumatic  Fever)  indicate  that  this  affection  is  a  "  rheumatic  myositis," 
due  to  streptococci  closely  related  to  those  found  in  articular  rheumatism. 

Treatment. — The  treatment  of  muscular  rheumatism  depends  somewhat  upon 
the  condition  which  has  produced  it.  If  it  has  followed  exposure  to  cold,  a  very 
hot  bath,  a  Turkish  bath,  or  a  hot  pack  will  often  serve  to  dissipate  the  pain  and 
stiffness,  particularly  if  after  the  bath  active  massage  of  the  part  affected  is  prac- 
tised. In  still  other  instances,  particularly  if  the  onset  of  the  condition  has  been 
very  acute,  relief  is  obtained  by  acupuncture.  This  consists  in  introducing  into 
the  substance  of  the  afTeeted  muscle  a  long  needle,  which  does  good,  it  may  be, 
by  relieving  tension  in  the  sheath  of  the  muscle,  and  allowing  some  of  the  serum 
to  escape.  In  many  cases  relief  is  obtained  by  rubbing  the  affected  part  with 
chloroform  liniment,  to  which  may  be  added  tincture  of  aconite,  tincture  of  bella- 
donna, and  tincture  of  opium.  Equal  parts  of  chloral  and  camphor,  which  deliquesce 
when  they  are  mixed,  may  be  rubbed  over  the  painful  area.  Before  giving  medicines 
internally,  the  urine  should  be  examined.  If  it  is  distinctly  acid,  the  patient 
should  receive  from  10  to  20  grains  of  bicarbonate  of  potassium  in  water  tlirec  or 
four  times  a  day.  In  other  instances  similar  do.ses  of  bicarbonate  of  sodium  will 
prove  equally  efficacious.  In  still  others  it  may  be  necessary  to  administer  one 
of  the  salicylates.  Thus,  much  benefit  will  often  follow  the  use  of  10  or  15  grains 
of  strontium  salicylate  given  three  times  a  day.  Often  it  is  advantageous  to 
combine  with  this  4  grains  of  acetanilid  or  the  same  quantity  of  phenacetin  or 
antipyrin.  In  obstinate  cases,  or  in  those  in  which  the  s^Tiiptoms  frequently  occur, 
the  use  of  iodide  of  potassium  or  iodide  of  strontium  in  the  dose  of  5  or  10  grains 


RICKETS  755 

three  times  a  day  is  advantageous,  and  sometimes  the  patient  requires  the  additional 
use  of  Yujf  of  a  grain  of  colchicine  three  or  four  times  daily.  It  is  not  to  he  forgotten 
that  some  of  these  patients,  particularly  those  that  sufl'er  from  lumbago,  owe  their 
condition  to  auto-intoxication  from  the  alimentary  canal,  which  is  due  to  constiija- 
tion,  and  in  such  patients  permanent  relief  w  ill  not  be  obtained  until  the  })oweis  are 
thoroughly  moved  each  day.  In  some  cases  the  use  of  one  of  the  saline  purgatives 
is  all  that  is  necessary. 

RICKETS. 

Definition. — Rickets,  or  rachitis,  is  a  nutritional  disease  of  childhood,  consisting 
in  a  general  perversion  of  the  processes  by  which  normal  growth  takes  place.  It 
is  chiefly  characterized  by  imperfect  osteogenesis.  The  ends  of  the  bones  are  often 
larger  than  normal,  and  there  is  faulty  growth  in  the  cartilages,  muscles,  and 
tendons. 

Etiology.— Tavo  factors  are  chiefly  concerned  in  the  production  of  rickets,  namely, 
dietetic  faults  and  bad  hygienic  surroundings.  Of  these  the  most  important  are 
errors  in  diet.  On  the  other  hand,  it  would  seem  that  in  some  cases  at  least  the 
diet  may  be  correct,  yet  the  faults  in  nutrition  exist  because  the  system  cannot 
utilize  the  materials  which  are  ordinarily  employed  in  the  production  of  normal 
tissues.  The  majority  of  children  suft'ering  from  rickets  improve  as  soon  as  their 
food  is  properly  adjusted. 

In  the  article  on  Scurvy  attention  has  been  called  to  the  fact  that  while  rickets 
affects  both  rich  and  poor,  it  is  chiefly  seen  in  the  latter  class,  whereas  scur\y  in 
infancy  is  frequently  a  disease  of  the  well-to-do.  In  many  cases,  however,  scurvy 
and  rickets  exist  simultaneously. 

The  most  common  fault  with  the  diet  consists  in  the  use  of  proprietary  foods 
for  infants,  in  the  use  of  condensed  milk,  and  in  the  carrying  on  of  lactation  until 
the  period  is  past  when  the  child  can  obtain  sufiicient  nutriment  from  a  breast 
which  is  secreting  a  poor  quality  of  milk. 

It  is  interesting  to  note  in  this  connection  that  valuable  observations  ha^'e  been 
made  upon  young  animals  as  to  the  effect  of  depriving  them  of  ordinary  diet  and 
providing  them  with  one  not  suited  to  their  needs.  Thus,  Bland-Sutton  fed  lion 
cubs  with  raw  meat  and  rickets  developed.  When  a  diet  of  milk,  cod-liver  oil, 
and  powdered  bones  was  given  them  they  speedily  got  well.  Experiments  made 
upon  other  animals  have  given  like  results. 

Edlessen  holds  that  the  disease  is  of  infective  origin.  Mendel  thinks  it  depends 
on  some  change  (atrophy)  in  the  thymus  and  has  formulated  a  system  of  treatment 
based  on  the  thymic  origin  of  the  malady.  Spillman  rejects  the  chemical  theory 
and  holds  that  the  deficiency  in  lime-salts  is  a  result  and  not  the  cause  of  rickets. 
There  has  been  much  unprofitable  discussion  as  to  the  congenital  origin  of  the 
disease.  Fede  and  Finizio  found,  among  975  newborn,  4  that  might  have  been 
called  cases  of  fetal  rickets;  but  most  of  the  cases  of  so-called  fetal  rickets  are 
instances  of  achondroplasia. 

Age  and  nationality  are  factors  of  some  importance  in  the  causation  of  the 
disease.  Holt  states  that  it  is  very  common  in  the  children  of  the  poorer  class  of 
Italians  found  in  all  our  large  cities,  and  it  is  certainly  very  common  in  negro 
children.  In  both  of  these  classes  the  race  has  not  so  much  influence  as  poor  food 
and  bad  surroundings. 

The  disease  is  rarely  met  with  in  children  over  three  years  of  age,  but  the  signs 
of  its  existence  often  persist  in  the  shape  of  bony  deformities  all  through  life.  Cases 
of  rickets  have  been  reported  in  children  at  the  time  of  birth  and  as  old  as  twelve 
years.     Both  sexes  suffer  equally  severely  from  it. 

Diseases  which  impair  nutrition  may  predispose  the  child  to  the  development 


756  DISEASES  OF  XfTRITlON 

of  rickets,  but  they  do  not  produce  it.     Tims,  congenital  syphilis  may  act  as  a 
cause,  hut  is  not  directly  resi)onsible. 

Morbid  Anatomy. — While  it  is  true  that  we  know  little  of  the  underlying  cause 
of  rickets,  we  have  very  clear  and  definite  knowledge  of  its  morbid  anatomy.  In 
healthy  children  the  bones  grow  longitudinally  by  the  de\elopment  of  bony  mate- 
rials at  the  space  between  the  diaphysis  and  the  epiphysis,  and  in  breadth  by  the 
deposition  of  bony  materials  by  the  inner  layers  of  the  periosteiun.  The  medullary 
canal  is  increased  in  diameter  by  the  gradual  absorption  of  the  adjacent  bone. 
In  rickets  the  process  is  abnormal  in  that  although  the  development  of  cells  at  the 
points  of  growth  may  be  carried  on  to  excess,  the  deposition  of  mineral  matter 
to  form  bone  is  inadequate.  The  resulting  structure  is  softer  in  texture  and  more 
vascular  than  normal,  that  is  the  osteoid  tissue  is  perverted  (Fig.  120) .  It  happens, 
therefore,  that  while  the  length  and  breadth  of  the  bone  is  being  abnormally  devel- 
oped, the  lamellffi  adjacent  to  the  medullary  canity  are  being  absorbed,  thus  leading 
to  structural  weakness.  Under  these  conditions  it  is  not  difficult  to  understand 
M^hy  it  is  that  the  bones  are  unable  to  bear  the  normal  stress  and  rapidly  become 
deformed  if  any  strain  is  placed  upon  them. 


Rachitic  epiphysitis,  showing  proliferated  cells  in  the  Syphilitic  epiphysitis, 

epiphysis.     (Graupner  and  Zimmermann.) 

Again,  the  process  of  development  may  be  so  abnormal  that  areas  of  bone  are 
found  in  the  midst  of  cartilage  and  far  in  advance  of  the  edge  of  the  normal  bone 
growth,  or  the  re\'erse  holds  true,  and  in  the  midst  of  bone  there  may  be  a  carti- 
laginous mass  with  little  mineral  matter  in  it. 

Histologically  there  is  excessive  proliferation  of  the  cartilages  preliminary  to 
ossification  with  irregular  distribution  of  the  cohunns  of  cells,  excessive  vascularity, 
and  imperfect  calcification.  These  enlargements  seem  particularly  marked  at  the 
ends  of  the  long  bones  and  at  the  costal  ends  of  the  ribs  and  consist  of  this  bone-like 
(osteoid)  tissue,  which  later  solidifies  and  perjjetuates  deformities  of  which  it  was 
originally  the  cause. 

In  addition  to  the  deformit\'  of  the  long  bones  jiroduced  in  this  manner  we  find 
similar  changes  occurring  in  the  bones  of  the  head  and  pelvis.  Not  only  do  the 
fontancllcs  remain  open  for  a  longer  time  than  is  normal,  but  in  addition  the  surfaces 
of  the  bones  are  found  to  be  soft  and  porous  and  unduly  vascular.  In  some  places 
the  occipital  bone  may  be  irregularly  developed  and  spaces  exist  which  are  closed 
by  membrane  alone.    This  condition  is  called  "craniotabes."    The  frontal  bones 


RICKETS  757 

are  often  large  and  bulging,  forming  the  so-called  "bossy  frontals"  described  by  the 
English  clinicians. 

The  actual  deformities  which  result  are  bending  of  the  long  bones,  particularly 
in  the  legs;  the  development  of  pigeon-breast,  with  an  increase  in  the  anteroi)osterior 
depth  of  the  chest,  and  the  production  of  spinal  curvature.  A  ^'ery^  constant 
state  is  the  presence  of  swellings  or  enlargements  of  the  ends  of  the  ribs  where 
they  join  the  cartilages,  producing  the  knobs  or  the  so-called  "rachitic"  rosary. 
The  spleen  and  liver  are  increased  in  size  and  Mendel  thinks  this  is  compensatory 
for  the  loss  of  thymic  functions.  Mettenlieimer  and  Friedleben  describe  atrophy 
of  the  thjTnus  in  rickets. 

Symptoms. — ^The  symptoms  of  rickets,  when  the  condition  is  well  developed, 
are  very  characteristic  and  can  scarcely  be  overlooked  e\en  by  the  most  careless 
observer.  In  the  earlier  stages,  however,  the  manifestations  of  the  disease  are 
not  so  evident,  and  yet  they  are  important  in  that  they  should  place  the  physician 
in  a  position  in  which  he  can  prevent  further  advance  of  the  malady.  These 
early  symptoms  consist  in  su'eaiing  of  the  head,  so  that  the  child's  pillow^  is  wet 
with  the  perspiration,  and  restless  sleep,  with  grinding  of  the  teeth.  Partly  because 
of  the  wet  pillow^  and  partly  because  of  lowered  vitality,  rachitic  children  are  very 
prone  to  colds  and  often  suffer  from  constant  catarrh  of  various  mucous  surfaces. 
Constipation  is  usually  a  marked  sj-mptom. 

In  addition  to  these  symptoms  a  physical  examination  of  the  patient  will  reveal 
in  some  cases  in  the  early  stages  heading  of  the  ribs,  that  is,  enlargement  of  the  juncture 
of  the  costal  cartilages  and  ribs,  the  so-called  "rachitic  rosary."  The  forehead 
may  be  full  and  large  from  the  bulging  of  the  frontal  bones,  the  so-called  "bossy 
frontals,"  already  referred  to,  and  the  belly  is  bulging  and  tumid. 

If  the  condition  is  far  advanced  all  these  signs  are  more  marked,  and  in  addition 
there  may  be  found  wide-open  fontanelles  and  soft  spots  in  the  skull  due  to  cranio- 
tabes.  This  state  of  craniotabes  is  much  more  marked  in  those  cases  wdiich  suffer 
from  syphilis,  and  some  observers  have  asserted  that  it  occurs  only  in  children 
who  have  inherited  this  malady.  Auscultation  over  the  open  fontanelles  may  reveal 
a  hmnming  murmur  synchronous  with  cardiac  systole.  Anemia  may  or  may  not 
be  a  marked  sjinptom. 

The  nervous  symptoms  consist  in  laryngeal  spasm  (spasmodic  croup)  and  great 
irritability.     Epileptoid  fits  or  tetany  may  develop. 

The  shape  of  the  thorax  is  also  modified  so  that  the  lateral  diameter  is  decreased 
and  the  anteroposterior  diameter  increased.  This  gives  it  a  somew-hat  bulging 
or  "chicken-breast"  appearance.  In  the  neighborhood  of  the  ensiform  cartilage 
there  is  seen,  in  some  cases,  a  shallow  depression  of  the  costal  cartilages  and  ribs, 
which  extends  outward  and  upward  toward  the  axilla  on  both  sides.  This  depres- 
sion covers  the  space  of  from  one  to  three  ribs  and  is  called  "  Harrison's  groove." 
It  is  chiefly  due  to  protrusion  of  the  lower  ribs,  which  are  pushed  outward  by  the 
bulging  of  the  abdominal  wall.  This  deformity  is  most  marked  in  children  who 
suffer  from  spasmodic  croup  and  obstruction  of  the  upper  respiratory  passages. 
Palpation  of  the  chest  wall  may  reveal  the  fact  that  it  is  abnormally  pliable  or 
yielding. 

If  the  child  is  old  enough  to  walk  the  long  bones  become  deformed  because  they 
bend  under  the  weight  of  the  body.  For  this  reason  the  bones  of  the  legs  may  be 
bent  and  badly  curved  anteriorly  or  laterally.  There  may  be  posterior  curvature 
of  the  spine. 

Dentition  in  rachitic  children  is  usually  considerably  delayed,  and  is  accompanied 
by  gastro-intestinal  disorders,  chiefly  because  a  tendency  to  catarrh  of  these  parts 
is  always  present.  The  teeth  when  cut  are  usually  fairly  well  developed  and  do 
not  readily  decay.  This  is  in  contrast  to  the  history  of  syphilitic  infants,  who  often 
cut  their  teeth  abnormally  early  and  then  promptly  suffer  dental  decay. 


758  DISEASES  OF  NUTRITION 

Several  of  the  symptoms  described,  while  often  found  when  rickets  is  present, 
are  by  no  means  characteristic  of  this  disease,  and  occur  frequently  in  other  con- 
ditions. These  arc  the  craniotabes  of  syphilis,  the  laryngeal  spasm,  the  systolic 
cranial  murmur,  restless  sleep,  and  j;rindini;  of  the  teeth. 

Diagnosis. — Rickets  should  be  separated  from  scurvy,  with  which  disease  it  is 
very  nearly  related,  and  which  may  be  i)resent  simultaneously.  In  scurvy  the 
nutrition  of  the  mucous  membranes  and  of  the  bloodvessels  seems  to  be  chiefly 
involved,  hematoma  and  purpuric  rashes  often  develop,  and  bleeding  gums  are 
seen.  These  lesions  are  practically  never  seen  in  rickets.  There  is  great  soreness 
on  moving  the  child,  and  paraplegia  is  more  commonly  met  with  in  scurvy, 
although  in  both  states  this  palsy  may  be  pre.sent.  Again,  the  scorbutic  child 
rapidly  improves  when  given  fresh  orange-juice  and  beef-juice.  Palsy  may  be  due 
to  acute  anterior  poliomyelitis,  but  if  a  careful  study  of  the  case  is  made  it  will  be 
found  in  rickets  that  the  muscular  weakness  is  universal,  whereas  in  poliomyelitis 
it  is  limited  to  certain  groups  of  muscles  and  the  associated  rachitic  symptoms  are 
absent. 

Prognosis. — ^The  prognosis  as  to  life  is  good  so  far  as  the  rickets  itself  is  concerned. 
That  is  to  say,  death  is  never  due  to  rickets.  On  the  other  hand,  a  child  with 
rickets  is  a  fair  mark  for  every  infection  to  which  it  may  be  exposed,  and  so  the 
mortality  of  these  cases  from  intercurrent  maladies  is  high.  If  marked  deformities 
exist  they  of  course  persist  through  life,  except  they  be  in  the  extremities,  when 
they  can  be  corrected  by  surgical  procedures. 

Treatment. — From  what  has  been  said  it  is  evident  that  the  first  thing  to  be 
done  In  a  case  of  rachitis  is  to  regulate  the  diet,  and  to  see  to  it  that  the  patient 
receives  foodstuffs  which  contain  all  the  ingredients  which  are  necessary  for  the 
maintenance  of  normal  nutrition.  It  not  infreciuently  happens  that  the  milk 
which  is  given  to  the  child  is  lacking  in  mineral  ingredients  or  contains  such  an 
excess  of  casein  that  the  child's  digestion  is  disordered  and  assimilation  is  disturbed. 
The  mere  fact  that  the  child  does  not  subsist  upon  market  milk,  but  upon  milk 
which  is  obtained  by  keeping  a  cow  for  the  special  purpose  of  providing  sustenance 
for  the  infant,  is  more  indicative  of  a  dietetic  cause  for  the  rickets  than  if  the  child 
is  obtaining  milk  which  is  given  by  a  number  of  cows,  for  it  not  infrecpiently  happens 
that  the  milk  of  a  single  cow  disagrees  with  the  child  or  does  not  contain  all  the 
materials  which  are  necessary  for  its  proper  growth.  If  the  child  has  been  largely 
fed  upon  proprietary  foods,  these  should  be  eliminated  from  the  diet  list  and  fresh 
milk  and  cereals  used  in  their  place.  In  some  instances,  as  already  stated,  the 
rickets  does  not  depend  upon  a  lack  of  normal  ingredients  in  the  food,  but  upon 
the  inability  of  the  child  to  utilize  these  ingredients.  This  may  depend  upon 
digestive  disorder,  or  upon  a  disturbance  of  trophic  function.  Under  these  circum- 
stances it  is  not  only  necessary  to  investigate  the  diet,  but  to  administer  tonics 
which  will  improve  digestion,  such  as  small  doses  of  quinine,  \  to  h  grain,  twice  or 
thrice  a  day;  minute  doses  of  nux  vomica,  or  small  quantities  of  the  hypophosphites 
or  the  more  modern  elixir  of  the  glycerophosphates.  Of  the  latter  10  to  25  minims 
may  be  given  twice  or  thrice  a  day.  In  other  instances  tt-^^^  grain  of  phosphorus 
given  in  a  sugar-coated  pill  may  be  used  twice  or  thrice  a  day;  or  in  its  place  we  may 
administer  drachm  doses  of  cod-liver  oil,  or  cod-li\er  oil  in  the  form  of  a  well-made 
emulsion. 

If  anemia  is  present  5  drops  of  the  syrup  of  the  iodide  of  iron  may  be  given  to  a 
child  of  two  or  three  years  of  age  two  or  three  times  a  day.  As  constipation  is 
often  a  troublesome  s\-mptom  in  rickets,  careful  attention  must  be  paid  to  the 
state  of  the  bowels.  They  may  be  moved  either  by  the  use  of  a  little  calcined 
magnesia  and  followed  by  a  few  teaspoonfuls  of  orange-juice,  or  by  one  of  the  non- 
bitter  ])rcparations  of  cascara  sagrada,  such  as  aromatic  cascara  or  cascara  cordial. 

It  is  important  that  a  child  suffering  from  rickets  should  be  allowed  to  have 


SCURVY  '■'!» 

exercise  without  bearinj;  weight  upon  its  long  bones.  Such  a  child  siiould  not  be 
encouraged  to  walk,  but  should  l)e  placed  upon  a  rug  on  the  floor,  where  it  can 
crawl  and  roll  about.  An  endca\'or  on  the  part  of  the  parents  to  teach  such  a  child 
to  walk  when  its  bones  are  unable  to  l)ear  its  weight  results  in  deformities  which 
may  be  so  severe  as  to  require  operative  measures  for  their  relief. 

It  is  hardly  necessary  to  add  that  fresh  air  and  sunshine  are  essential  in  the  care 
of  such  children.  A  few  weeks  at  the  seashore  will  often  cause  a  remarkable 
change  in  nutrition;  whereas  the  most  skilful  dietetic  and  medicinal  treatment, 
if  carried  out  with  unfavorable  hygienic  surroundings,  may  produce  no  results 
whatever. 

In  families  in  which  rickets  is  prone  to  occur  it  is  often  wise  to  administer  to  the 
mother  during  the  later  months  of  pregnancy  the  hypophosphites  or  the  glyceroi)hos- 
phates,  and  other  nerve  and  bone  tonics,  as  by  this  means  the  antenatal  nutrition 
of  the  child  can  be  materially  influenced.  In  a  well-known  case  in  Philadelphia 
the  first  three  pregnancies  resulted  in  the  destruction  of  the  mother's  teeth  and 
in  the  birth  of  children  who  speedily  showed  rickets;  whereas,  the  last  three 
pregnancies,  during  which  a  diet  rich  in  mineral  ingredients  was  provided,  resulted 
in  the  birth  of  children  who  remained  perfectly  healthy. 

SCURVY. 

Definition. — Scurvy,  or  scorbutus,  is  a  disease  characterized  by  more  or  less 
profound  nutritional  changes  in  the  body  which  are  largely  dependent  upon  the 
use  of  certain  forms  of  unsuitable  food.  There  may  be  extravasations  of  blood 
into  the  subcutaneous  tissues,  under  the  mucous  membranes,  and  about  the  joints, 
and  there  is  often  great  spinal  tenderness  when  the  disease  occurs  in  infants. 

Etiology. — There  can  be  no  doubt  that  scurvy  is  due  entirely  to  the  use  of  food 
which  fails  to  provide  all  the  substances  needed  for  the  perfect  nutrition  of  the 
body.  Not  only  does  it  follow  the  continued  use  of  food  which  is  bad  in  the  sense 
that  it  is  unwholesome,  but  it  arises  in  those  who  are  subjected  to  a  very  limited 
diet  of  certain  kind  for  long  periods  of  time.  Prior  to  the  introduction  of  steamships 
it  was  a  prevalent  disease  upon  vessels  in  both  the  na^y  and  in  the  mercantile 
marine,  often  disabling  the  crews  and  rendering  impossible  commercial  and  explor- 
ing expeditions.  The  use  of  steam  now  causes  short  voyages,  and  the  better  method 
of  preserving  foodstuffs  provides  a  change  of  diet  almost  daily,  if  it  be  needed. 

In  certain  parts  of  Russia  scurvy  still  occurs  in  epidemics  and  is  thought  to  be 
infectious.  If  this  be  true  it  is  probably  only  because  lowered  -s-ital  resistance 
permits  an  infection  to  take  place. 

Some  investigators  ha^'e  belie\'ed  that  the  disease  arises  from  a  lack  of  vegetable 
acids  found  in  fruits  and  vegetables,  others  that  the  condition  is  due  to  an  excess 
of  sodium  chloride  in  the  blood,  and  still  others  that  it  is  due  to  the  presence  of 
certain  toxic  substances  developed  in  the  food.  Albertoni  has  recently  shown  that 
in  scurvy  there  is  a  complete  absence  of  free  hydrochloric  acid  in  the  gastric  juice, 
that  intestinal  putrefaction  is  marked,  and  that  the  absorption  of  fats  and  car- 
bohydrates is  impaired. 

Pathology  and  Morbid  Anatomy. — ^Anatomically  there  is  nothing  characteristic. 
The  condition  of  the  blood  in  scurvy  resembles  that  of  the  blood  in  ordinary 
secondary  anemia  with  a  decrease  in  the  color-index  which  is  quite  marked.  If 
the  case  is  studied  at  autopsy  hemorrhages  into  the  internal  organs  and  upon  the 
serous  surfaces  of  the  abdominal  and  thoracic  viscera  are  found  and  ulceration 
of  the  small  and  large  bowel  may  be  present.  Swelling  of  the  gums,  loosening  of 
the  teeth,  enlargement  of  the  spleen,  and  degenerative  changes  in  the  heart,  liver, 
and  kidneys  are  found.  Subperiosteal  hemorrhages  may  detach  the  periosteum 
over  the  shafts  of  the  long  bones  and  hemorrhage  into  the  joints  may  also  occur. 


700  DISEASES  OE  NUTRITION 

Symptoms. — The  symptoms  of  sc'iir\y  in  adults  l)('i;iii  witli  a  sciisu  of  (jcncral 
u'rdchedncss ,  paUor,  and  feebleness.  These  are  followed  l)y  swelliii;/  and  sponginess 
of  the  gums,  whieh  may  bleed  if  pressed  ujjon,  and  whieh  may  jiartly  co\er  the  teeth 
by  a  process  of  granulation.  The  teeth  become  loosened,  the  inoidh  becomes  foul, 
the  salivary  glands  swell,  and  iKtechias  appear  o\'er  the  surface  of  the  body.  The 
skin  is  dry  and  badly  nourished,  and  extravasations  of  blood  may  take  place  into 
the  sheaths  of  the  muscles  and  joints  or  beneath  the  periosteimi  of  the  long  bones. 
These  lesions  at  times  cause  patches  of  hardness  or  induration  in  the  muscles  of 
the  thighs  or  calves.  I  saw  this  well  developed  in  an  adult  patient  whom  I  had  in 
the  wards  of  St.  Agnes'  Hospital  many  years  ago. 

Infantile  scurvy,  sometimes  called  "Barlow's  disease,"  is  an  interesting  result 
of  modern  life.  As  seamen  have  escaped  the  disease  by  a  better  diet,  babies 
have  fallen  victims  to  it  as  a  result  of  feeding  them  with  artificial  foods,  and 
these  babies  are  not,  as  a  rule,  the  children  of  the  poor,  but  the  offspring  of 
the  rich. 

It  is  only  within  the  last  decade  that  the  possibility  of  scurvy  occurring  in  young 
children  has  been  generally  recognized  by  the  profession.  During  this  period, 
howe\'er,  evidence  has  been  presented  which  shows  very  clearly  that  scurvy  is  by 
no  means  a  very  rare  affection  in  early  life,  and  that  it  often  manifests  itself  in 
such  a  way  as  to  lead  the  physician  to  make  a  ^■ery  erroneous  diagnosis  when  the 
patient  is  first  brought  to  him. 

Perhaps  the  most  frequent  error  in  diagnosis  under  these  circumstances  is  that 
the  child  is  suffering  from  muscular  or  articular  rheumatism;  this  decision  being 
reached  by  reason  of  the  fact  that  the  child  seems  to  suffer  great  pain  upon  move- 
ment, and  sometimes  has  a  moderate  degree  of  fever. 

The  characteristic  symptoms  of  scurvy  in  a  young  child,  when  they  are  well 
developed,  are  so  pathognomonic  that  it  is  difficult  to  see  how  an  error  in  diagnosis 
can  be  made  if  the  physician  is  acquainted  with  the  possibility  of  the  occurrence 
of  this  disease.  Like  all  diseases,  however,  instances  are  met  with  in  which  many 
of  the  characteristic  sjTiiptoms  are  entirely  absent,  and  it  is  not  uncommon  for 
the  painful  manifestations  .spoken  of  to  be  the  only  evidence  of  the  malady.  In 
still  others,  we  find  a  peculiar  spongy  state  of  the  gums,  which  tend  to  bleed  when 
lightly  touched,  and  which  are  frequently  so  swollen  that  teeth  which  have  recently 
broken  through  the  gimi  are  speedily  covered  by  the  overgrowth  of  the  mucous 
membrane,  the  edges  of  which,  about  the  teeth,  frequently  look  as  if  they  were 
composed  of  tiny  blebs  of  blood  of  a  dark  color.  Another  sjTiiptom  of  scurvy,  which 
is  by  no  means  as  constant,  and  yet  which  is  equally  characteristic,  when  it  occurs, 
is  the  development  of  petechiae  in  dift'erent  portions  of  the  body,  very  frequently 
about  the  ankles  and  feet.  In  still  other  cases  subperiosteal  hematoma  develops 
with  surprising  rapidity,  and  as  pain  on  movement  and  the  development  of  great 
swelling  are  frequently  first  noticed  after  a  fall  or  a  blow,  it  not  rarely  occurs  that 
the  physician  is  led  into  the  belief  that  traumatism  is  the  cause  of  the  illness, 
without  recognizing  the  fact  that  it  has  played  but  a  small  part  in  causing  the 
sudden  de^•elopment  of  a  state  which  really  indicates  gra^-e  systemic  conditions. 
It  is  true  that  these  subperiosteal  hematomata  ha\e  been  chiefly  reported  by  French 
clinicians,  and  have  been  rarely  seen  in  this  country;  whereas,  on  the  other  hand, 
considerable  extravasations  of  bloody  serum  have  been  met  with  in  the  loose  tissues 
after  exposure  to  injuries  which  in  the  healthy  infant  would  produce  no  sjiiiptoms 
whate\-er.  Such  a  hematoma  may  have  great  medico-legal  importance.  Paraplegia 
may  also  be  present. 

The  peculiar  characteristics  of  scurvy  in  infants  are  the  ^•e^y  grave  appearance 
of  the  child  Avhen  suffering  from  the  disease  in  its  severe  froms,  the  rapidity  with 
which  it  improA'es  under  proper  treatment,  and  the  rarity  with  which  death  occurs 
as  the  direct  result  of  the  malady,  since  a  fatality  is  usually  produced  by  some 


SCURVY  761 

intercurrent  disease.  Reincrt  has,  however,  recorded  a  fatal  case  \\itli  red  cells 
at  976,000  and  hemoglobin  at  17  per  cent. 

Scorbutus  in  infancy  is  distinctly  a  disease  of  the  children  of  the  well-to-do  in 
distinction  from  rickets  which,  on  the  other  hand,  seems  to  he  a  disease  of  the 
poor.  Clinical  experience,  I  think,  indicates  that  seorljutic  cases  are  rarely  brought 
to  hospital  dispensaries  while  rachitic  cases  are  constantly  seen.  On  the  other 
hand,  .scorbutic  cases  are  not  uncommonly  met  with  in  private  practice.  This 
clinical  fact  seems  to  carry  out  certain  theories  which  have  been  advanced  in  regard 
to  rickets  in  a  way  which  is  interesting.  It  is  not  many  years  since  everyone 
believed  that  rickets  Avas  due  to  a  deficient  cjuantity  of  bone-forming  material  in 
the  food  of  a  child,  but  since  that  time  other  clinicians  lune  stated  their  belief 
that  more  commonly  it  depends  upon  inability  of  the  child  to  assimilate  and  utilize 
the  ingredients  in  its  food  which  it  needs  for  projoer  bone  groA\th.  Or,  in  other 
words,  the  fault  lies  not  with  the  food,  but  with  the  child.  Among  the  poor  this 
inability  is  probably  due  to  unhealthy  surroundings  and  a  general  lack  of  sanitation 
which  interferes  w'ith  deA^elopment.  On  the  other  hand,  such  influences  are  not  at 
work  among  the  children  of  the  well-to-do,  but  these  children  often  recei\e,  for 
long  periods  of  time,  the  various  artificial  foods  which,  in  manj'  instances,  they  are 
incapable  of  digesting;  and  not  only  this,  but  no  change  is  made  in  their  diet  for 
months,  either  in  the  quantity  of  the  various  ingredients  which  it  contains,  or  in 
their  quality.  These  children,  therefore,  suffer  from  the  nutritiAC  changes  which 
come  on  as  a  result  of  a  limited  and  fixed  diet  with  no  variation;  whereas,  the 
children  of  the  poor,  who  often  have  too  great  a  variation  in  their  diet,  rarely 
present  scorbutic  symptoms  and  often  do  manifest  distinct  rachitic  sjoiiptoms. 

Diagnosis. — Physicians,  in  the  presence  of  obscure  illness  occurring  in  early 
childhood,  should  remember  the  possibility  of  either  one  of  these  affections  being 
the  underlying  cause  for  the  manifestations  of  disease,  and  thoroughlj-  investigate 
the  question  of  diet  before  administering  remedies,  such  as  the  salicylates  for 
rheumatism,  iron  for  the  blood,  or  bromides  for  nervous  irritation. 

As  has  been  well  pointed  out  by  a  niunber  of  writers,  scurvy  is  not  infrequently 
confused  with  rheumatism  and  rickets,  and  sometimes  with  A-arious  forms  of  specific 
arthritis.  The  loss  of  power  may  lead  to  a  diagnosis  of  anterior  poliomj'elitis. 
So,  too,  cases  are  recorded  in  wdiich  a  diagnosis  of  sj'philitic  epiphysitis,  or  sarcoma 
of  the  femur  or  osteomyelitis  or  deep  abscess  has  been  made  when  scurvy  was  the 
cause.  The  bloody  urine  of  scurvy  has  given  rise  to  a  diagnosis  of  nephritis,  and 
the  bloody  stools  to  one  of  dysentery  or  ileocolitis.  The  subcutaneous  extravasa- 
tions of  blood  have  also  misled  the  physician  into  a  diagnosis  of  purpura  hemor- 
rhagica, and  in  one  instance,  to  the  writer's  knowledge  it  is  quite  possible  that  the 
ecchymoses  which  were  found  on  a  child's  body  and  which  were  thought  to  lend 
force  to  a  charge  of  homicide,  were  due  to  this  form  of  malnutrition.  When  pain 
and  bloody  extravasations  take  place  in  the  abdominal  cavity,  the  diagnosis  of 
intestinal  obstruction  may  be  made  if  care  is  not  exercised. 

Treatment. — The  treatment  of  scurvy  in  adults  consists  in  providing  good  and 
varied  food,  with  plenty  of  oranges  or  lemons  and  green  vegetables.  Sunshine 
and  fresh  air  are  also  essentials.  Arsenic  and  iron  may  be  given  as  hematics. 
If  digestion  is  impaired  it  should  be  aided  by  hydrochloric  acid  and  pepsin  or 
lime-juice  and  pepsin.  For  the  lesions  in  the  mouth  a  chlorate  of  potash  and  myrrh 
mouth-wash  (see  Stomatitis)  may  be  used. 

If  the  disease  occurs  in  a  child  it  is  to  be  treated  by  changing  the  food  and  by 
using  raw  milk  instead  of  sterilized  milk.  Beef-juice  squeezed  from  a  half-cooked 
steak  and  orange-juice  are  also  very  useful. 


762  DISEASES  OF  NVTRITIOX 

OBESITY. 

Definition. — Tlie  term  obesity,  or  adiposity,  is  used  to  deserihc  a  state'  in  w  iiicii 
an  individual  suffers  from  an  excessi\-e  deposit  of  fat  in  those  jjarts  of  the  body 
where  a  moderate  amount  of  fat  is  found  in  health.  In  its  advanced  forms  fat 
is  also  deposited  in  parts  where  it  is  never  found  in  the  normal  state. 

Etiology. — It  must  be  clearly  understood  that  the  mere  presence  of  an  unusual 
amount  of  fat  does  not  in  any  way  indicate  ill-health  or  that  the  functicjus  of  the 
body  are  perverted.  In  many  instances  a  considerable  degree  of  obesity  exists, 
because  it  is  the  natural  state  of  the  individual.  In  others,  however,  the  deposition 
of  fat  in  excess  is  a  manifestation  of  disease  or  at  least  of  perverted  function. 

In  the  first  class,  of  what  may  be  called  normally  obese  persons,  the  condition 
arises  from  inherited  tendency.  It  is  in  this  class  that  we  find  individuals  who 
have  never  been  heavy  eaters  and  who  for  years  have  deprived  themselves  of  foods 
of  which  they  are  fond,  but  still  gained  weight.  In  another  class  it  develops  from 
overeating  and  lack  of  exercise,  and  in  the  third  class  it  is  due  to  disorders  of  metab- 
olism, whereby  foodstuffs  are  not  properly  dealt  with  by  the  economy  after  they 
are  ingested. 

These  three  types  are  worth  recalling,  because  when  a  patient  seeks  relief  from 
obesity  much  depends  upon  the  type  to  which  he  or  she  belongs,  as  to  advice, 
prognosis,  and  treatment. 

Symptoms. — It  is  not  necessary  to  describe  all  the  symptoms  of  obesity,  for  the 
manifest  increase  in  the  size  of  the  patient  determines  the  diagnosis  of  an  excess  of 
fat.  There  are,  however,  certain  other  symptoms  which  are  of  importance,  not 
only  because  they  are  part  of  the  symptom-complex  of  obesity,  but  also  because 
their  presence  determines  the  degree  to  which  the  excess  of  fat  is  really  annoying 
or  harmful.  A  symptom  usually  complained  of  by  the  patient  is  dyspnea  on 
exertion,  which  arises  from  the  fact  that  the  heart  and  lungs  are  put  under  stress 
because  great  muscular  activity  is  needed  to  mo\'e  the  hea\'y  bod\'.  This  dyspnea 
is  also  due  to  the  fact  that  the  vascular  network  is  greater  in  the  obese  than  in 
those  who  are  lean,  and  therefore  the  heart  has  to  drive  the  blood  through  a  greater 
number  of  bloodvessels.  Thirdly,  the  heavy  deposits  of  fat  on  the  chest  walls, 
in  the  omentum,  in  the  mesentery,  about  the  diaphragm,  and  around  the  heart 
interfere,  mechanically,  with  the  free  action  of  the  respiratory  and  cardiac  muscles. 
In  many  cases  of  severe  obesity  the  layers  of  fat  are  projected  between  the  cardiac 
muscular  fibres,  and  thus  seriously  impede  its  movements,  forming  the  so-called 
"fatty  heart  of  the  obese,"  which  is,  of  course,  a  very  different  state  from  the  true 
fatty  heart  of  myocardial  degeneration.  The  inilse  is  often  small  and  rapid.  The 
arterial  tension  is  also  lower  than  normal,  as  a  rule. 

While  many  of  these  patients  are  mentally  and  physically  slow  and  somewhat 
somnolent,  others  are  active  and  restless  and  even  unduly  wakeful. 

Next  to  the  dyspnea  the  chief  complaint  is  of  consfipafion  or  indigestion  and 
excessive  sweating.  Some  cases  of  obesity,  however,  have  a  digestive  sy.stem  all  too 
good. 

In  some  cases,  too,  there  is  an  excess  of  urates  in  the  urine,  and  these  cause 
vesical  irritability,  chiefly  because  the  larger  surface  of  the  body  and  the  free  perspi- 
ration cause  a  great  loss  of  fluid,  and  this  in  time  results  in  a  scarcity  of  urinary 
flow  with  consequent  concentration  of  the  urinary  solids. 

Treatment. — The  first  point  in  treatment,  as  von  Noorden  has  said,  is  to  determine 
whether  we  shall  diminish  the  fat  already  present  or  content  ourselves  with  the 
pre\enti()n,  if  possible,  of  an  increase  in  the  obesity.  As  a  rule,  the  patient  is 
not  content  with  a  plan  of  treatment  which  does  not  actually  diminish  the  fat, 
partly  because  he  has  delayed  consulting  a  physician  until  the  condition  is  far 
beyond  wliat  he   desires.      This  is  particularly  the  case  with  women  who  have 


OBESITY  703 

arrived  at  middle  life  and  who  begin  accumulating  weight  at  the  time  of  late  child- 
bearing,  or  in  other  cases  immediately-  after  marriage.  These  patients  arc  often 
normally  fat — that  is  to  say,  their  condition  is  physiological — and  they  should  be 
content  in  the  majority  of  cases  to  try  to  p^e^•ent  further  obesity,  rather  than  to 
remove  fat  already  in  existence.  Such  patients  are  often  not  unduly  fat,  and  in 
their  desire  to  maintain  a  "  girlish  figure"  Are  willing  to  resort  to  almost  any  measure 
to  become  thin.  Indeed,  women  in  the  fashionable  walks  of  life,  with  little  to 
think  about,  often  make  their  lives  miserable  and  destroy  good  health  of  mind  and 
body  by  endeavoring,  on  the  one  hand,  to  get  thin,  or,  on  the  other  hand,  to  get 
stout. 

In  such  cases  the  physician  should  advise  against  severe  measures,  point  out 
that  the  plumpness  is  natural,  and,  if  need  be,  assert  that  it  is  better  to  be  in  good 
health,  and  a  little  more  weighty  than  the  average  woman,  than  to  be  in  bad  health 
and  slender.  I  have  seen  many  splendid  specimens  of  healthy  womanhood  made 
physical  wrecks  by  ill-advised  efforts  to  get  thin. 

The  great  difficulty  with  all  plans  of  treatment  for  the  reduction  of  fat,  in  those 
women  who  desire  to  be  slim  for  the  sake  of  canity,  is  that  no  plan  can  be  so  nicely 
adjusted  as  not  to  remo^ve  fat  from  where  its  presence  is  needful  to  good  looks. 
With  the  decrease  in  the  bulkiness  of  the  hips  and  waist  a  hideous  leanness  of  the 
chest  and  mammary  glands  ensues  and  leaves  these  parts  covered  with  a  skin 
thrown  in  MTinkles  by  disappearing  fat,  so  that  a  well-preserved  woman  of  middle 
age  is  soon  converted  into  a  hag.  Further  than  this,  pads  of  fat  keep  organs  in 
place,  and  those  who  wilfully  remove  these  pads  may  subsequently  suffer  from 
floating  kidney,  gastroptosis,  uterine  disorders,  and  constipation. 

There  is  a  sad  lack  of  knowledge  on  our  part  as  to  the  metabolism  of  obesity  and 
nutrition  in  general,  and  the  patient  and  physician  must  be  careful  how  they 
attempt  to  disarrange  processes  so  intricate  and  important. 

On  the  other  hand,  it  is  often  necessary  to  arrest  a  process  which  is  manifestly 
excessive  and  in  need  of  control. 

In  young  persons  whose  nutritive  processes  are  still  in  a  formative  stage  and 
who  are  obese,  w"e  should  not  reduce  weight  already  present,  but  simply  try  to 
prevent  an  abnormal  increase.  This  holds  true  of  those  persons  in  later  life  who 
give  a  history  of  having  ahvays  been  fat.  It  is  ^ery  unwise  to  ignore  this  rule  if 
advanced  years  are  already  upon  the  patient,  for  under  these  conditions  the  effects 
of  age  and  the  efforts  at  reduction  may  produce  disastrous  nutritional  changes. 

The  most  favorable  period  of  life  for  reduction  in  weight  is  from  twenty-five 
to  forty  years  of  age. 

Before  ordering  a  diet  and  mode  of  life  the  patient  should  be  subjected  to  a 
very  careful  physical  examination;  the  urine  should  be  repeatedly  examined,  and 
the  state  of  the  heart  and  vascular  system  carefully  noted.  If  the  urine  contains 
albumin  and  sugar  a  reduction  treatment  is  contra-indicated,  and  if  the  heart  is 
weak  from  myocardial  degeneration  and  if  the  vessels  are  fibroid  it  is  dangerous 
to  institute  a  plan  of  this  sort. 

When  it  is  determined  that  the  patient  is  in  normal  health  as  to  his  vital  organs 
the  treatment  for  the  prevention  of  increase  is  to  be  instituted,  the  patient  being 
informed  that  a  good  result  cannot  be  reached  by  a  sudden  and  rapid  process, 
and  that  patience  and  persistence  are  necessary  for  really  valuable  results. 

The  first  factor  is  exercise  taken  to  the  degree  of  moderate  fatigue.  Many 
patients  take  it  to  excess,  and  then  not  only  eat  and  drink  heavily,  but  lie  down 
and  rest  while  the  nervous  system  lazily  permits  A-ital  oxidizing  processes  to  go  on 
too  slowly,  and  so  more  weight  is  gained  than  lost. 

In  many  cases  no  material  reduction  in  fat  can  be  attained  unless  the  patient 
can  be  treated  in  a  sanatorium,  or  at  least  in  some  place  where  an  absolute  diet 
can  be  maintained  for  a  long  period  of  time.     It  is  not  sufficient  to  order  a  reduced 


764  DISEASES  OF  WTRITIOX 

diet  and  but  little  to  drink  and  iinioh  exercise.  Such  aids  to  reduction  in  weight 
will  not  in  the  ordinary  case  produce  much  improvement,  l)ecause  the  jiatient  is 
not  Milling  to  persist  in  the  annoyance  of  such  a  strict  diet  for  a  suflieieut  length 
of  tiiue  to  estiiblish  a  new  nutritional  abscissa.  Unless  the  state  of  reduced  weight 
is  maintained  for  a  long  period  the  patient  often  gains  more  flesh  on  returning  to 
the  ordinary  diet  than  if  no  attempt  at  reduction  had  been  made. 

The  order  for  actual  reduction  of  weight  consists  in  cutting  from  the  diet  list 
all  sugars  and  sweet  articles,  all  fats  and  riclily  jjrepared  foods,  and  in  the  prescribing 
of  lean  meat,  and  of  vegetables  which  are  bulky  but  contain  little  starch.  Celery, 
lettuce,  string  beans,  spinach,  cabbage,  cauliflower,  and  limited  amounts  of  tomatoes 
may  be  permitted;  whereas  potatoes,  bread,  peas,  and  beans  are  to  be  forbidden. 
All  alcoholic  drinks  'are  to  be  avoided,  because  the  alcohol  has  to  be  oxifiized  in 
the  body  and  so  prevents  an  active  oxidation  of  the  foodstuffs  and  tissues.  Alcohol 
is  also  contra-indicated,  because  it  stimulates  the  digestive  organs  and  so  increases 
the  desire  for  food. 

If  the  avoidance  of  the  fattening  foods  named  above  does  not  prevent  an  increase 
in  weight,  then  a  more  rigid  diet  must  be  arranged.  The  patient  is  not  to  be  given 
all  the  food  he  desires,  but  must  suil^^er  from  pri\ation  and  hunger.  Instead  of 
ordering  an  amount  of  food  which  will  give  the  2500  to  3000  calories  necessary 
for  comfortable  existence,  an  amount  calculated  to  allow  about  2000  calories  or 
less  must  suffice. 

For  breakfast  the  patient  is  allowed  3  ounces  of  lean  meat,  1  ounce  of  bread 
with  no  butter,  and  a  cup  of  tea  or  coffee  with  no  milk  and  no  sugar,  the  sweetening 
being  done  by  the  use  of  saccharin.  At  an  early  luncheon  a  single  soft-boiled  egg 
may  be  given  with  an  ounce  of  bread.  At  dinner  a  cup  of  clear  soup,  such  as 
consomme  or  Julienne  (but  no  thickened  soup  or  puree),  may  be  allowed,  followed 
by  2  ounces  of  fresh  or  salt  fish,  and  this  by  2  or  3  ounces  of  lean  meat.  At  this 
meal  small  quantities  of  the  various  green  vegetables  already  named  may  be  taken. 
The  dessert  should  consist  of  some  fresh  fruit,  such  as  an  apple,  an  orange,  a  grape 
fruit,  or  a  pear.  In  the  middle  of  the  afternoon  a  glass  of  milk  or  a  cup  of  tea 
with  a  thick  Avater  cracker  may  be  given,  and  at  supper-time  3  ounces  of  lean  meat, 
some  lettuce  with  oil  and  A'inegar,  celery,  2  ounces  of  toasted  bread  or  zweibach 
or  crackers  may  be  given.  At  bedtime  a  biscuit  and  a  glass  of  milk  may  be  allowed. 
While  excessive  drinking  of  water  is  unAvise,  the  patient  should  not  be  dci)ri\cd 
of  Avater  to  such  extent  that  he  suffers  from  thirst  or  has  not  sufficient  liquid  in 
his  body  to  carry  out  to  the  full  every  physiological  function.  Although  overfilling 
the  tissues  Avith  water  Avill  make  the  patient  appear  fat,  a  certain  amount  of  fluid 
is  necessary  to  healthy  life. 

In  the  Avay  of  drugs  there  is  but  one  remedy  AAhich  exercises  a  great  influence 
in  reducing  flesh,  and  that  is  the  thvToid  gland.  This  substance  does  not  reduce 
the  Aveight  of  all  cases  of  obesity,  and  often  fails  unless  it  is  given  in  doses  which 
are  so  large  as  to  cause  distinct  cardiac  feebleness.  The  doses  usually  given  vary 
from  2  to  6  grains  of  the  extract  of  the  gland  once,  tAvice,  or  thrice  a  day.  It  is 
important  to  giA'e  a  large  amount  of  nitrogenous  food  at  the  same  time,  for  the 
thyroid  causes  a  loss  of  nitrogenous  tissue  in  the  body  as  Avell  as  a  loss  of  fat.  Small 
doses  of  strychnine  and  of  digitalis  are  also  useful  to  protect  the  heart  from  depres- 
sion. The  patient  should  be  Avarned  against  severe  exercise  Avhile  using  this  drug, 
and  often  Avill  do  best  if  confined  to  bed  and  given  massage  and  electricity. 

ADIPOSIS  DOLOROSA. 

Under  the  name  of  adiposis  dolorosa  my  colleague,  F.  X.  Dercimi,  first  described 
in  1SS9  a  condition  in  which  masses  of  fat  are  deposited  in  different  parts  of  the 
body,  cliicHy  on  the  chest,  arms,  buttocks,  and  legs.    These  formations  are  usually 


SCLERODERMA  705 

symmetrical,  and,  as  the  name  implies,  are  accompanied  by  neuralgic  pains  which 
vary  from  slight  dartings  to  severe  sufl'ering.  The  disease  is  of  unknown  origin, 
and  affects  women  in  or  past  middle  life,  as  a  rule.  The  deposits  on  the  extremities 
are  usually  firm  and  e^'en  brawny,  but  they  may  be  so  soft  as  to  be  pultaceous  in 
character.  So  far  the  best  results  in  its  treatment  have  been  obtained  by  the  use 
of  thjToid  gland  to  the  point  of  tolerance.  The  condition  is  quite  uncommon, 
but  a  considerable  muuber  of  cases  have  been  reported. 

OSTEITIS  DEFORMANS. 

Osteitis  deformans  is  sometimes  called  "Paget's  disease."  It  is  characterized 
by  enlargement  and  softening  of  the  shafts  of  the  long  bones,  by  pain  and  deformity. 
The  bones  of  the  face  are  not  affected,  but  the  bones  of  the  rest  of  the  head  are 
often  involved.  A  careful  examination  of  the  long  bones  in  a  case  of  this  kind 
reveals  the  presence  of  a  rarefying  osteitis  associated  with  the  development  of 
new  but  imperfect  lamellae  in  the  bones.  The  face  has  a  curious  triangular  appear- 
ance because  of  the  broadening  of  the  upper  portion  and  the  narrowness  of  the  chin. 
By  the  yielding  of  the  bones  under  pressure,  not  only  the  tibiae  but  the  femurs 
also  undergo  great  deformity,  so  that  an  extreme  degree  of  bow-legs  develops. 
Occasionally,  the  bending  of  these  bones  is  forward  or  backward.  There  is  also 
some  spinal  curvature.  Osteitis  deformans  rarely  develops  before  the  fiftieth 
year.    No  treatment  which  has  yet  been  discovered  is  of  any  value. 

HYPERTROPHIC  PULMONARY  OSTEO-ARTHROPATHY. 

This  is  a  condition  first  recognized  by  Bamberger,  but  the  name  was  given  by 
Marie.  It  does  not  aft'ect  the  bones  of  the  head  or  of  the  face,  nor  the  long  bones 
of  the  arms  or  leg.  In  every  instance  it  develops  in  association  with  chronic 
pulmonary  disease,  such  as  chronic  bronchitis,  bronchiectasis,  fibroid  lung,  and 
chronic  emphysema. 

The  symptoms  consist  in  the  enlargement  of  the  hands  and  feet,  particularly 
about  the  small  joints.  The  growth  of  the  nails  is  often  influenced  so  that  they 
are  thickened  and  incurvated. 

LEONTIASIS  OSSEA. 

Leontiasis  ossea  is  a  disease  in  which  there  is  a  development  of  multiple  osteo- 
phj-tes  or  s\Tnmetrical  enlargement  in  the  bones  of  the  cranium,  and  sometimes 
in  those  of  the  face.     It  is  a  very  rare  affection. 

SCLERODERMA. 

Scleroderma  is  a  chronic  disease  characterized  by  localized  or  general  stiffening 
or  rigidity  of  the  skin,  which  is  usually  pigmented,  and  which  seems  to  be  bound 
over  the  tissues  beneath  it  in  much  the  same  manner  that  a  leather  cover  is 
sometimes  placed  over  a  wooden  or  metal  object.  In  some  instances  the  scleroder- 
matous process  is  sharply  circumscribed.  In  other  cases  it  shades  off  into  the 
surrounding  tissues,  and  may  have  a  slightly  reddened  edge. 

The  first  sjonptom  usually  noticed  by  the  patient  is  stiffness  of  the  part  affected, 
which  gradually  increases  until  movement  may  become  almost  impossible.  The 
skin  undergoes  atrophic  changes,  and  becomes  silvery  and  shiny  in  appearance, 
with  a  certain  amount  of  yellowish  or  light-brown  'discoloration.  When  the  disease 
affects  the  skin  of  the  extremities,  it  may  cause  much  interference  with  the  move- 
ment of  the  large  joints,  and  be  followed  by  atrophy  of  the  muscles  underlying 


7()(5  DISEASES  OF  NUTRITION 

tlie  area  iinohcd.  The  lesions  most  commonly  take  place  in  the  skin  of  the  neck, 
in  the  neifilihorliood  of  the  shoulders,  and  o\er  the  back  and  chest.  It  not  infre- 
quently attacks  the  skin  of  the  face.  The  general  health  is  not  seriously  impaired. 
There  may  be  some  local  discomfort,  with  a  sense  of  formication,  or  tingling.  The 
skin  is  exceedingly  dry,  and  rarely  sweats. 

Treatment. — In  the  way  of  treatment  thyroid  extract  has  been  highly  recom- 
niciidcd  by  certain  clinicians.  Locally  the  parts  should  be  treated  by  massage 
and  the  local  application  of  oils,  which  should  be  of  a  sedative  character.  Occa- 
sionally, however,  if  the  process  is  exceedingly  chronic,  it  may  be  advisable  to 
apply  turpentine  diluted  with  six  times  its  amount  of  sweet  oil.  Even  with  the 
best  of  treatment  the  prognosis  is  anything  but  favorable  as  to  cure,  although  the 
spread  of  the  malady  may  be  delayed. 


OCHRONOSIS. 

Ochronosis  is  an  extremely  rare  disease  characterized  by  the  development  in 
the  sclerotic  coat  of  the  eyes  of  a  semilunar  patch  of  black  pigment  which  does 
not,  however,  involve  the  entire  sclera.  A  somewhat  similar  discoloration  of  the 
cartilage  of  the  ears  and  of  the  tendons  of  the  hands  also  occurs,  and  the  urine  is 
dark  in  hue  at  times,  but  by  no  means  constantly.  Sometimes  there  is  an  associated 
arthritis.  The  disease  does  not  shorten  life,  nor  impair  the  health,  but  in  the 
presence  of  alkaptonuria,  the  copper-reducing  substance,  may  mislead  the  physician 
into  making  a  diagnosis  of  glycosuria  or  diabetes  mellitus.  Occasionally  intense 
black  patches  develop  in  the  skin  and  are  distinctly  limited  in  outline. 


AINHUM. 

Ainhum  is  a  peculiar  trophoneurotic  disease,  commonly  affecting  the  feet  of 
negroes  and  other  dark-skinned  races.  It  is  widely  distributed  in  Africa,  i)articu- 
larlj'  along  the  west  coast,  and  it  occurs  in  India,  and  Brazil.  It  is  a  rare  affection 
among  negroes  in  the  United  States.  The  disease  usually  begins  in  the  little 
toe  of  one  foot  or  both  feet,  as  a  narrow  fissure  or  groove,  on  the  plantar  surface 
at  the  junction  of  the  toe  and  foot.  The  groo\'e  surrounds  the  toe  and  slowly 
deepens  until  eventually  it  is  amputated.  Microscopic  examination  shows  that 
the  constricting  band  consists  of  dense  fibrous  tissue.  As  it  tightens,  the  toe 
becomes  very  much  enlarged,  and  disorganized  before  it  finally  separates.  As  a 
rule,  the  disease  is  confined  to  the  one  toe,  although  other  toes  may  be  successively 
attacked  and  the  disease  may  even  appear  in  the  leg. 

The  cause  of  this  condition  has  not  been  determined.  It  has  been  ascribed  to 
traumatism,  such  as  frequent  cuts  from  blades  of  grass.  By  some  writers  it  has 
even  been  regarded  as  an  expression  of  a  \ery  much  attenuated  form  of  leprosy. 
It  is  evidently  a  trophic  disturbance. 

Treatment. — The  treatment  is  surgical,  and  consists  in  free  division  of  the  con- 
stricting bands  in  recent  cases  and  amputation  in  advanced  cases. 


BERIBERI. 

Definition. — Beriberi  is  sometimes  called  Endemic.  Multiple  Neuritis,  and  is  a 
disease  occurring  in  nearly  all  tropical  and  sulitropical  countries.  The  disease  is 
associated  \\\i\\  marked  e\idences  of  peripheral  neuritis,  with  sensory  and  motor 
palsies,  and  profound  alteration  of  the  motor  mechanism  of  the  heart. 


BERIBERI  767 

History. — The  recognition  of  ))eril)eri  as  a  distinct  morbid  entity  is  almost  as 
old  as  recorded  medicine.  The  first  mention  of  it  was  made  by  Strabo,  wlio  de- 
scribes the  development  of  this  disease  in  the  Roman  armies  operating  in  Arabia 
(24  B.C.).  It  is  also  described  in  the  medical  writings  of  the  Chinese  of  the  second 
and  seventh  centuries.  It  has  occupied  an  important  place  in  the  histories  of  all 
colonizing  powers.  Dutch  and,  later,  British  observers  recognized  its  peculiar 
nature  in  the  beginning  of  the  nineteenth  century.  Our  later  knowledge  of  the 
disease,  particularly  the  recognition  of  the  specific  pathological  lesions,  is  due  to 
the  labors  of  the  German  teachers,  Scheube  and  Baelz,  in  Japanese  universities, 
and  of  Wright  and  Durham,  in  the  Malay  Peninsula,  and  Herzog,  Vedder,  and 
Chamberlain  in  the  Philippines. 

Distribution. — Speaking  generally,  the  centres  of  greatest  intensity  of  beriberi 
are  the  Malayan  and  in  all  rice-eating  countries.  It  devastates  the  coolie  mining 
camps  and  the  plantations  of  the  ^lalayan  peninsula.  It  is  always  present  in 
Japan,  and  in  portions  of  the  Philippine  Islands  it  is  A-ery  common.  It  has  occurred 
in  widespread  epidemics  throughout  the  whole  tropical  and  subtropical  zones. 
Within  recent  years  it  has  been  observed  among  Chinese  fishermen  from  the  Alaskan 
coast;  by  Currie  and  by  Bailey  in  a  settlement  of  Japanese  at  Cumberlands,  British 
Columbia. 

Etiology. — The  studies  of  Eraser  and  Stanton  in  1909  in  the  Federated  ]\Ialay 
States,  and  more  especially  those  of  Strong  and  Crowell  in  the  Philippines,  ha^-e 
definitely  proved  that  the  cause  of  beriberi  is  due  to  star\-ation  of  the  body  of 
certain  substances  found  on  the  surface  of  rice  grain  and  which  is  lacking  in  polished 
or  cleaned  rice.  If  non-polished  rice  is  used  it  does  not  occur,  nor  does  it  take 
place  if  meat  and  potatoes  are  added  to  a  diet  of  polished  rice. 

Heiser  points  out  a  readj'  method  of  determining  whether  rice  is  polished  and 
therefore  lacking  in  P2O5,  namely,  that  grains  of  rice  which  are  polished  and  contain 
less  than  0.4  per  cent.  P2O5  will  stain  deeply  with  Loeffler's  methylene  blue  or 
Churchill's  iodine,  whereas,  if  not  polished  they  stain  only  slightly. 

Frequency. — Beriberi  is  observed  much  more  frequently  in  males  than  in  females; 
not  because  there  is  any  greater  susceptibility  in  the  male,  but  because  women  form 
a  comparatively  small  number  in  coolie  camps,  jails,  prisons,  and  ships.  With 
respect  to  age,  beriberi  may  be  said  to  be  a  disease  of  early  adolescence  and  adult 
life,  but  it  occurs  in  infants  who  are  at  the  breast  of  mothers  suffering  from  this 
malady.  The  great  majority  of  cases  occur  between  the  twentieth  and  fortieth 
years. 

Beriberi  is  chiefly  a  disease  of  the  yellow  races,  occurring  principally  in  prisoners. 
At  the  present  day  beriberi  is  very  rarely  observed  in  Europeans  and  North  Ameri- 
cans. The  white  races  enjoy  a  nearly  complete  immunity,  due  in  part  to  the  better 
nutritional  conditions  under  which  they  live. 

Pathology  and  Morbid  Anatomy. — When  death  occurs  rigor  mortis  is  usually 
severe  if  the  disease  has  been  rapid.  In  slow  cases  it  is  often  slight.  If  the  case 
be  recent  and  acute,  or  if  death  be  due  to  cardiac  paralysis,  the  cadaver  bears  all 
the  evidence  of  intense  dyspnea  and  cyanosis.  The  eyes  are  staring,  the  conjunctiva 
suffused  with  blood,  the  cervical  veins  tumid  and  full,  the  lips  covered  with  bloody 
froth.  In  the  atrophic  cases  there  is  very  considerable  wasting.  In  the  dropsical 
cases  the  effusion  is  commonly  associated  with  huge  thoracic,  pericardial,  and 
abdominal  dropsies  and  edema  of  the  lungs.  In  acute  cases  marked  congestion 
of  the  pyloric  end  of  the  stomach  and  of  the  duodenum  with  punctiform  hemor- 
rhages is  found.  The  duodenal  glands  are  swollen  and  congested.  Wright  con- 
siders this  to  be  specific  lesion  of  the  disease,  and  states  that  it  is  always  found  when 
the  case  ends  fatally  within  three  weeks  of  the  beginning  of  the  disease. 

The  liver  and  kidneys  are  enlarged,  hyperemic,  and  show  cloudy  swelling.  The 
spleen  is  enlarged,  but  otherwise  shows  no  characteristic  changes.    The  heart  is 


7().S  DISEASES  OF  Sl'TRITIOX 

enlarged,  tlic  principcal  changes  being  found  in  tlic  right  side.  The  \entricle  is 
both  hypertrophied  and  dilated.  Microscoiiieally  there  is  usually  niarkeil  fatty 
degeneration  of  the  myocardium.  Chicken-fat  clots  are  commonly  found  in 
chronic  cases.  The  intrinsic  nerve  cells  of  the  heart  show  marked  atrophic  changes. 
The  terminations  of  the  vagus  are  also  atrojihied.  The  trunk  of  the  vagus  is 
not  in^'oIved  in  early  cases,  but  in  later  cases  the  trunk  of  this  ner\e  as  well  as  the 
splanchnics  and  phrenics  are  profoundly  degenerated.  The  peripheral  nerves 
show  striking  and  constant  changes.  These  begin  with  degeneration  of  the  terminal 
branches  of  the  nerves.  Not  only  the  muscular  but  also  the  cutaneous  twigs, 
and  in  advanced  cases  the  main  nerve  trunks,  may  be  involved.  The  nerve  changes 
are  present  in  proportion  to  the  extent  and  intensity  of  the  paralysis  during  life 
but  they  are  always  degenerative  and  not  inflammatory  in  type. 

The  voluntary  muscles  show  distinct  changes  in  the  distribution  of  the  degenerated 
nerves.  The  muscle  fibres  undergo  fatty  degeneration,  the  striations  disappear, 
the  nuclei  are  enlarged,  and  the  interstitial  connective  tissue  may  be  increased. 
The  central  nervous  system  shows  congestion  of  the  brain  meninges  and  cord,  with 
increase  in  the  cerebrospinal  fluid.  I)egenerati\'e  changes  can  be  found  in  the 
posterior  ganglia,  and  sometimes  atrophy  of  the  posterior  columns  is  present. 

Symptoms. — Clinically,  several  types  of  the  disease  are  recognized.  There  are 
atrophic  cases  (paraplegic  or  dry  beriberi),  dropsical  cases  (wet  berilieri),  acute 
pernicious  cases,  and  viild  or  rudimentary  cases.  These  classes  represent  not  only 
variations  of  type,  but  variations  of  intensity. 

The  disease  is  usually  ushered  in  by  marked  prodromata.  There  is  loss  of 
appetite,  with  severe  pain  in  the  epigastrium  and  oppression  in  the  chest.  With 
these  symptoms  there  is  a  slight  febrile  rise.  In  a  few  cases  rigors,  lassitude, 
mental  disturbances,  and  head  pains  are  observed. 

Atkophic  Cases. — After  a  fe\\-  days  or  weeks  the  patient  notices  a  sloA\ly  increas- 
ing weakness  of  the  legs,  with  pain  and  tension  in  the  calf  muscles.  There  is  next 
a  loss  of  sensation  in  the  soles  of  the  feet.  The  patient  does  not  "feel"  the  floor, 
or  feels  as  though  a  soft  insole  had  been  placed  between  the  foot  and  the  shoe  ur 
sandal.  This  increases  until  the  patient  becomes  bedridden.  As  a  rule,  the  palsies 
are  confined  to  the  legs  and  trunk,  sometimes  invading  the  arms,  and  \ery  rarely 
affecting  the  head  and  neck.  The  paralyzed  limbs  rapidly  atrophy  and  areas  of 
anesthesia  and  hyperesthesia  develop.  Examination  shows  the  superficial  reflexes 
preserved;  the  deep  reflexes  lost.  The  calf  muscles  and  extensors  of  the  legs  are 
extensively  wasted.  The  palsj'  is  nearly  always  flaccitl,  may  be  quite  profound, 
and  is  more  marked  in  the  extensors  than  in  the  flexors,  resulting  in  ^\■rist-drop 
and  paralytic  equino\'arus.  The  electric  muscle  reactions  are  markedly  altered. 
From  the  beginning  there  is  marked  diminution,  going  on  to  total  loss  of  reaction 
to  both  galvanic  and  faradic  stimulation. 

The  sensory  sj'mptoms  closely  parallel  the  distribution  of  the  motor  s\'mptoms, 
and  are  even  more  constant.  Spots  of  anesthesia  and  paresthesia  are  formed  on 
the  feet,  calves,  legs,  trunk,  and  arms.  Recovery  from  the  condition  is  extremely 
tedious.  Gradually  the  areas  of  hyperesthesia  disappear,  sensation  and  motion 
return,  and  in  the  course  of  ten  to  twelve  months  the  atrophied  muscles  regain 
their  contour. 

Dropsical  Cases  resemble  the  atrophic  cases  i)lus  marked  cardiac  phenomena 
with  dropsy.  Sometimes  the  dropsical  cases  de\-elop  from  the  atrophic.  The 
dropsy  begins  in  the  feet  and  legs  and  spreads  until  the  whole  body  is  affected. 
The  face  and  lips  are  puff>'  and  heavy.  The  arms,  legs,  and  trunk  are  pudgy. 
With  this  there  are  marked  evidences  of  cardiac  distress.  There  are  ci/aiiosis  of 
the  lips  and  fingers,  dysj)nea,  and  a  marked  sense  of  oppression  in  the  precordium. 
Usually  the  patient  is  quite  helpless,  or,  if  he  can  walk,  the  slight  exertion  is  attended 
by  breathlcssness  and  palpitation,  these  symptoms  licing  very  much  increased 


BERIBERI  709 

by  effusion  into  the  serous  cavities.  The  urine  is  greatly  diminishefl,  but  contains 
no  albumin.  After  persisting  for  weeks  or  months  the  dropsy  may  rapidly  dis- 
appear, with  an  enormous  increase  in  the  urine.  As  a  rule,  these  cases  do  not 
present  the  extreme  grades  of  paralysis  and  atrophy  that  are  found  in  the  first 
type.  Yet  the  absorption  of  the  dropsical  fluid  will  re-\-cal  marked  wasting  that 
may  have  been  completely  masked  by  the  semisolid  appearance  of  the 
effusion. 

In  both  types  of  cases  the  cardiac  changes  are  marked.  The  pulse  rate  is  usually 
increased  and  slight  exertion  serves  to  further  increase  the  rapidity  to  120  to  140 
beats  per  minute.  The  heart  is  enlarged,  particularly  on  its  right  side.  The  caro- 
tids pulsate  violently  and  in  the  severe  cases  pulsation  is  seen  in  the  jugular  veins. 
Systolic  and  diastolic  murmurs  are  heard,  the  murmurs  being  propagated  very 
widely,  sometimes  even  into  the  bronchial  and  femoral  arteries.  Reduplication 
of  the  sounds  is  frequently  heard,  and  there  is  equal  spacing  between  the  sounds. 
Despite  the  forcible  cardiac  beat  and  the  violent  pulsation  in  the  vessels  of  the 
neck,  the  peripheral  pulse  is  remarkably  small  and  weak.  All  these  cardiac  pheno- 
mena are  exceedingly  fugitive.  Even  the  most  pronounced  murmurs  and  evidences 
of  dilatation  come  and  go  with  rapidity. 

Acute  Pernicious  Beriberi. — This  form  attacks,  as  a  rule,  the  more  vigorous 
adults.  It  may  appear  as  an  acute  type  from  the  very  beginning,  or  it  may  repre- 
sent a  sudden,  fatal  episode  in  mild  or  convalescent  cases.  Beginning  in  the  ordi- 
nary way,  the  disease  advances  with  great  rapidity,  so  that  the  man  becomes  bed- 
ridden in  a  few  days.  The  symptoms  of  cardiac  involvement  begin  early  and  are 
marked.  When  this  type  develops  from  the  milder  forms  of  the  disease  the  change 
is  very  sudden.  Palpitation,  and  dysjmea  become  more  and  more  severe.  The 
patient  gasps  and  struggles  for  breath.  He  complains  of  extreme  pain  in  the  pre- 
cordium.  He  breathes  with  tremendous,  laboring,  gasps.  The  vessels  of  the  neck 
pulsate  violently.  The  eyes  are  suft'used  and  staring.  A  blood-flecked  foam 
collects  on  the  lips ;  unless  speedily  relieved  the  patient  dies  a  most  dreadful  death. 
In  these  cases  the  urine  is  notably  diminished  or  even  suppressed.  Nausea  and 
vomiting  are  common  toward  the  end. 

Mild  and  Rudimentary  Beriberi  of  all  degrees  are  observed.  These  cases 
usually  complain  of  pain  and  tension  in  the  legs,  with  weakness  and  numbness. 
The  anesthetic  areas  may  be  very  small  and  sharply  marked.  The  patient  usually 
develops  some  degree  of  cardiac  irritability  and  'palpitation.  There  may  or  may 
not  be  edema  of  the  legs.  These  cases  are  important  because  here  and  there  a  very 
mild  case  may  suddenly  develop  an  acute  pernicious  cardiac  attack.  As  a  rule, 
however,  they  clear  up  completely,  rarely  lasting  over  the  cool  season. 

Special  mention  should  be  made  of  the  skin  symptoms.  Petechia;  and  herpes 
of  the  lips  are  very  common  in  beriberi,  as  is  also  a  diffuse  or  blotchy  redness  in  the 
arms  and  legs.  After  the  very  beginning  of  the  disease  there  is  no  fever.  A 
marked  rise  of  temperature  means  a  reinfection  or  the  development  of  some 
complication. 

The  hlood  shows  no  characteristic  nor,  indeed,  any  marked  changes  in  beriberi. 
As  a  rule,  there  is  a  very  moderate  diminution  of  the  red  cells.  In  severe  and  long- 
continued  cases  the  anemia  may  become  more  marked,  with  some  considerable 
loss  of  hemoglobin,  the  color  index  being  minus.  In  the  average  cases  there  is  no 
change  in  the  white  corpuscles.  In  severe  cases  a  moderate  leukocytosis  is  found. 
The  bacteriological  findings  are  negative. 

The  urine  shows  very  little  change.  The  urea  is  diminished,  and,  as  a  rule, 
the  specific  gravity  is  also  decreased.  Sugar  and  albumin  are  not  found.  Indican 
is  present  in  large  amounts  (Baelz).  ^The  urine  is  diminished  in  quantity  in  the 
pernicious  cases,  even  to  complete  suppression.  In  the  cases  of  wet  beriberi  the 
urine  is  greatly  diminished.  The  secretion  is  re-established  when  the  exudations 
49 


770  DISEASES  OF  NUTRITION 

hefiin  to  Ik-  absorbed.  Under  these  circumstances  an  unusually  large  amount  of 
urine  may  be  passed,  and  this  re-establishment  of  the  renal  function  is  a  very 
favorable  prognostic  symptom. 

Diagnosis. — When  the  cases  occur  in  groups  of  rice  eaters,  the  symptoms  of 
peripheral  neuritis  point  to  nothing  else.  In  isolated  cases,  however,  the  diagnosis 
is  not  by  any  means  easy,  and  the  distinction  between  arsenical  or  alcoholic  neuritis 
and  beriberi  may  be  difficult.  The  presence  of  edema  is  significant  of  beriberi. 
The  earlier  and  more  decided  alterations  in  the  deep  reflexes  and  the  palpitating 
and  irritable  heart  also  point  to  beriberi. 

Prognosis. — The  percentage  mortality  of  beriberi  depends  on  the  pernicious 
cases.  The  latter  are  almost  always  fatal  and  furnish  certainly  90  per  cent,  of 
the  total  mortality.  In  the  remaining  cases  the  mortality  varies  widely  in  different 
epidemics.  Ten  per  cent,  would  be  a  very  fair  average  mortality,  although  it 
may  run  as  high  as  40  per  cent.  There  is,  however,  no  disease  in  which  prognosis 
is  so  uncertain  and  hazardous.  Again  and  again  cases  considered  practically  well, 
certainly  out  of  all  danger,  die  with  rapidity  in  the  appalling  cardiac  crisis  of  this 
disease.  The  prognosis  is  favorable,  without  regard  to  the  extent  of  the  paralytic 
lesions,  in  proportion  to  the  integrity  of  the  innervation  of  the  heart.  Increase  of 
the  urine  is  a  favorable  sign.  So,  too,  are  return  of  appetite  and  sexual  desire. 
On  the  other  hand,  increasing  irregularity  of  the  heart;  equal  spacing  of  the  cardiac 
intervals,  the  short  and  long  pause  becoming  ecpial  or  nearly  so;  increasing  cyanosis, 
paralysis  of  the  diaphragm,  and  diminishing  urine  are  very  unfavorable  signs. 
The  presence  of  bronchitis,  pneumonia,  dysentery,  alcoholism,  and  icterus  are 
unfavorable.  Vomiting  is  as  sinister  a  symptom  in  beriberi  as  is  black  vomit  in 
yellow  fever. 

Treatment. — The  main  point  in  treatment  is  to  provide  an  ample  diet,  easily 
digested,  of  barley,  unpolished  rice  and  meat  or  meat  extracts.  Chamberlain 
and  Vedder  have  shown  that  in  infantile  beriberi  20  drops  of  extract  of  rice  polish- 
ings  a  day  produced  remarkable  betterment.  N'edder  and  Williams  of  the  I'nited 
States  Army  in  the  Philippines  have  found  rice  polishings  to  contain  a  neuritis 
preventing  substance,  or  vitamine,  which  when  given  to  persons  ill  of  beriberi 
produces  a  cure.  The  unhydrolyzed  extract  is  a  specific  in  wet  beriberi  and  also 
in  cardiac  cases.  This  extract  does  the  paralytic  cases  little  good  but  these  cases 
are  in  time  cured  by  the  use  of  a  crystalline  base  from  the  polishings.  Apparently 
the  polishings  contain  at  least  two  protective  or  curative  substances. 

For  cardiac  cases,  particularly  those  with  dropsy,  digitalis  is  the  best  remerly. 
It  must  be  given  freely  in  large  doses.  This  remedy  should  always  be  readily 
accessible  in  beriberi  wards.  If  the  symptoms  of  cardiac  failure  liecome  se\"ere, 
the  patient  should  l)e  bled.  It  will  frequently  be  found  imjjossible  to  bleed 
at  the  elbow,  under  which  circumstances  the  patient  should  be  liled  from  the 
jugulars.  About  400  c.c.  should  be  drawn.  The  relief  from  this  measure  is  prompt 
but  evanescent,  but,  as  Manson  says,  "the  patient  is  for  the  time  being  tided  over 
an  acute  danger  and  given  another  chance." 

The  patient  should  be  put  on  a  liberal  diet  scale  in  which  nitrogenous  foods 
and  fats  form  a  conspicuous  part.  He  should  be  kept  in  a  dry,  sunny  room,  and 
whenever  possible  should  be  out  of  bed  in  the  open  air. 

The  treatment  of  the  residual  palsies  is  the  same  as  that  of  any  other  form  of 
severe  polyneuritis. 


INTOXICATIONS. 


ALCOHOLISM. 


Definition. — By  alcoholism  is  meant  a  condition  in  which  the  patient  sufl'ers 
from  the  effects  of  alcohol  when  taken  in  sufficient  quantities  to  act  as  a  poison. 

Etiology. — An  idea  exists  among  the  laity  that  chronic  alcoholism  is  a  manifesta- 
tion of  an  inherited  tendency  in  many  instances,  and  this  is  sometimes  offered  as 
an  excuse  by  a  patient  for  his  unlimited  libations.  There  is  no  such  disease  as 
alcoholism,  nor  does  an  alcoholic  have  any  justification  in  this  excuse.  The  ten- 
dency to  consume  alcohol  is  not  an  inheritance.  The  inheritance  is  a  lack  of  self- 
control,  a  cowardly  inability  to  meet  the  hard  sides  of  life,  and  a  willingness  to 
escape,  if  only  for  a  time,  by  droAvning  sensation  in  the  stupor  of  a  narcotic.  In 
many  cases,  therefore,  we  may  not  only  have  to  combat  a  habit,  but  a  state  of 
degeneracy  m  hich  permits  a  habit  to  exist. 

Symptoms. — Alcoholism  may  be  divided  for  readiness  of  consideration  into  the 
acute  and  chronic  form. 

Acute  Alcoholism. — The  symptoms  of  the  acute  form  are  familiar  to  everyone 
who  sees  life  in  the  town  or  city,  and  consist  in  disorderly  condvct  due  to  removal 
of  the  inhibitory  functions  of  the  brain,  so  that  CA'ery  silly  thought  or  foolish  idea 
is  carried  out  in  action.  Later,  as  the  drug  affects  the  muscle  sense,  and  conse- 
quently disorders  co-ordination,  the  individual  staggers  and  perhaps  falls,  and  finally, 
if  the  quantity  of  the  drug  is  adequate,  passes  into  a  deep  sleep,  or  coma,  from  which 
he  wakes  more  or  less  confused,  with  depression  of  the  nervous  system  and  a  dis- 
ordered digestive  tract.  In  cases  where  the  dose  has  been  very  large,  death  may  be 
caused  by  depression  of  all  the  vital  functions,  of  which  the  one  most  involved 
is  bodily  heat,  the  death  being  in  part  due  to  cold.  In  the  majority  of  cases, 
however,  in  M'hich  death  follows  acute  alcoholism,  it  is  due  not  directly  to  the 
depressing  effects  of  the  alcohol,  but  to  the  fact  that  the  lowering  of  temperature 
and  the  disorder  of  vital  function  in  the  various  organs  permits  infection  by  the 
pneumococcus  to  take  place  so  that  pneumonia  causes  death,  or  some  complication 
such  as  acute  nephritis  is  developed. 

The  symptoms  of  profound  acute  alcoholism  are  pallor  of  the  face,  dulness  of 
the  eyes,  widely  dilated  pupils,  pirofound  unconsciousness,  stertorous  breathing,  and  a 
temperature  several  degrees  below  normal.  Occasionally  conmlsive  attacks  may 
develop. 

Although  the  symptoms  of  acute  alcoholism  are  so  familiar,  there  is  no  state  so 
often  confused  with  conditions  of  disease  or  with  the  results  of  injury.  This  is 
due  to  the  fact  that  the  symptoms  of  acute  alcoholism  are  much  like  those  of  cerebral 
congestion,  apoplexy,  uremia,  or  hemorrhage  from  a  meningeal  artery,  or  fracture 
of  the  skull.  It  is  also  due  to  the  fact  that  alcohol  often  causes  all  these  states 
directly  or  indirectly,  and  as  there  is  a  history  of  alcoholism  or  an  odor  of  alcohol 
on  the  breath,  it  is  natural  to  make  a  diagnosis  of  alcoholism  without  recognizing 
that  another  condition  is  present.  Again,  it  not  rarely  happens  that  an  alcoholic 
takes  a  poisonous  dose  of  opium,  and  so  suffers  and  dies  from  the  effect  of  this  drug. 
The  raised  temperature  in  apoplexy  is  in  contrast  to  the  lowered  temperature  of 

(771) 


772  INTOXICAriOXS 

alcoholism,  as  is  also  the  full-bounding  pulse  as  compared  to  the  rapid-running 
pulse  of  alcoholic  poisoning.  Again,  apoplexy  is  characterized  by  lieiniplegia 
and  facial  palsy.  Opium  poisoning  is  characterized  by  pinpoint  pupils,  slow 
breathing,  and  a  warm  skin,  as  opposed  to  the  normal  or  relaxed  pupils,  the  cool, 
moist  skin,  and  the  normal  or  rapid  breathing  of  alcoholism. 

Treatment. — The  treatment  of  acute  alcoholism  consists  in  the  administration 
of  an  emetic  to  empty  the  stomach  of  any  alcohol  still  unabsorbed.  Apomorphine 
is  probably  the  best  drug  for  this  purpose,  as  it  can  be  given  hypodermically,  acts 
promptly,  is  sedative  in  its  influence,  and  is  safe  in  a  moderate  emetic  dose  of  | 
grain.  In  other  cases,  or  after  the  emetic  has  acted,  an  active  cathartic,  such  as 
30  grains  of  compound  jalap  powder  or  15  grains  of  compound  extract  of  colocynth, 
maybe  used  to  unload  the  bowels  and  portal  system,  and  decrease  cerebral  conges- 
tion. If  circulatory  feebleness  is  present,  the  aromatic  spirit  of  ammonia  in  drachm 
doses,  diluted  with  water,  may  be  given.  In  other  cases  the  physician  must  give 
full  doses  (ttV  grain)  of  strychnine  by  the  mouth,  or  by  the  h\']iodermic  needle  if 
depression  is  marked,  and  hot  bottles  must  be  applied  to  maintain  body  heat. 
Strong  black  cofl'ee  by  the  mouth  or  by  the  rectum  may  be  given  if  active  stimula- 
tion seems  needful.  The  effects  manifested  on  the  next  day  are  to  be  removed  by 
the  use  of  calomel,  followed  by  a  saline  purge  and  the  administration  of  elixir 
of  celery  and  guarana,  or,  if  the  patient  is  very  nervous,  by  the  use  of  guarana  and 
bromide  of  sodium,  5  grains  of  the  extract  of  the  former  and  30  grains  of  the  latter 
at  a  dose. 

Subacute  and  Chronic  Alcoholism. — Chronic  alcoholism  is  divisible  into  three 
classes.  In  one  the  patient  suffers  from  a  prolonged  alcoholic  debauch  lasting 
over  days,  or  even  weeks,  during  Avhich  time  he  is  ne-\'er  completely  sober.  In  the 
other  type  he  is  never  drunk,  but  always  under  the  influence  of  the  drug  to  an 
extent  which  eventually  produces  a  train  of  symptoms  even  more  gra\e  than  those 
which  follow  a  debauch.  Those  who  have  made  a  special  study  of  alcoholism 
also  recognize  that  there  is  a  certain  class  of  persons,  of  the  first  division  just  named, 
who  take  no  alcohol  for  a  comparatively  long  period,  varying  from  weeks  to  months, 
and  then  go  on  a  terrific  debauch,  the  so-called  "periodical  drunkard."  It  is  the 
individual  who  takes  alcohol  up  to  the  stage  of  intoxication  for  several  days  consecu- 
tivel}^  and  who  has  often  used  alcohol  in  large  quantities  for  weeks  before  the  acute 
exacerbation,  who  most  commonly  develops  delirium  tremens;  while  the  constant, 
moderate  "soaker"  is  more  prone  to  hepatic  cirrhosis  and  affections  of  the  periph- 
eral nerves.  Delirium  tremens  is  very  prone  to  develop  in  persons  who  are  the 
subjects  of  subacute  or  chronic  alcoholism  if,  perchance,  they  suft'er  from  a  severe 
injury,  surgical  operation,  or  great  shock.  Not  rarely  the  onset  of  an  acute  illness 
may  precipitate  an  attack. 

Morbid  Anatomy. — The  morbid  changes  produced  by  the  continuous  use  of 
alcohol  in  excess  are  chiefly  found  in  the  organs  by  which  the  drug  gains  access  to 
and  egress  from  the  body;  that  is,  the  stomach,  the  liver,  and  the  kidneys.  Next 
to  the  effect  of  the  drug  upon  these  organs  it  expends  its  deleterious  influences 
upon  the  circulatory  system.  The  passage  of  alcohol  directly  to  the  liver  from 
the  stomach  through  the  portal  vessels  causes  congestion,  irritation,  and  finally 
atrophic  cirrhosis  of  this  organ.  (See  Hepatic  Cirrhosis.)  By  reason  of  the  direct 
effect  of  the  drug  upon  the  stomach,  and  the  indirect  effect  produced  by  the  impair- 
ment of  its  blood  supply,  which  arises  from  the  hepatic  changes,  chronic  gastric 
catarrh  develops.  The  changes  found  in  the  kidneys  in  very  chronic  alcoholism 
consist  in  a  condition  practically  identical  with  that  found  in  contracted  kidney, 
and  with  this  state  an  arteriocapillary  fibrosis  develops,  just  as  it  does  in  cases 
of  cardiovascular  changes  arising  from  other  causes.  The  most  common  change 
in  the  kidneys,  however,  consists  in  a  hypostatic  congestion,  or  stasis,  which  causes 
them  to  be  sw^ollen,  cyanotic,  and  to  be  functionally  inactive.    Not  rarely  these 


ALCOHOLISM  773 

patients  develop  acute  tuberculosis,  because  of  their  lowered  vital  resistance. 
An  alcoholic  multiple  neuritis  may  develop,  and  atrophy  of  the  optic  nerve  may 
occur. 

Symptoms. — The  symptoms  of  delirium  tremens  are  great  nervous  restlessness 
and  apprehension  with  anxiety,  and  finally  delusions  of  persecution  and  terror. 
The  delusions  are  largely  those  connected  with  vision,  and  all  sorts  of  hideous 
objects  are  described  as  crawling  about  the  patient.  Because  of  these  delusions 
the. ■patient  is  often  violent  and  difficult  to  control,  but  is  rarely  offensive  unless  he 
believes  that  the  attendant  is  in  league  with  the  "objects  of  evil"  about  him.  The 
pulse  is  usually  rapid  and  feeble,  the  skin  relaxed,  and  the  tongue  exceedingly  joul. 
The  bowels  are  constipated  and  the  urine  scanty.  Hypostatic  congestion  of  the 
lungs  and  congestion  of  the  kidneys  are  very  commonly  developed,  and  these  states 
often  contribute  to  the  death  of  the  patient. 

It  is  not  to  be  forgotten  that  acute  croupous  pneumonia  at  the  apex  not  rarely 
is  associated  with  an  acute  delirium  not  unlike  that  of  delirium  tremens. 

In  that  form  of  chronic  alcoholism  in  which  the  patient  is  never  drunk,  but 
always  has  alcohol  in  his  body,  the  chief  sj^mptoms  are  irritability  of  temper, 
gradual  mental  deterioration,  localized  sensory  and  motor  palsies,  and  finally 
dementia. 

Treatment. — The  treatment  of  this  state  consists  in  the  use  of  an  active  cathartic, 
as  already  advised  for  acute  alcoholism,  and  the  use  of  full  doses  of  morphine 
hypodermically,  if  the  kidneys  are  not  diseased,  to  produce  nervous  rest  if  the 
patient  is  becoming  exhausted  by  his  lack  of  sleep  or  struggling.  Care  must  be 
taken  that  more  than  a  few  doses  are  not  given,  for  such  a  patient  may  become  a 
morphine  habitue  very  quickly.  Strychnine  and  atropine  are  to  be  used  hypo- 
dermically if  any  signs  of  pulmonary  congestion  arise,  and  they  must  be  given 
boldly.  Dry  cups  should  be  applied  to  the  back  of  the  chest,  and  Hoffmann's 
anodyne  is  useful  as  a  rapidly  acting  diffusible  stimulant.  Every  measure  must 
be  taken  to  disperse  and  prevent  the  congestion,  which,  if  it  develops  in  full  degree, 
means  the  death  of  the  patient. 

The  question  as  to  the  medicinal  use  of  alcohol  in  these  cases  is  debatable.  In 
those  who  are  not  accustomed  to  its  constant  use,  and  who  may  have  been  intoxi- 
cated for  but  a  few  days,  it  is  not  necessary  to  give  the  drug;  but  if  the  patient  has 
been  in  the  habit  of  taking  alcohol  in  considerable  amounts  prior  to  his  acute 
alcoholic  outbreak,  whiskey  must  be  used  freely  in  many  cases  if  signs  of  great 
nervousness  develop.  Aside  from  pulmonary  and  renal  complications  the  most 
frequent  one,  and  a  most  fatal  one,  is  a  state  of  nervous  tension  in  which  the  symp- 
toms are  those  of  meningeal  irritation  with  stiffness  of  the  limbs  and  neck.  This 
stage  of  tonicity  in  the  muscles  is  preceded  by  muttering  delirium,  with  periods 
of  wakefulness  in  which  hallucinations  may  make  the  patient  difficult  of  control. 
The  pupils  are  contracted  and  the  pulse  rapid  and  feeble.  The  temperature  is 
often  as  high  as  103°  or  even  104°,  and  not  rarely  hypostatic  congestion  of  the  lungs 
can  be  found  if  the  bases  are  examined.  Marked  hyperesthesia  of  the  skin  usually 
exists.  Patients  with  these  manifestations  usually  die,  but  they  may  recover 
after  a  prolonged  illness  lasting  several  weeks.  My  experience  is  in  accord  with 
that  of  Dana,  that  if  there  is  stiffness  of  the  cervical  muscles  the  patient  usually 
dies.  This  condition  is  not  due  to  a  true  meningitis,  but  to  a  toxemia  with  serous 
effusion  into  the  meninges.  Dana  and  others  have  given  the  name  "wet  brain" 
to  this  condition. 

The  diet,  if  food  can  be  given  to  the  patient,  should  consist  of  hot  and  stimulating 
liquid  nourishment,  such  as  highly  seasoned  beef-tea  or  peptonized  milk,  to  M'hich 
capsicimi  and  salt  have  been  added  to  stimulate  the  digestion  to  activity.  The 
various  highly  seasoned  broths  are  useful. 


774  INTOXICATIONS 

The  treatment  of  the  alcohoHc  who  continually  takes  the  drug  clay  in  and  day 
out  j)resents  grave  difficulties.  Those  who  have  been  wont  to  take  this  drug 
e\ery  day  for  many  years  are  rarely  willing  to  put  up  with  the  discomfort  which 
follows  ahstinencc,  and  after  a  few  days  almost  in\arial)ly  return  to  the  use  of 
alcohol.  The  only  treatment  which  is  of  any  \aiue  in  such  cases  is  to  send  the 
patient  to  some  isolated  region  where  he  is  too  far  removed  from  the  grog  shop  to 
be  able  to  obtain  alcohol  when  his  desire  for  it  arises,  and  to  take  care  that  he  does 
not  provide  himself  beforehand  with  alcohol  to  be  used  during  the  trip.  Usually, 
if  the  man  is  well-to-do,  several  weeks  or  months  of  hunting  in  isolated  regions, 
and  in  the  company  of  someone  who  does  not  drink  alcohol  and  has  considerable 
mental  force,  will  be  the  best  means  of  cure. 

For  those  who  take  alcohol  more  or  less  constantly  to  the  point  of  intoxication, 
either  this  measure  can  be  employed  or  the  patient  may  be  placed  in  a  private 
room  in  a  hospital,  where  he  is  under  absolute  control  of  the  nurses  and  physicians 
attached  to  the  institution,  and  the  alcohol  can  then  be  immediately  stricken 
off  the  list  of  permissible  articles,  or,  if  his  condition  is  one  of  feebleness,  it  can  be 
gradually  diminished  so  that  at  the  end  of  a  week  he  is  getting  none  of  it.  In 
the  great  majority  of  instances  it  is  utterly  futile  to  attempt  home  treatment  of 
these  cases.  Even  if  the  family  can  prevent  the  man  from  getting  alcohol,  home 
life  lacks  the  discipline  which  is  necessary  for  the  control  of  the  patient,  not  only 
in  the  sense  of  preventing  him  from  procuring  alcohol,  but  in  the  sense  of  making  a 
powerful  mental  impression. 

In  those  cases  in  which  removal  of  alcohol  causes  nervous  excitation  and  evidences 
of  threatened  delirium  tremens,  it  is  occasionally  permissible  to  administer  full 
doses  of  chloral  and  the  bromides  to  produce  nervous  quiet  at  night.  Small  doses 
of  these  drugs  practically  have  no  influence  whatever,  and  if  tlie  heart  is  at  all 
feeble  full  doses  of  chloral  are  dangerous.  ^Morphine  possesses  the  disadvantage 
that  the  alcoholic  is  very  prone  to  develop  the  morphine  habit  in  addition  to  his 
alcoholism.  This  drug  is,  howe\'er,  exceedingly  valuable  if  used  on  those  occasions 
when  the  violence  of  the  patient's  nervous  symptoms  demanrl  sedation.  It  should 
not  be  given  day  after  day,  but  only  occasionally,  when  insomnia  is  so  pressing 
that  the  consequent  exliaustion  demands  relief. 

Within  the  last  few  years  ^•ery  strong  claims  ha\'e  been  made  for  the  use  of 
hyoscine  for  the  purpose  of  relieving  the  ner^'ous  irritation  and  craving  for  alcohol. 
The  drug  must  be  given  in  sufficiently  large  doses,  hypodermic-ally,  to  place  the 
patient  deeply  under  its  influence.  If  necessary  as  much  as  y^^^  of  a  grain  every 
two  hours  may  be  given  hypodermically  until  the  patient  sleeps  or  is  resting  quietlx'. 
These  doses,  of  course,  produce  the  full  physiological  action  of  hyoscine  and  often 
cause  great  dryness  of  the  mouth  and  talkative  delirium.  They  may  be  continued 
for  several  days  and  then  gradually  remitted  until  the  patient  is  no  longer  taking 
either  alcohol  or  hyoscine. 

If  the  circulation  fails  in  these  cases  .strychnine  and  digitalis  may  lie  administered. 
For  the  purpose  of  combating  signs  of  acute  collapse  Hoffmann's  anodyne  and 
strychnine  are  valuable,  as  is  also  the  aromatic  spirit  of  ammonia.  Another  drug 
which  has  been  highly  praised  in  this  condition  is  apomorphine  given  in  the  dose 
of  -g-V  of  a  grain  hypodermically  as  a  nervous  sedati^■e,  the  emetic  effect  of  the  drug 
not  being  desired.  In  some  instances  larger  do.ses  have  to  be  given  and  may  be 
used  without  producing  emesis. 

It  must  be  constantly  borne  in  mind  that  the  most  important  portion  of  the 
treatment  consists  in  the  isolation  of  the  patient,  and  in  a  complete  control  of 
his  methods  of  life  for  the  period  covering  several  weeks.  Drugs  are  of  little  value 
except  to  su])port  him  through  the  period  when  his  system  lacks  his  customary 
do.ses  of  alcohol.  If  the  jiatient  is  unwilling  or  unable  to  resort  to  this  form  of 
treatment,  the  einploynu-nt  of  drugs  is  usually  worse  than  useless. 


MORPHINISM  775 

Careful  attention  to  the  digestive  system  is  needful  in  all  these  cases.  The 
liver  should  be  unloaded  by  blue  mass,  followed  by  a  saline  puige,  every  few  days, 
and  bitter  tonics,  such  as  gentian  with  bicarbonate  of  sodium,  are  advantageous. 

MORPHINISM. 

Chronic  morphinism,  or  the  morphine  habit,  is  usually  acquired  as  the  result 
of  the  employment  of  this  drug  for  the  purpose  of  relieving  insomnia.  Sometimes 
the  insomnia  is  due  to  neurasthenia,  but  more  frequently  the  patient  is  one  who 
primarily  suffers  from  sleeplessness  due  to  pain.  If  the  condition  producing  the 
pain  is  continued  over  any  considerable  period  of  time,  the  patient  finally  becomes 
so  dependent  upon  the  use  of  morphine,  as  a  nervous  sedative,  that  he  cannot 
sleep  without  it,  and  so  even  although  the  pain  no  longer  continues  he  resorts  to 
the  drug  for  the  nervous  quiet  which  can  be  obtained  only  under  its  influence. 
Not  infrequently  these  patients  continue  the  use  of  the  morphine  long  after  the 
physician  intends  that  it  should  be  stopped,  and  so  develop  the  habit  of  taking  the 
drug  without  the  knowledge  of  the  physician  who  has  first  prescribed  it.  Because 
of  the  possibility  of  this  occurrence  he  should  prescribe  only  that  quantity  of 
morphine  which  is  absolutely  essential  for  the  relief  of  pain  upon  a  particular 
occasion,  and  if  he  writes  a  formal  prescription  ordering  the  drug  from  a  pharmacist, 
this  prescription  should  contain  the  words  "Do  not  renew,"  so  that  the  patient 
will  not  be  able  to  continue  taking  the  drug  after  the  physician  believes  that  he 
has  stopped  it. 

In  a  certain  number  of  cases  of  morphine  habit,  the  emplo\Tnent  of  the  drug 
rests  upon  the  fact  that  the  patient  is  a  degenerate  without  the  necessary  mental 
and  nervous  vigor  to  meet  the  vicissitudes  of  life.  In  other  words,  he  is  one  who, 
in  the  presence  of  any  condition  which  produces  mental  perturbation  or  distress, 
at  once  resorts  to  some  sedative  to  quiet  his  nervous  system,  instead  of  dominating 
it  by  his  will  power  and  conquering  the  depression  with  a  knowledge  that  any 
yielding  either  to  that  depression  or  to  the  desire  for  a  drug  is  certain  in  the  end 
to  wreck  his  moral  and  physical  condition.  This  is  an  important  factor  to  be  taken 
into  consideration  whenever  a  morphine  habitue  is  to  be  treated.  This  condition 
may  be  hereditary,  or  it  may  be  acquired.  Not  rarely,  when  it  is  acquired,  the 
mental  and  physical  condition  of  the  patient  has  been  impaired  by  grief,  excessive 
business  worry,  illness,  or  other  cause.  ^Yhen  the  morphine  has  been  used  for 
any  length  of  time  this  very  fact  tends  to  increase  the  lack  of  moral  stamina  on 
the  part  of  the  patient. 

Symptoms. — One  of  the  most  noteworthy  symptoms  of  morphinism  is  great 
irritability  of  the  nervous  system  so  that  slight  causes  may  produce  outbreaks  of 
rage,  or,  on  the  other  hand,  a  lachrymose  state  may  develop.  In  some  instances, 
where  the  drug  has  been  used  for  a  long  time,  there  is  not  only  a  loss  in  mental 
power,  but  the  patient  develops  melancholia  or  delusions  closely  resembling  those 
seen  in  an  ordinary  case  of  insanity.  Before  the  mental  degradation  is  so  complete 
that  intellectual  processes  are  greatly  impaired,  the  patient  de^'clops  a  slyness 
quite  different  from  his  ordinary  frank  methods  of  life  when  in  health.  In  associa- 
tion with  this  slyness  there  is  always  developed  a  skill  in  -prevarication  or  lying  which 
is  quite  remarkable.  Persons  who  previously  haA-e  been  regarded  as  eminently 
truthful  tell  the  most  skilful  falsehoods,  and  in  such  a  way  that  the  hearer  is  con- 
vinced of  their  truth.  As  a  rule,  these  falsehoods  are  never  so  cle\'er  as  when  they 
are  intended  to  result  in  the  obtaining  of  the  drug  which  is  desired,  the  patient 
resorting  to  every  possible  means,  honest  and  dishonest,  in  order  that  he  may 
obtain  the  nervous  quiet  which  his  system  craves. 

Treatment. — It  may  be  asserted  with  truth  that  it  is  useless  to  attempt  to  treat 
a  patient  who  is  suffering  from  the  morphine  habit,  with  the  idea  of  curing  him 


77G  IXTOXICATIOXS 

of  his  taste  for  the  drug,  unless  lie  or  she  is  willing  to  enter  a  pri\atc  room  at  a 
hospital  and  be  placed  imder  the  constant  sujxTvision  of  a  night  and  day  nurse. 
This  isolation  is  necessary  not  only  because  it  is  a  form  of  discipline  which  is  advan- 
tageous for  the  mental  condition  of  the  patient,  but  it  is  the  only  way  in  which  the 
physician  can  be  assured  that  the  patient  is  not  surreptitiously  continuing  his 
daily  dose  of  the  narcotic.  It  must  be  remembered  that  the  most  pious  individuals, 
when  they  become  addicted  to  this  drug,  develop  an  extraordinary  ability  to  tell 
lies  which  are  so  like  the  truth  that  they  can  deceive  the  most  cautious.  In  one 
breath,  the  patient,  Avith  tears  running  down  his  face,  will  beseech  the  physician 
to  cure  him  of  the  habit  which  is  destroying  his  haj^piness,  and,  at  the  next  moment, 
he  will  use  every  form  of  deceit  and  cleA-erness  th  obtain  the  drug  which  he  craves. 
Even  when  the  patient  is  under  the  observation  of  trained  nurses  night  and  day, 
any  sudden  improvement  in  his  condition  after  withdrawal  of  the  morphine,  or 
failure  to  develop  symptoms  produced  by  its  withdrawal,  should  make  the  jihysician 
belie\-e  that  in  some  unknown  \\ay  the  drug  has  been  obtained.  In  some  instances 
the  patient  enters  the  hospital  with  the  mori^hine  carefully  sewed  in  the  hem  of 
the  night-dress;  in  others^  a  friend  or  servant  is  bribed  to  bring  the  drug  each  day 
in  some  article  of  food.  Nothing  but  ceaseless  watchfulness  can  possibly  prevent 
these  patients  from  obtaining  morphine.  This  being  so,  it  can  readily  be  understood 
that  home  treatment  can  rarely  succeed. 

Having  obtained  special  control  of  the  patient,  the  method  of  treating  him  would 
consist  in  one  of  two  plans  which  ha-\'e  found  general  accej^tance.  The  first  of 
these  is  the  gradual  diminution  of  the  morphine  so  that  at  the  end  of  three  or  four 
days,  or  a  week,  none  of  the  drug  is  permitted.  If  this  method  is  carried  out  the 
patient  usually  develops  after  a  few  days,  or  sooner,  great  restlessness  and  irri- 
tability, not  infrequently  active  purging,  and  profound  mental  and  physical  depres- 
sion. Cramps  in  the  extremities  also  add  to  the  suft'ering.  Under  these  circum- 
stances it  is  necessary  to  support  the  patient  by  the  use  of  hot,  stimulating  foods, 
such  as  broths  highly  seasoned  with  pepper  and  salt,  the  use  of  digitalis  and  strych- 
nine if  the  circulation  fails,  and  the  emplo^Tiient  of  hyoscyamus  or  hyoscine  to 
diminish  irritability  of  the  nervous  system.  The  employment  of  alcohol,  coca 
wine,  or  similar  stimulants  for  the  purpose  of  aiding  the  patient  at  this  time  is 
is  unwise,  because  he  is  prone  to  develop  the  alcohol  or  coca  habit.  If  the  diarrhea 
is  so  A-iolent  as  to  require  control,  aromatic  sulphuric  acid  with  a  \egetable  astrin- 
gent, like  the  fluid  extract  of  hematoxylon,  may  be  used.  Hot  compresses  may  be 
applied  about  the  painful  limbs.  Great  mental  excitement  may  be  relieved  by 
chloral,  but  the  danger  of  producing  the  chloral  habit  is  not  to  be  forgotten.  In 
place  of  chloral,  sulphonal  or  trional  may  be  used.  Occasionally  nerve  quiet 
can  be  produced  by  A\Tapping  the  patient  in  a  hot,  wet  blanket,  care  being  taken 
that  the  hot  pack  is  not  continued  so  long  as  to  produce  cardiac  depression. 

A  second  method  of  treatment  is  one  which  has  been  largely  employed  in  the 
last  few  years,  and  for  which  we  are  chiefly  indebted  to  a  Texas  physician.  Dr. 
Lott.  This  consists  in  putting  the  patient  where  we  can  haA-e  him  under  absolute 
control,  and  in  the  administration  of  full  doses  of  hyoscine  hypodennically,  giving 
him  as  much  as  f^jj  of  a  grain  every  two  hours,  if  need  be,  until  a  condition  of 
nervous  quiet  is  produced.  In  the  writer's  experience  these  large  doses  fail  to 
produce  sleep,  and  instead  cause  a  condition  in  which  the  patient  lies  awake  but 
stupefied,  and  often  mumbles  continuously.  Curiously  enough  the  mouth  does 
not  become  as  dry  as  one  would" ex]5cct  from  the  administration  of  such  a  poA\erful 
drug  in  these  large  doses.  Should  the  circulation  seem  at  all  feeble,  .strychnine 
may  also  be  given.  The  idea  in  employing  hyoscine  is  to  use  that  quantity  Avhich 
is  necessary  to  keep  the  patient  under  control,  and  to  prevent  suffering.  These 
doses  may  be  continued  for  a  number  of  days,  at  the  end  of  which  time  they  are 
gradually  diniinishcd  and  the  patient  is  permitted  to  return  to  his  normal  condition 


ARSENICAL  POISONING  777 

as  the  efl'ects  of  the  hyoscine  pass  away.  By  this  means  the  acute  mental  and 
physical  suffering  caused  by  tlie  sudden  withdrawal  of  morphine  is  avoided,  and 
in  some  instances  the  patient  actually  seems  to  be  cured  of  his  malady,  although, 
of  course,  there  is  great  danger  in  every  case  of  his  speedily  returning  to  its  use, 
particularly  if  any  nervousness  or  mental  stress  is  experienced.  So  common  is  it 
for  the  habitue  to  go  back  to  the  employment  of  this  drug  habit  that  many  men 
of  experience  have  gone  so  far  as  to  assert  that  no  case  of  the  morphine  habit  is 
ever  permanently  cured.  This  view  is,  however,  undoubtedly  incorrect.  The 
writer  has  seen  a  number  of  cases  in  which  permanent  cure  certainly  took  place. 

ARSENICAL  POISONING. 

Arsenical  poisoning  occurs  in  two  forms,  the  acute  and  chronic.  Usually  after 
the  first  stage  of  acute  poisoning,  if  the  patient  surs'ives,  there  develops  a  second 
stage  due  to  the  effects  of  the  arsenic.  Acute  poisoning  usually  follows  the 
ingestion  of  "Rough-on-Rats,"  Paris  green,  or  Scheele's  green.  The  s\"mptoms 
are  those  of  severe  gastro-enteritis,  with  vomiting  and  purging,  followed  by  death 
in  collapse.  The  antidote  is  the  hydrated  sesquioxide  of  iron  with  magnesia. 
When  the  patient  survives  the  acute  stage  he  suffers  from  secondary  lesions  in  the 
stomach  and  intestines,  kidneys,  and  liver.  Widespread  fatty  degeneration  also 
occurs  and  peripheral  neuritis  may  be  present.' 

The  causes  of  chronic  arsenical  poisoning  are  almost  as  numerous  as  are  those 
of  lead  poisoning.  It  may  find  its  way  into  the  body  through  the  lungs  from  the 
air  of  a  room  the  walls  of  which  are  covered  by  a  paper  heavily  laden  with  arsenical 
dyes;  it  may  enter  in  beer  made  from  glucose  prepared  by  the  use  of  iron  pyrites 
contaminated  with  arsenic,  as  in  the  recent  celebrated  epidemic  in  England;  or  it 
may  be  given  in  moderate  poisonous  dose  for  a  long  time  with  homicidal  intent, 
as  in  a  case  recently  tried  in  the  Philadelphia  courts. 

Not  very  rarely  a  mild  form  of  chronic  arsenical  poisoning  is  met  with  in  cases 
to  which  a  physician  has  found  it  necessary  to  give  large  doses  of  arsenic  for  long 
periods,  as  in  chorea,  in  leukemia,  and  Hodgkin's  disease. 

Symptoms. — Chronic  arsenical  poisoning  manifests  itself  chiefly  in  the  form  of  a 
widespread  perifheral  neuritis,  with  the  development  of  a  secondary  degeneration 
of  the  epithelium  of  the  kidneys.  The  chief  symptoms  are  tingling  and  i^ains 
in  the  limbs,  followed,  after  a  time,  by  paralysis  which  affects  the  distal  portions 
of  the  body  much  more  than  it  does  the  nerves  and  muscles  of  the  thighs  or  arms. 
Atrophy  of  the  muscles  supplied  by  the  paralyzed  nerves  soon  takes  place.  Other 
trophic  changes  also  develop,  such  as  herpetic  eruptions  resembling  those  of  herpes 
zoster  or  pemphigus,  and  glossiness  of  the  skin  sometimes  supervenes.  At  times 
curious  deposits  of  pigment  take  place  in  the  skin.  As  in  lead  poisoning,  the  nerve 
supply  to  the  extensor  muscles  suffers  chiefly,  but  in  addition  the  small  flexor  muscles 
are  also  affected  much  more  commonly  than  they  are  in  neuritis  due  to  alcohol 
or  lead.  The  lower  limbs  are  aft'ected  as  much  as  the  upper  limbs,  whereas  in 
lead  poisoning  it  is  the  upper  extremities  which  suffer  most.  Again,  arsenical 
neuritis  affects  the  sensory  and  motor  fibres,  and  for  this  reason  pain  as  well  as 
anesthesia  is  often  met  with.  The  pulse  is  quickened  and  the  mind  confused  in 
some  cases.  Because  of  the  involvement  of  the  sensory  and  motor  fibres  of  the 
peripheral  nerves  the  patient  may  present  symptoms  of  tabes  dorsalis  {arsenical 
pseudotabes) .  The  Argyll-Robertson  pupil  is  a  useful  differential  factor,  for  if  it  is 
present  the  cause  of  the  disordered  gait  is  probably  due  to  true  locomotor  ataxia. 

Prognosis. — The  prognosis  in  such  cases  depends  upon  the  severity  of  paralysis 
and  the  state  of  the  kidneys.     If  the  latter  organs  are  affected  the  outlook  is  more 

'  For  this  train  of  symptoms  see  the  author's  Text-boolc  of  Therapeutics,  15th  edition. 


778  INTOXICA  770.V.S' 

grave  than  if  they  are  intact.  Even  when  the  symptoms  of  neuritis  are  severe, 
remarkable  recovery  may  ensue  if  the  i)atient  is  remo\'efi  from  tlie  c.xpf)siire  to  the 
(Irus;- 

Treatment. — The  treatment  consists  in  the  removal  from  exposure,  the  use  of 
iodide  of  ])otassium  to  aid  in  the  elimination  of  the  poison,  the  administration 
of  strychnine  in  full  doses  if  the  nerves  are  not  irritable,  and  in  the  application  of 
massage  and  electricity  to  improve  the  nutrition  of  the  affected  parts.  Iron  may 
be  used  to  combat  the  anemia. 


LEAD  POISONING  OR  PLUMBISM. 

Acute  lead  poisoning  is  not  of  frequent  occurrence.  Its  consideration  is  distinctly 
toxicological  in  character,  and  for  this  reason  it  is  not  discussed  in  these  pages. 

Chronic  lead  poisoning,  on  the  other  hand,  is  of  exceedingly  common  occurrence, 
not  only  in  those  who  are  exposed  to  the  poison  by  reason  of  their  occupation,  but 
in  persons  who  have  suffered  no  such  exposure  but  have  absorbed  the  lead  from 
sources  in  which  its  presence  would  not  be  suspected.  Further  than  this,  lead 
poisoning  in  its  clu-onic  form  may  produce  the  most  varied  symptoms,  which  are 
oftentimes  so  unusual  that  no  thought  of  lead  as  a  cause  is  entertained.  In  speaking 
of  the  nervous  manifestations  which  are  often  present,  a  well-known  teacher  was 
wont  to  say:  "When  you  cannot  explain  a  curious  train  of  nervous  s^^^lptoms, 
always  suspect  SA'philis,  hysteria,  or  lead  as  the  cause." 

Etiology. — It  is  the  insoluble  rather  than  the  soluble  salts  of  lead  which  usually 
cause  chronic  lead  poisoning.  The  most  frequent  sufferers  are  workers  in  manu- 
factories where  paint  is  made,  and  house  painters  who  are  continually  engaged  in 
the  handling  of  lead  paint.  In  rarer  instances  the  patient  is  poisoned  by  the  use 
of  water  which  in  passing  through  new  lead  pipes  dissolves  some  of  the  lead;  or 
lead  is  present  in  a  hair-dye  or  cosmetics  and  is  absorbed  by  the  skin;  or,  again,  it 
has  occurred  that  a  miller  has  filled  holes  in  his  grind.stones  with  lead,  which  has 
then  been  ground  with  the  flour  and  eaten  in  bread.  In  one  instance,  in  Pennsyl- 
vania, a  peddler  sold  a  large  number  of  crocks  to  farmers'  wives.  In  these  was 
placed  apple  butter,  and  as  the  acid  in  the  fruit  eroded  the  lead  glazing  which 
lined  the  jars,  a  widespread  epidemic  of  chronic  lead  poisoning  developed.  Perhaps 
the  most  notorious  illustration  of  how  lead  may  cause  poisoning  in  unsuspecting 
persons  is  the  celebrated  "chrome-yellow  cases"  in  Philadelphia,  in  which  a  whole- 
sale druggist  sold  chrome  yellow  to  a  number  of  confectioners,  who  saved  the  cost 
of  eggs  by  coloring  their  cakes  with  this  substance.  As  a  result  a  large  number  of 
men,  women,  and  children  died,  and  a  much  larger  number  suffered  from  c'hronic 
poisoning  for  months  before  the  source  of  the  trouble  was  discovered.  An  extraor- 
dinary cause,  however,  is  the  habit  of  chewing  silk  thread  weighted  with  lead. 
At  least  two  cases  of  chronic  poisoning  from  this  cause  have  been  met  with  in 
seamstresses. 

The  fact,  therefore,  that  no  history  of  exposure  to  lead  is  to  be  found  in  a  given 
case  does  not  negative  the  diagnosis  of  lead  poisoning. 

Prevention. — Chronic  lead  poisoning  is  to  be  prevented  in  workers  in  lead  by 
the  exercise  of  the  greatest  possible  cleanliness  as  to  their  hands,  which  should  lie 
thoroughly  washed  before  food  is  touched,  as  othenvise  lead  may  be  taken  in 
small  amounts  and  finally  cause  poisoning.  If  the  workman  is  employed  in  grinding 
lead,  he  must  wear  a  mask  to  prevent  the  poison  from  being  inhaled  in  dust.  The 
u.se  of  vessels,  the  glazing  of  which  contains  lead,  for  holding  food  should  be  avoided. 
Small  amounts  of  dilute  sulphuric  acid  to  form  insoluble  sulphates  in  the  mouth  and 
stomach  may  be  resorted  to,  and  i)urgation  every  few  days  by  sulphate  of  mag- 
nesium is  ad\antageous. 


LEAD  POISONING  OR  PLUMBISM  779 

Pathology  and  Morbid  Anatomy. — There  is  no  other  poison  from  the  mineral 
kingdom  ■which  taken  into  the  l)o(ly  produces  such  widespread  changes  in  different 
organs  as  does  lead  in  the  chronic  form  of  jioisoning.  Even  alcohol,  that  most 
ubiquitous  poison,  does  not  cause  such  a  multitude  of  changes.  The  nervous 
system  is  the  portion  of  the  body  which  bears  the  brunt  of  the  attack,  and  it  is  the 
peripheral  ner\'es  that  suffer  most.  In  them  the  lead  produces  a  toxic  neuritis. 
In  advanced  cases  there  is  segmentation  of  the  myelin  and  breaking  up  of  the  axis 
cylinder,  with  a  proliferation  of  the  imclei  in  the  sheath  of  Schwann.  The  early 
changes  in  the  nerves  affect  chiefly  the  medullary  sheath,  which  is  affected  in  patches 
at  irregular  intervals — the  so-called  periaxial  neuritis  of  Gombault.  Although 
the  lesions  are  more  severe  as  the  distal  end  of  the  nerves  is  approached,  Dejerine 
has  found  them  even  in  the  anterior  roots.  Conspicuous  changes  in  the  .spinal 
cord  are  almost  never  seen,  but  Oppenheim  states  that  he  has  found  alterations 
in  the  anterior  cornua,  and  Gowers  asserts  that  in  some  cases  the  cells  in  these 
cornua  are  degenerated.  No  constant  lesions  are  found  in  the  brain,  even  in 
those  cases  in  which  severe  cerebral  symptoms  are  present,  except  those  dependent 
upon  vascular  lesions  which  are  part  of  the  general  vascular  disease  produced  by 
the  poison. 

It  is  to  be  especially  noted  that  the  sensory  fibres  of  the  nerves  are  not  affected, 
and  that  the  musculospiral  is  the  ner\-e  chiefly  involved  in  those  cases  which  have 
peripheral  neuritis.  As  a  result  of  the  neuritis,  produced  by  the  lead,  atrophy 
of  a  severe  character  may  develop  in  the  muscles  supplied  by  the  affected  nerves. 
Fatty  degeneration  of  the  muscles  does  not  ensue.  The  second  portion  of  the  body 
to  feel  the  effect  of  the  lead  is  the  kidneys,  which  are  not  rarely  the  seat  of  chronic 
interstitial  nephritis,  and  with  this  renal  lesion  a  process  of  arterioflbrosis  develops, 
which  associated  conditions  often  cause  the  death  of  the  patient. 

Sailer  has  recently  shown  that,  in  some  cases  at  least,  there  is  an  absence  of 
hydrochloric  acid  in  the  gastric  juice. 

Symptoms. — From  what  has  been  said  of  the  changes  in  various  organs  caused 
by  lead,  it  is  evident  that  the  symptoms  may  be  very  varied.  Paralysis  of  the 
extensor  imtscles  of  the  forearm,  causing  wrist-drop,  is  the  most  constant  sjTnptom. 
This  paralysis  is  nearly  always  bilateral,  but  occasionally  but  one  arm  is  affected. 
The  supinator  longus  muscle  and  the  short  extensor  of  the  thmnb,  however,  usually 
escape,  Avhich  is  curious  in  view  of  the  fact  that  the  supinator  longus  muscle  receives 
its  nerve  supply  from  the  musculospiral  nerve.  In  atypical  cases  Oppenheim 
states  that  the  supinator  longus,  the  biceps,  and  even  the  deltoid  are  involved. 

In  the  legs  palsy  is  far  less  frequent  than  in  the  forearms,  and  the  muscles  im'olved 
are  the  peroneal  group,  but  the  tibialis  anticus  is  not  affected. 

Although  motor  paralysis  is  present  sensory  disturbances  are  rare. 

Palsy  of  the  ocular  muscles  producing  squifit  may  be  due  to  lead,  as  may  also 
optic  neuritis.  In  very  rare  cases  of  se^^ere  phuribism  cerebral  sjTnptoms  develop, 
consisting  in  epileptiforvi  conmlsions,  or  coma.  This  state  is  called  "  encephalopathia 
saturnina." 

Tremor  of  the  forearms  is  sometimes  present  in  lead  poisoning. 

Chronic  lead  poisoning  greath^  aids  in  producing  go2tty  lesions,  probably  by 
forming  a  urate  of  lead  in  the  tissues  about  the  joints.  Others  believe  that  the 
lead  decreases  the  alkalinity  of  the  blood  and  so  permits  the  precipitation  of  urates 
to  occur. 

There  still  remain  to  be  considered  several  sjTnptoms  of  chronic  lead  poisoning 
which  are  so  constant  in  their  appearance  and  so  characteristic  that  they  are  most 
valuable  aids  in  diagnosis.  The  first  of  these  is  the  bhie  line  in  the  edges  of  the 
gums  next  the  teeth,  formed  by  the  deposit  of  sulphide  of  lead  in  the  capillaries 
of  the  part.  This  sign  is  often  absent  in  those  who  are  cleanly  in  the  care  of  the 
mouth.     The  second  is  the  characteristic  pain  in  the  belly,  which  is  exceedingly 


780  INTOXICATIONS 

severe  in  the  region  of  the  umbilicus,  and  is  described  as  a  j)ain  due  to  twisting 
the  bowels  around  a  stick.  This  is  called  "painters'  colic,"  or  "colica  pictonuni." 
The  latter  term  is  given  to  this  state  because  it  was  frequently  met  with  in  Picton 
at  one  time.  A  third  sjiiiptom  of  chronic  lead  poisoning  is  anemia,  which  is  in 
part  due  to  the  direct  efi'ect  of  the  lead  and  in  part  to  the  renal  changes  induced 
by  this  agent.  Microscopic  examination  of  the  Ijlood  will  often  reveal  a  r/raniilar 
degeneration  of  the  erythrocytes. 

Diagnosis. — In  a  case  in  which  the  blue  line  on  the  gum  is  present  the  diagnosis 
is  easy.  When  wristTdrop  is  present  it  must  be  separated  from  that  due  to  pressure, 
as  by  resting  the  head  on  the  arm  when  sleeping  or  liy  the  pressure  of  a  crutch. 
As  a  rule,  pressure  palsy  is  unilateral  and  lead  palsy  bilateral,  but  this  is  not  so 
invariably,  and  the  history  of  the  patient  may  be  necessary  to  decide  the  diagnosis. 
When  the  palsy  is  distributed  in  various  parts,  particularly  if  it  affects  the  legs,  it 
must  be  separated  from  acute  poliomyelitis.  Lead  poisoning  is  rare  in  children 
and  acute  poliomyelitis  is  common.  In  adults  chronic  lead  poisoning  is  more 
frequent  than  is  acute  poliomyelitis.  Poliomyelitis  in  its  acute  form  has  a  history 
of  sudden  onset  with  fever,  and  the  onset  of  lead  palsy  is  rarely  so  abrupt  and  is 
usually  not  febrile.  The  history  of  exposure  to  lead  will  aid  in  deciding  the  diagno- 
sis. In  chronic  poliomyelitis  the  only  way  to  determine  the  question  is  by  the 
history  and  the  frequent  examination  of  the  patient's  urine  for  lead.  Often  lead 
will  not  be  found  in  the  urine  unless  iodide  of  potassium  is  given  to  set  it  free  from 
the  tissues  where  it  has  been  deposited. 

Saturnine  epilepsy  must  be  separated  from  true  epilepsy  by  the  history  of  the 
patient  and  by  the  association  of  other  signs  of  phmibism.  It  must  also  be  separated 
from  uremic  convulsions,  if  possible,  by  the  urinary  examinations,  but  this  may 
be  impossible  because  the  lead  may  at  once  cause  encephalopathia  saturnina  and 
uremia  through  its  effects  on  the  cerebral  vessels  and  the  kidneys. 

Prognosis. — The  prognosis  as  to  the  duration  of  life  in  chronic  lead  poisoning 
is  good  unless  cerebral  sjinptoms  are  present,  or  renal  changes  are  well  marked. 
The  prognosis  as  to  the  paralysis  depends  largely  upon  the  general  nutrition  of 
the  patient  and  the  stage  to  which  the  neuritis  has  advanced.  If  the  muscles 
involved  have  lost  all  reaction  to  electrical  stimulation,  the  prognosis  must  be  bad 
as  compared  with  that  in  a  case  in  which  the  palsy  has  lasted  for  but  a  short  time. 
Even  when  the  reactions  of  degeneration  are  present  the  outlook  is  not  hopeless, 
because  if  the  patient  is  no  longer  exposed  to  the  poison  recovery  sometmies  ensues, 
particularly  in  young  persons. 

Treatment. — The  treatment  of  chronic '  lead  poisoning  consists  in  removing 
the  patient  from  continued  exposure  to  the  poison.  If  he  is  an  artisan  he  must 
cease  working  in  lead.  If  he  has  been  poisoned  by  the  metal  through  some  accident, 
the  source  must  be  discovered  and  he  must  no  longer  be  exposed  to  it. 

The  second  duty  of  the  physician  is  to  eliminate  the  lead  already  in  the  body 
as  rapidly  as  possible.  For  this  purpose  the  iodide  of  potassium  should  be  given 
in  full  doses,  with  the  object  of  forming  double  soluble  iodides  with  the  lead.  Not 
only  have  we  every  reason  to  believe,  from  a  chemical  standpoint,  that  this  medi- 
cinal treatment  is  advantageous,  but  it  is  a  well-known  clinical  fact  that  chemical 
examination  of  the  urine  in  a  case  of  lead  poisoning  will  fail  repeatedly  to  show 
lead,  and  will  at  once  indicate  its  presence  after  iodide  of  potassium  is  administered, 
proving  that  by  this  means  lead  is  carried  to  the  kidneys  and  speedily  passed  out 
of  the  body.  It  must  also  be  remembered  that  the  liAer  eliminates  lead  freely  in 
the  bile. 

The  third  indication  is  to  improve  the  patient's  general  health  not  only  by 
the  use  of  such  tonics  as  iron  and  strychnine,  but  also  by  ordering  an  out-door 
existence,  with  as  much  sunshine  as  it  is  possible  for  the  patient  to  find  in  the 
twentv-four  hours. 


FOOD  POISONING  781 

The  paralysis  of  chronic  lead  poisoning  is  to  be  treated  by  the  administration 
of  full  doses  of  strychnine  and  the  simultaneous  use  of  large  doses  of  iodide  of 
potassium.  The  paralysis  of  the  extensor  muscles  of  the  arms  and  legs  is  to  be 
treated  not  only  by  the  use  of  strychnine,  but  by  the  emplovment  of  the  slowly 
and  rapidly  interrupted  faradic  current.  In  those  cases  in  which  cerebral  sjinptoms 
develop,  the  patient  should  receive  full  doses  of  iodide  of  potassium,  with  the 
object  of  getting  rid  of  the  lead  as  rapidly  as  possible.  If  the  s\-mptoms  are  acute, 
and  if  a  convulsion  is  already  present,  the  patient  should  receive  a  hot  pack  in 
order  that  the  sedative  effect  of  this  therapeutic  measure  may  be  exercised  upon 
the  nervous  system,  in  order  that  the  blood  may  be  drawn  away  from  the  congested 
brain,  and  with  the  hope  that  by  increasing  the  action  of  the  skin  the  kidneys 
may  be  relieved  of  some  of  the  work  which  they  would  otherwise  be  forced  to 
perform.  In  other  respects  the  convulsions  should  be  treated,  as  are  all  other 
convulsions,  by  the  use  of  nitrite  of  amyl  inhalations,  and  by  the  employment  of 
full  doses  of  chloral  and  the  bromides  to  ciuiet  the  brain  and  spinal  cord. 

Painters'  colic  with  its  attendant  constipation  is  not  to  be  treated  by  the  use 
of  purgatives,  but  by  the  use  of  morphine  given  hA-podermically.  This  drug, 
which  so  often  causes  constipation  in  the  ordinary  patient,  not  rarely  produces 
active  purgation  in  these  cases,  by  quieting  the  intestinal  irritation  and  spasm  and 
simultaneously  relieving  the  pain. 

FOOD  POISONING. 

Bromatotoxismus. — Symptoms  of  poisoning  produced  by  the  ingestion  of  food 
which  is  impure  by  reason  of  faulty  preparation,  or  the  changes  due  to  decomposi- 
tion, are  occasionally  met  with.  It  is  rather  remarkable,  considering  the  long  period 
of  time  during  which  many  foods  are  kept  after  they  are  prepared  for  the  table, 
that  more  cases  of  poisoning  do  not  ensue.  ]Much  of  the  information  given  in 
this  article  is  obtained  from  the  excellent  summary  of  this  subject  which  can  be 
found  in  Vaughan  and  No^y's  Cellular  Toxins. 

Poisoning  may  be  produced  by  the  use  of  grains  which  have  become  infected 
by  poisonous  fungi.  Animals  may  eat  substances  which  may  render  their  milk 
or  flesh  or  both  poisonous.  The  flesh  of  certain  animals  also  becomes  poisonous 
at  certain  stages  of  their  life  history.  Foods  may  also  become  infected  by  the 
discharges  of  himian  beings;  the  flesh  of  animals  may  suffer  from  some  specific 
disease  which  may  be  transmitted  to  man,  and  milk  may  carry  the  disease  of  an 
animal  to  man  or  may  be  infected  by  the  discharges  of  man,  and  so  convey  specific 
germs  to  other  individuals.  Food  may  also  contain  micro-organisms  which  in 
their  process  of  development  produce  poisonous  sjTnptoms  in  man. 

Sitotoxismus  is  applied  to  poisoning  by  vegetable  foods  which  are  infected  by 
moulds  or  bacteria. 

The  most  familiar  form  of  poisoning  by  grains,  or  vegetable  food,  is  Ergotism 
due  to  the  eating  of  rye  flour  made  from  rye  which  has  been  infected  by  the  fungus 
Claviceps  purpurea.  This  ergot  is,  of  course,  largely  employed  in  medicine.  Several 
poisons  are  found  in  ergot,  such  as  ergotinic  acid,  sphacelinic  acid,  and  cornutin. 
The  first  of  these,  however,  seems  to  be  poisonous  only  when  it  is  injected  hypo- 
dermically.  Sphacelinic  acid,  on  the  other  hand,  is  supposed  to  be  responsible 
for  the  gangrene  and  cachexia  which  sometimes  develop  in  persons  who  have  eaten 
infected  rye.  On  the  other  hand,  cornutin  seems  to  be  the  poison  which  affects  the 
nervous  system  and  produces  spasms  and  convulsions. 

Mytilotoxismus. — Under  the  name  of  mytilotoxismus  is  described  the  symptoms 
of  poisoning  which  are  produced  by  eating  poisonous  mussels.  These  symptoms 
consist  in  some  cases  in  violent  gastro-intestinal  irritation  with  purging,  but  in  the 
majority  of  instances  the  manifestations  of  the  poisoning  are  nervous  in  character. 


782  JXTOXICATIONS 

A  rash  rescmhlirif;  urticaria  and  finally  becoming  vesicular  may  develop  over  the 
body,  and  the  eyelids  may  be  so  swollen  as  to  prevent  vision  by  extravasation  of 
the  serum  into  their  tissues.  There  is  often  difficulty  in  breathing,  apparently 
due  to  intense  hyperemia  of  the  bronchial  mucous  membrane.  Convulsions  and 
coma  may  develop  and  death  may  be  due  to  tliis  cause. 

Treatment. — The  treatment  of  mytilotoxismus  consists  in  the  use  of  an  acti\e 
saline  cathartic  to  sweep  the  poisonous  material  from  the  alimentary  canal,  and 
in  the  use  of  ether  as  a  diffusil)le  stimulant. 

Ichthyotoxismus. — When  fish  produces  poisonous  symptoms  the  term  ichthyo- 
toxismus  is  used  to  describe  the  condition.  As  is  well  known,  certain  fish  are 
unfit  to  eat,  and  other  fish  become  poisonous  during  the  season  at  which  they  are 
spawning.  In  still  other  instances  fish  suffer  from  bacterial  infections  which  render 
their  flesh  unsuitable  as  food.  The  ingestion  of  poisonous  fish  so  seldom  occurs, 
at  least  in  this  country,  that  the  symptoms  produced  need  not  be  descril)ed. 

Poisoning  from  the  fle.sh  of  fish  which  has  undergone  decomposition  is  often 
very  violent  in  its  manifestations.  The  mo.st  common  symptoms  are  dilatation 
of  the  pupils,  nausea,  vomiting,  and  severe  abdominal  pain,  followed  by  the  develop- 
ment of  a  scarlatinal  rash  all  over  the  body.  In  such  cases  a  purge  to  sweep  out 
the  ofVending  materials  and  also  stimulants  are  needed. 

Kreotoxismus. — The  word  kreoioxismus  is  applied  to  poisoning  resulting  from 
the  ingestion  of  meat  unfit  for  food,  because  of  the  presence  of  bacterial  or  animal 
poisons.  Perhaps  the  most  frecjuent  instance  of  this  is  in  so-called  sausage  poison- 
ing. Sausages  are  often  made  from  what  may  be  called  the  refuse  following  the 
butchering  of  animals  ordinarily  employed  as  food,  and  the  treatment  of  this 
material  is  such  that  early  decomposition  changes  may  readily  set  in.  In  most 
instances  the  process  of  cooking  destroys  the  poisons,  but  M'hen  cooking  is  not 
resorted  to  the  sjTiiptoms  which  are  induced  are  exceedingly  se\ere,  and  death 
may  ensue.  There  is,  in  many  cases  of  sausage  poisoning,  difficulty  in  breathing 
and  swallowing,  violent  vomiting,  severe  abdominal  pain,  hoarseness,  dimness  of 
vision,  and  delirimn.  In  other  cases  the  mind  remains  clear.  I'rom  some  of 
the.se  forms  of  food  ptomaines  have  been  isolated.  In  other  instances  certain 
bacteria  have  been  found  which  have  been  considered  responsible,  either  directly 
or  indirectly,  for  tiie  symjrtoms.  ]Meat-i)ie  poisoning  and  poisoning  by  mince-meat 
arc  essentially  similar  to  sausage  poisoning. 

Tyrotoxismus  and  Galactotoxismus. — Under  the  name  gaIacfoto.ri.wuis  is  de- 
described  the  jwisoning  which  results  from  tlie  ingestion  of  impure  milk.  When 
poisoning  follows  the  use  of  bad  cheese  it  is  called  ti/rofo.rismiis.  This  term  is  also 
applied  to  the  poisoning  produced  by  impure  ice-cream.  The  symptoms  are 
sometimes  exceedingly  severe,  and  consist  in  evidences  of  gastro-enteritis  followed 
by  collapse.  To  a  substance  which  Yaughan  states  he  is  able  to  isolate  from  cheese 
and  ice-cream  he  gave  the  name  of  "tyrotoxicon." 


PELLAGRA. 

Synonyms. — Erythema  eudemicum,  Lombardiau  leprosy,  P.tyclioneurd.si.'i  itiaidica, 
Mai  de  .sole,  and  many  other  terms. 

History. — Pellagra  is  a  disease  -which  has  been  recognized  for  more  than  250 
years,  but  the  first  authentic  study  of  it  was  made  by  Casal,  a  Spaniard,  in  17.35, 
although  his  account  of  it  did  not  appear  until  1762.  In  1771  Frapolli  of  Milan 
gave  it  the  name  pellagra  which  had  already  been  given  it  by  the  laity.  In  the 
United  States  the  first  case  was  not  adequately  reported  until  1902  by  Sherwell. 
In  the  same  year  Harris,  of  Atlanta,  recorded  another  case.  The  first  large  series 
of  cases  which  called  general  attention  to  the  malady  was  reported  by  Searcy,  in 


PLATE    XI 


Atrophy   of  the   Skin    of  the    Back   of  the   Hand 
succeeding    Pellagrous    Erythema. 


Reproduced   through   the    courtesy   of    Prof.    Luclwig    Merk,    of    Ii 


PELLAGRA  7S3 

an  insane  asylum  in  Mt.  Vernon,  Alabama,  in  1907.  Since  that  time  hunrlreds 
of  cases  have  been  recorded  and  medical  literature  has  teemed  with  its  discussion. 

In  Italy  in  the  latter  part  of  the  last  century  pellagra  was  so  prevalent  as  to 
affect  1  in  19  of  the  inhabitants,  but  it  has  now  been  largely  eradicated.  It  has 
been  reported  in  nearly  all  civilized  and  semi-civilized  countries. 

Etiology. — The  cause  of  pellagra  is  unknown.  A  large  number  of  investigators 
believe  it  to  be  due  to  damaged  corn  which  is  impaired  in  its  nutritional  value  or 
contains  a  fungus  which  is  productive  of  the  symptoms.  Still  others  think  it  a 
result  of  the  growth  of  some  other  form  of  micro-organism  in  the  corn  which  induces 
an  intoxication.  Sambon  and  his  followers  believe  it  to  be  induced  by  the  bite 
of  the  simulium  reptans,  a  small  insect  of  worldwide  distribution.  It  is  certain 
that  care  as  to  corn  used  as  food  prevents  the  disease. 

Pellagra  is  a  non-contagious  and  non-hereditary  disease  characterized  by  great 
variation  in  its  manifestations  but  chiefly  in  its  early  stages  by  an  er\thematous 
appearance  of  the  skin  of  the  forearms  and  hands  on  the  extensor  surfaces,  and  of 
the  face,  associated  with  a  sense  of  languor  and  wretchedness  particularly  in  the 
spring  months,  at  which  time  the  disease  nearly  always  develops.  These  s\Tnptoms 
if  mild  in  many  cases  disappear  to  return  with  the  advent  of  the  next  spring,  and 
by  frequent  recurrence  finally  become  constant,  or  in  the  severe  cases  there  may 
be  no  such  period  of  immunity.  The  manifestations  of  the  disease  may  therefore 
extend  over  many  years  and  the  malady  is  never  acute  in  the  sense  of  running  a 
short,  sharp,  course  as  do  many  acute  infectious  diseases.  In  rare  instances  an 
acute  type  of  pellagra  is  met  with  which  has  its  onset  in  a  sharp  attack  of  vomiting, 
headache,  and  diarrhea.,  the  latter  condition  being  so  severe  as  to  resemble  dysen- 
tery. Not  only  is  blood  in  the  stools,  but  bleeding  from  the  gmns  and  tongue 
may  occur.  Fever  as  high  as  102°,  in  some  cases  is  present,  and  emaciation  is 
rapid  and  severe.  Death  nearly  always  occurs  in  these  cases  after  a  period  of 
about  two  to  six  weeks. 

The  more  severe  sjTuptoms  of  pellagra  appearing  in  those  who  have  the  well 
developed  type  consist  in  obstinate  diarrhea,  the  tongue  is  denuded  of  epithelium 
and  sometimes  ulcerated.  Not  rarely  a  collar-like  erj-thema  appears  on  the  neck 
where  the  collar  band  of  the  shirt  encircles  it  {il  coUare  peUagroso). 

All  parts  of  the  skin  exposed  to  weather  are  often  involved  so  that,  in  bare-footed 
persons,  the  dorsum  of  the  foot  may  be  affected  like  the  back  of  the  hands.  Ulti- 
mately the  whole  leg  or  forearm  on  both  surfaces  may  be  affected.  The  er\'thema 
is  red,  yet  not  as  bright  in  hue  as  in  acute  sunburn,  and  disappears  on  pressure, 
but  when  the  disease  is  well  developed  is  not  altered  greatly  by  pressure,  and 
becomes  darker  in  hue  or  even  plum  colored.  In  some  cases  the  early  erythematous 
rash  disappears  after  a  short  time,  a  fine  desquamation  of  the  skin  taking  place, 
followed  by  pigmentation.  In  the  dark  races  the  skin  may  be  grayish  in  hue  and 
darker  than  normal  in  the  affected  parts.  The  patient  complains  of  a  sense  of 
tenseness  or  swelling  in  the  affected  parts  and  of  heat  and  burning,  but  itching 
is  not  common.  In  other  instances  vesicular  or  bullous  eruptions  take  the  place 
of  the  dry  erythema  just  described  ("Wet  Pellagra").  Such  eruptions  are  char- 
acteristic of  the  severe  types.  After  repeated  exacerbations  and  fadings  of  the 
erythema  the  skin  atrophies,  appearing  as  a  thin  parchment-like  membrane,  but 
in  the  wet  type  ulcerations  may  extend  as  deeply  as  the  tendons  of  the  hand.  Even 
these  deep  lesions  may  heal. 

As  the  disease  develops  into  its  second  stage  nervous  manifestations  take  place. 
The  languor  of  the  first  stages  changes  into  a  more  or  less  profound  melancholia 
and  sometimes  there  are  suicidal  tendencies,  particularly  by  drowning.  In  other 
instances  delusions  of  persecution  are  met  with  and  finally  stupor  and  coma  develop. 
In  Italy  the  mental  disorders  seem  more  common  than  in  the  United  States. 

A  third  set  of  symptoms,  connected  with  the  alimentary  canal,  may  develop 


784  INTOXlCAriOXS 

in  any  stage  of  the  disease,  often  as  early  as  the  enlhema.  Tliey  consist  chiefly 
in  an  intractable  diarrhea,  often  dysenteric  in  character.  There  may  be  also  much 
meteorism  and  pyrosis. 

When  the  disease  reaches  its  final  stages  in  addition  to  the  stupor  or  coma  already 
described  the  patient  becomes  typhoidal  in  appearance  and  for  the  first  time  may 
have  fever.  There  is  profound  prostration,  marked  wasting  and  a  low  delirium. 
At  the  close  there  may  be  opisthotonos. 

An  examination  of  the  blood  does  not  show  any  marked  changes.  The  red 
cells  are  moderately  decreased  in  number  and  do  not  show  degenerative  changes. 
The  relative  number  of  the  wliite  cells  is  approximately  normal  but  there  may  be 
a  slight  leukocj'tosis  of  about  13,000. 

Autopsy  shows  a  general  atrophy  of  the  fatty  and  muscular  tissues,  especially 
of  the  muscular  coat  of  the  bowel.  The  liver  is  enlarged,  the  spleen  shrunken  and 
the  ribs  very  fragile.  The  kidneys  are  cirrhotic  and  the  large  vessels  atheromatous. 
The  nervous  lesions  consist  in  hemorrhages  into  the  subarachnoid,  and  the  meninges 
of  the  brain  and  cord  are  thickened  by  low-grade  chronic  inflammation.  Curiously 
enough  the  periplieral  nerves  seem  to  escape  but  degenerations  of  tlie  posterior 
and  posterolateral  columns  of  the  cord  are  marked  and  the  nerve  triuiks  show 
degeneration  of  the  myelin  sheath.  Harris  has  also  emphasized  the  presence  of 
pancreatic  atrophy. 

Prognosis. — Much  depends  on  the  severity  of  the  symptoms  and  \\hether  the 
patient's  conditions  of  life  can  be  changed  as  to  habits,  food  and  climate.  The 
mortality  based  on  all  cases  is  said  to  be  about  10  per  cent.,  but  this  includes  the 
very  mildest  manifestations.  A  more  correct  percentage  is  probably  about  35 
per  cent. 

Treatment. — As  far  as  is  known  there  is  no  cure  for  pallagra  so  far  as  any  drugs 
are  concerned,  and  perhaps  not  even  under  suitable  dietary  and  climatic  influences. 
Arsenicals  have  been  used  in  large  doses  with  asserted  benefit.  The  best  of  these 
is  apparently  atoxyl  or  possibly  salvarsan.  The  best  diet  is  milk  with  rest  in  bed. 
Drugs  do  not  seem  to  control  the  diarrhea. 


DISEASES  OF  THE  NERYOUS  SYSTEM. 


DISEASES  IN  WHICH  THE  CHIEF  MANIFESTATIONS  ARE  IN  THE 
BRAIN  AND  ITS  MEMBRANES. 

HEMORRHAGE  INTO  THE  BRAIN,  CEREBRAL  THROMBOSIS,  AND 
EMBOLISM. 

Definition. — Apoplexy  consists  in  the  sudden  onset  of  paralysis  and  loss  of 
consciousness  from  an  abrupt  intracranial  lesion.  In  its  most  typical  form  it  is 
due  to  hemorrhage  in  the  cerebrum,  but  it  may  also  be  due  to  hemorrhage  into  the 
cerebellum,  into  the  brain-stem,  or  into  the  meninges,  and  it  may  result  from 
embolism  or  from  thrombosis.  When  it  arises  without  being  accompanied  by  a 
demonstrable  brain  lesion,  it  is  spoken  of  as  an  "  apoplectiform  attack."  An  inflam- 
matory process  in  the  central  nervous  system,  so  acute  that  minute  hemorrhages 
occur  in  the  affected  area,  is  also  spoken  of  as  apoplectiform,  as,  for  example, 
"apoplectiform  bulbar  paralysis." 

The  term  "apoplexy,"  as  commonly  employed,  is  nearly  equivalent  to  the 
popular  term  "stroke,"  and  is  used  so  indefinitely  that  it  is  better  to  use  the  more 
accurate  terms  cerebral  hemorrhage,  cerebral  thrombosis,  or  embolism  when 
describing  the  condition  present.  The  symptoms  produced  by  thrombosis  and 
embolism  are  almost  identical  with  those  due  to  hemorrhatre,  and  will  be  found 
discussed  in  the  consideration  of  the  differential  diagnosis  of  the  disease. 

Etiology. — As  already  stated,  the  usual  cause  of  apoplexy  is  the  rupture  of  a  blood- 
vessel in  the  brain  or  its  meninges.  This  is  due  in  the  great  majority  of  cases  to 
changes  in  the  bloodvessel  produced  by  disease  or  by  injury.  These  changes  are 
described  in  the  article  on  Arteriosclerosis.  The  immediate  causes  which  produce 
rupture  of  an  intracranial  vessel  are  numerous,  for  all  factors  which  cause  a  sudden 
increase  in  blood  pressure  may  result  in  so  great  a  strain  on  a  weakened  vessel 
wall  that  it  gives  way.  Thus,  apoplexy  not  rarely  follows  a  paroxysm  of  rage,  a 
severe  nervous  shock,  a  sudden  muscular  effort,  as  in  running  for  a  car,  in  straining 
at  stool,  and  during  sexual  intercourse.  The  use  of  alcoholic  and  other  stimulants 
may  also  cause  rupture. 

Frequency. — Men  are  more  frequently  attacked  by  apoplexy  than  are  women, 
because  they  suffer  so  much  more  commonly  from  arteriocapillary  fibrosis.  The 
ratio  is  about  as  80  to  20  per  cent.,  according  to  Starr,  but  Gintrac  puts  it  at  56.6 
to  4.3.4  per  cent.  Of  816  cases  of  cerebral  hemorrhage  collected  by  me  from  various 
sources,  454  occurred  in  men  and  362  in  women. 

The  period  of  life  at  which  cerebral  hemorrhage  most  commonly  occurs  is  from 
fifty  to  eighty  years  of  age.  This  is  the  age  period  during  which  the  patient  is 
actually  most  liable  to  this  accident;  but  if  the  ages  of  the  entire  number  of  persons 
dying  of  apoplexy  in  a  given  series  of  statistics  be  added  together  and  an  average 
obtained,  the  largest  number  of  cases  is  found  between  forty  and  sixty  years, 
because  so  few  persons  live  to  eighty  years  that  not  many  persons  of  that  age  are 
to  he  found  in  such  a  series.  The  following  table  is  a  combination  of  the  cases  of 
.50  (785) 


786  DISEASES  OF  THE  NERVOUS  SYSTEM 

Gintrac  and  Breese,  and  shows  tlie  age  incidence  of  cerebral  hemorrhage  by  decades 
from  thirty  to  eighty  years: 

Between  30  and  40  years  of  age        74 

"       40    "     50    "           ''          98 

"       50     "     GO     "           "          138 

"       60     "     70     "           "          172 

"       70    "     80     "           "          124 

The  question  of  age  in  its  relation  to  apoplexy  is,  however,  more  dependent  upon 
the  state  of  the  bloodvessels  than  upon  the  actual  years  of  existence,  for  not  in- 
frequently a  syphilitic  of  thirty  years  of  age  may  suffer  more  from  degeneration  of 
the  arteries  than  another  man  at  seventy. 

Available  statistics  do  not  show  any  increase  in  the  frequency  of  cerebral  hemor- 
rhage. Thus,  from  1879  to  1SS4,  12,408  patients  were  admitted  to  the  medical 
wards  of  St.  Bartholomew's  Hospital,  London,  and  of  this  nmnber  79  were  affected 
with  cerebral  hemorrhage.  During  the  five  years  from  1897  to  1902, 12,089  medical 
patients  were  admitted  to  the  hospital,  and  among  them  there  were  62  cases  of 
cerebral  hemorrhage. 

Pathology. — The  changes  which  take  place  in  the  bloodvessels  of  the  brain  which 
result  in  apoplexy  are  those  of  arteriosclerosis  as  we  meet  it  in  other  parts  of  the 
body;  the  intima  becomes  roughened  and  eroded,  the  muscular  sheath  imdergoes 
fatty  degeneration,  and  the  fibrous  sheath  becomes  less  elastic  than  in  health. 
Aneurysmal  dilatations  frequently  develop,  and  these  are  the  parts  of  the  vessel 
from  which  hemorrhage  often  ensues.  In  the  article  on  Arteriosclerosis  it  was 
shown  that  the  causes  of  this  state  are  syphilis,  lead,  gout,  renal  disease,  and,  not 
least  important,  advanced  years;  but  of  all  these  causes  renal  disease  is  probably 
the  one  which  most  frequently  produces  vascular  rupture,  because  it  is  usually 
associated  with  cardiac  hypertrophy  and  a  high  arterial  tension,  which  increases 
the  stress  on  the  weakened  vessel  wall. 

Rupture  of  a  vessel  occurs  very  much  more  frequently  in  certain  areas  than 
in  others,  as  already  pointed  out.  This  is  because  certain  vessels  suffer  from  arterial 
sclerosis  earlier  than  others,  and  also  because  of  the  anatomical  relationship.  Thus, 
the  blood  current  reaches  the  left  middle  cerebral  artery  more  directly  from  the 
heart  than  it  does  on  the  right  side,  where  it  first  passes  through  the  innominate 
artery,  which  diminishes  its  force.  Diirand  Fardel  states  that  75  per  cent,  of  the 
miliary  aneurysms  which  affect  cerebral  vessels  involve  the  branches  of  the  middle 
cerebral  artery  which  enter  the  anterior  perforated  space,  namely,  the  lenticulo- 
striate  and  the  lenticulo-thalamic  vessels.  For  this  reason  the  lenticulo-striate 
branch  was  called  by  Charcot  the  "artery  of  cerebral  hemorrhage."  About  50 
to  60  per  cent,  of  all  cerebral  hemorrhage  is  from  this  vessel,  and  therefore  occurs 
in  the  internal  capsule  or  near  it.  (See  Hemiplegia.)  The  sharp  spurt  of  blood 
which  follows  rupture  of  the  vessel  wall  may  break  through  the  corpus  striatum  in 
either  direction,  often  internally  through  the  caudate  nucleus,  or  it  may  break 
through  the  optic  thalamus;  and  when  the  rupture  is  large  and  the  blood  pressure 
high,  the  blood  thus  finds  its  way  into  the  lateral  ventricles  (see  Fig.  128),  into  the 
third  ventricle,  and  even  into  the  fourth  ventricle,  where  it  causes  death  by  pressure 
on  the  vital  centres,  if  death  has  not  already  ensued  from  shock  and  the  damage  to 
the  cerebral  tissues. 

When  these  "capsulo-ganglionic"  vessels  do  not  give  way  the  cause  of  the  sjinp- 
toms  is  usually  rupture  of  some  of  the  outer  branches  of  the  Sylvian  artery,  produc- 
ing lesions  in  the  cortex.  In  still  other  cases,  which  are  less  frequent,  the  hemor- 
rhage takes  place  into  the  pons  and  still  more  rarely  into  the  cerebellum. 

Cerebellar  hemorrhages  are  especially  prone  to  inundate  the  fourth  ventricle. 
A  very  much  rarer  form  of  apoplexy  is  that  in  which  by  reason  of  disease  of  the 


HEMORRHAGE  INTO   THE  BRAIN 


787 


blood,  or  of  the  vessels,  small  oozings  or  extravasations  take  place  through  the 
vessel  walls,  which  on  subsequent  examination  do  not  reveal  any  rupture.  This 
extravasated  fluid  finds  its  way  alongside  the  vessels,  and  so  does  damage  to  a 
wide  area  without  causing  any  very  gross  lesion  in  the  brain  tissues.     Such  a  state 


Diagram  showing  the  fibres  from  the  cortex  forming  the  corona  radiata,  which  after  they  are  approxi- 
mated pass  into  the  internal  capsule.  It  also  shows  the  decussation  of  the  pyramid  of  the  left  side,  which 
passes  to  the  right  side  of  the  spinal  cord,  and  the  direct  or  uncrossed  tract  (Turck's  column).  Finally,  it 
also  shows  the  secondary  degeneration  which  occurs  after  cerebral  hemorrhage  or  softening,  and  which 
follows  the  course  of  the  motor  tracts  into  the  spinal  cord.  H,  site  of  lesion.  The  continuoiis  lines  are 
fibres  going  to  the  legs,  the  dotted  are  those  going  to  the  arms  and  motor  cranial  nerves.  The  Roman 
numerals  refer  to  the  origins  of  the  cranial  nerves.    (Modified  from  Van  Gehuchten.) 


may  develop  in  the  course  of  purpura  or  leukocythemia.     Extravasations  of  blood 
into  the  meninges  and  cortex  also  occur  as  the  result  of  injury. 

In  those  cases  in  which  the  hemorrhage  is  arrested  before  it  does  great  damage 
much  depends  upon  the  part  of  the  brain  which  is  affected. 


788 


DISKASKS  OF  THE  XKRVOVS  SYSTEM 


If  the  hcmorrliage  occurs  on,  or  in,  the  cortex,  and  is  small  in  amount,  the  con- 
vulsions and  paralysis  which  ensue  may  involve  only  part  of  the  arm,  or  leg,  or 
face,  or  one  of  the  special  senses,  or  a  particular  function  controlled  by  the  centre 
that  has  been  destroyed,  or  such  a  monoplegia  may  be  due  to  a  small  hemorrhage 
in  the  subcortex  cutting  off  the  fibres  of  the  corona  radiata  descending  from  the 
cortical  centre.  But  an  equally  small  hemorrhage  still  lower  down,  where  the 
fibres  from  the  entire  cerebral  hemisphere  come  together  in  the  internal  capsule, 
will  produce  a  complete  hemiplegia  (Fig.  128,  lesion  of  ordinary  hemiplegia).  On 
the  other  hand,  if  the  lesion  occurs  still  lower  down — that  is,  in  the  l)rain-stem, 


Lesion  of  cfostf  paralysis 
(/ace  of  same  side  with 
liitibn  of  other  side) 


1  lesion  eausinu  j^araplcfjia 


-Motor  nerve  to  face 

Decussation  of  pyra- 
mids 
Crossed  pyramidal  tract 


Crossed pyrantidal  tract 


Sensory  nerves  entering 
cord,  and  decnssating 
soon  after  entry 


Diagram  showing  the  general  arrangement  of  the  motor  tract  and  the  efTcet  of  iesioDS  at 
various  points.    (Ormerod.) 


where  bundles  of  fibres  are  separating  from  the  main  ])aths  and  crossing  to  the 
opposite  sides  to  connect  with  cranial  nerves — it  will  jiroduce  crossed  paraly.sis — 
for  example,  the  face  is  paralyzed  on  one  side  and  the  body  on  the  other.  Ordinary 
"crossed  paralysis"  indicates  a  lesion  in  the  lower  third  of  the  pons  liecause  at 
this  point  the  motor  fibres  for  the  face  Iiave  crossed  lint  the  fibres  for  the  limbs 
have  not  done  so  (Fig.  129,  lesion  of  crossed  paralysis).  If  the  posterior  third 
of  the  internal  capsule  is  affected  as  well  as  the  anterior  and  middle  thirds,  we 
find  hemianesthesia  as  well  as  motor  paralysis  on  the  opposite  side  (Fig.  130); 
and  if  the  very  posterior  portion  of  this  limb  is  afi'ected  the  optic  radiations 


HEMORRHAGE  INTO  THE  BRAIN  789 

are  implicated  and  hemianopsia  is  added  to  tiie  symptoms.  (See  Fig.  130). 
If  the  patient  survives  the  attack  the  extravasated  blood  coagulates  and  is  sur- 
rounded by  a  protective  wall  of  lymph,  which  undergoes  organization  while 
the  clot  softens,  and  contracts  as  its  contents  are  being  absorbed.  The  per- 
manent lesion  of  apoplexy  is  thus  commonly  a  cyst,  but  sometimes,  absorption 
having  been  complete,  only  a  scar  remains.  Not  only  do  these  changes  take  place 
at  the  site  of  the  hemorrhage,  when  it  afi'ects  the  cortex  or  motor  fibres  in  the 


Cross-section  of  the  brain,  showing  the  lateral  ventricles,  the  cerebellum,  and,  most  important,  the'cross- 
section  of  the  motor  fibres  in  the  internal  capsule.     (Modified  from  Fuller.) 

corona  radiata  or  in  the  internal  capsule,  but  degenerative  alterations  follow  along 
the  motor  pathways  through  the  peduncles  of  the  cerebriun,  the  pons,  the  pyramids 
of  the  medulla,  and  so  on  into  the  direct  and  crossed  pyramidal  tracts  of  the  cord. 
(See- Fig.  128.) 

Symptoms. — The  symptoms  of  apoplexy  depend  upon  the  site  of  the  lesion  and 
upon  the  suddenness  and  severity  of  the  hemorrhagic  extravasation,  as  already 
stated.  A  few  cases  have  some  premonitory  symptoms  such  as  numbness  or  tingling 
in  the  part  of  the  body  about  to  be  affected,  but  most  cases  are  attacked  without 


790  DISEASES  OF  THE  NERVOUS  SYSTEM 

warning.  When  the  hemorrliage  takes  phu-r  from  the  ttiiddic  crrchritl  nrlery  the 
symptonas  are  usually  as  follows: 

An  individual  who  is  apparently  in  his  normal  health  is  sinldenli/  seized  with 
vertigo,  which  causes  him  to  stagger  and  fall.  The  face  is  at  first  pallid  and  later 
somewhat  conqested.  The  respiration  is  altered  almost  immediately.  At  first  it 
may  be  .ilif/htli/  gasping  and  irregvlar,  but  soon  becomes  full  and  deep.  The  air 
is  drawn  into  the  lungs  with  considerable  force  and  then  equally  forcibly  e.\i)elled. 
As  it  enters  it  causes  the  relaxed  soft  palate  to  vibrate  and  as  it  escapes  through  the 
angle  of  the  mouth,  which  is  paralyzed,  it  i^roduces  a  noise  to  which  the  term 
"stertorous  breathing"  has  been  applied.  The  pulse  is  slow  and  its  tension  high 
except  for  a  few  moments  after  the  onset  of  the  sjinptoms,  when  it  may  be  rapid 
and  irregular  from  the  shock.  In  some  cases,  too,  in  which  the  hemorrhage  into 
the  brain  is  very  great  and  death  imminent,  the  pulse  may  not  become  full  and 
strong. 

An  examination  of  the  patient's  limbs  may  show  that  both  sides  are  almost 
equally  relaxed  and  powerless,  but  this  is  usually  a  temporary  state  due  to  shock, 
and  in  a  very  short  time  it  will  be  found  that  the  limbs  on  one  side  are  moved,  or 
at  least  are  not  quite  powerless,  while  those  on  the  opposite  side  are  paralyzed. 
In  other  words,  the  typical  paralysis  of  cerebral  hemorrhage  called  hemiplegia 
is  present. 

The  muscles  of  the  trunk  are  never  as  completely  paralyzed  as  those  of  the  limbs. 
The  muscles  of  the  lower  part  of  the  face  share  in  the  paralysis,  and  for  this  reason 
the  features  will  be  drawn  away  from  the  paralyzed  side  because  the  normal  balance 
between  the  muscles  on  the  two  halves  of  the  face  has  been  destroyed.  Unlike 
the  facial  paralysis  due  to  a  lesion  in  the  facial  nucleus  in  the  pons  or  in  the  facial 
nerve  itself,  the  upper  muscles  escape,  and  so  we  find  that  the  muscles  of  the  forehead 
and  eyes  are  not  paralyzed ;  the  forehead  can  be  wrinkled  and  the  eyes  can  be  closed. 

In  the  stage  of  onset  we  sometimes  find  the  head  and  eyes  turned  sharply  to 
one  side  (conjugate  deviation),  usually  away  from  the  paralyzed  side.  When 
this  occurs  it  is  said  that  the  eyes  "look  at  the  lesion."  The  pupils  are  sometimes 
contracted,  but  more  commonly  are  dilated,  the  pupil  on  the  side  upon  which  the 
hemorrhage  has  taken  place  being  more  dilated  than  its  fellow. 

Pricking  or  pinching  the  skin  of  the  paralyzed  side  is  not  followed  by  any  reflex 
contraction  soon  after  the  onset,  though  the  deep  reflexes  may  be  present,  but  later, 
when  the  primary  shock  has  passed  away,  it  will  be  found  that  the  skin  reflexes 
as  well  as  tiie  knee-jerk  and  other  deep  reflexes  are  exaggerated,  particularly  upon  the 
paralyzed  side.  Irritation  of  the  sole  of  the  foot  almost  invariably  causes  extension 
of  the  big  toe  (Babinski's  reflex),  a  reversal  of  the  normal  plantar  reflex,  which  is 
flexion  of  the  toes.     Ankle-clonus  is  also  frequently  present. 

In  cases  in  which  the  bladder  and  the  bowel  are  full  at  the  time  of  the  "stroke," 
the  shock  of  the  hemorrhage  may  result  in  in\-oluntary  evacuations,  but  in  some 
cases  the  bladder  and  rectimi  are  not  only  retentive,  in  the  ordinary  sense,  but 
fail  to  empty  themselves  when  they  become  full.  The  bladder  of  an  apoplectic 
patient  should,  therefore,  be  frequently  examined,  and  if  the  urine  accumulates 
in  excess  it  must  be  withdrawn  by  the  catheter.  If  the  urine  is  examined  a  trace 
of  albimiin  is  usually  found  in  it,  even  if  actual  renal  disease  is  not  present.  The 
temperature  of  tlie  body  immediately  after  a  hemorrhage  is  usually  subnormal. 
With  reaction  from  the  primary  shock,  wliich  is  often  of  brief  duration,  the  tem- 
perature rises  from  one  to  three  degrees,  the  chief  change  being  on  the  paralyzed 
side. 

The  unconsciousness  of  the  early  stage  of  apoplexy  may  last  from  a  few  hours  to 
several  days,  according  to  the  severity  of  the  lesion.  When  it  persists  for  any  length 
of  time  the  jjrognosis  is  correspondingly  bad.  In  some  cases  the  depth  of  the  coma 
decreases  and  the  patient  emerges  to  some  extent,  only  to  sink  back  again  into 


HEMORRHAGE  INTO   THE  BRAIN  791 

deep  coma  and  high  fever  a  few  days  later  when  a  secondary  hemorrhage  takes 
place,  perhaps  bursting  into  the  ventricle,  or  secondary  irritation  of  the  brain, 
produced  by  the  presence  of  the  extravasated  blood,  develops.  In  other  cases 
in  which  the  extravasation  of  blood  has  been  limited,  and  the  parts  damaged  are 
not  of  vital  importance,  the  patient  gradually  improves  in  his  mental  state  and 
progresses  toward  recovery.  In  most  cases,  however,  the  mind  never  completely 
recovers  its  previous  acuity. 

The  persistency  of  the  hemiplegia  also  varies  greatly  in  different  cases.  It 
may  remain  absolutely  unchanged,  one-half  of  the  body  being  helpless,  or  it  may 
diminish  in  severity  and  even  greatly  improve  to  the  extent  that  the  patient  can 
walk  about  and  write.  In  most  of  the  cases,  however,  in  wliich  this  much-to-be- 
desired  result  is  attained,  the  lesion  has  probably  been  due  to  embolism  or  throm- 
bosis rather  than  to  an  actual  hemorrhage. 

Many  patients  after  an  attack  of  apoplexy  not  only  suffer  from  a  degree  of 
mental  failure,  but  in  addition  become  exceedingly  irriiahle  or  emotional,  crying, 
laughing,  or  getting  into  a  furious  temper  at  slight  causes.  Distinct  loss  of  emo- 
tional control  has  been  said  to  be  particularly  prone  to  occur  when  the  lesion 
involves  the  frontal  lobes. 

There  still  remain  to  be  considered  several  additional  sjonptoms  of  apoplexy 
which  are  often  present.  The  most  important  of  these  is  aphasia.  It  is  most 
common  in  cases  in  which  the  right  side  is  paralyzed,  because  the  speech  centre  is 
chiefly  in  the  third  left  frontal  convolution.  If  the  patient  is  left-handed,  however, 
the  aphasia  is  present  when  the  left  side  is  paralyzed.  The  symptom  aphasia 
varies  very  greatly  in  the  time  at  wliich  it  is  first  evident  and  in  its  se^•e^ity.  Not 
infrequently  it  is  one  of  the  first  signs  of  a  beginning  apoplexy,  the  speech  becoming 
suddenly  confused  and  indistinct.  In  most  cases,  however,  the  aphasia  is  first 
noticed  after  the  patient  recovers  from  the  immediate  effects  of  the  stroke.  The 
persistency  of  tlie  aphasia  varies  greatly.  In  some  cases  it  remains  so  severe 
that  the  patient  has  great  difficulty  in  making  himself  understood.  In  others  it 
improves  so  greatly  that  it  may  entirely  disappear,  or  only  be  present  when  the 
patient  becomes  very  tired  or  excited. 

Another  special  sjmiptom  is  hemianopsia,  which  is  of  the  homonymous  type, 
that  is,  the  corresponding  halves  of  the  visual  fields  are  darkened  because  the 
temporal  half  of  one  retina  and  the  inner  or  nasal  half  of  the  other  retina  has  lost 
its  visual  fimction. 

Hemianesthesia  persisting  after  recovery  from  the  primary  shock  is  a  rare  symp- 
tom and  is  never  complete,  thereby  differing  from  the  hemianesthesia  of  hysteria. 
The  sense  of  heat  or  cold  or  touch  may  be  impaired,  but  total  loss  of  the  senses  does 
not  take  place. 

When  the  power  of  recognizing  objects  placed  in  the  hand  is  lost  (astereognosis) 
it  indicates  a  lesion  in  the  superior  parietal  portion  of  the  cortex  on  the  opposite 
side.     (See  Fig.  131.) 

In  some  cases  of  hemiplegia  of  a  severe  t}npe  bed-sores  develop  on  the  heel  or 
buttock  of  the  aft'ected  side.  The  tendency  to  this  accident  can  be  greatly  decreased 
if  the  patient  is  not  permitted  to  lie  in  one  position  for  long  periods  of  time,  and  if 
great  care  is  taken  as  to  the  cleanliness  of  the  skin  in  the  places  where  pressure  is 
marked. 

As  a  sequence  to  an  apoplexy  we  find  not  only  persistent  paralysis,  but  as  time 
goes  on  contractures  occur  in  the  affected  limbs.  The  forearm  and  hand,  however, 
suffer  far  more  than  the  leg.  The  flexor  muscles  being  stronger  than  the  extensors, 
the  hand  is  usually  found  in  marked  flexion  upon  the  wrist,  and  the  fingers  are 
turned  into  the  palm  of  the  hand.  The  leg  is  usually  held  in  the  position  of  exten- 
sion so  that  it  cannot  be  bent  at  the  knee,  and  for  this  reason  it  is  often  swung  with 
a  lateral  movement  from  the  hip  when  the  patient  attempts  to  walk.    These 


792  DLSEASES  OF  THE  NERVOUS  SYSTEM 

contractures  are  usually  much  diminished  when  the  patient  is  asleep,  and  are  due 
to  degenerative  changes  in  the  crossed  p.\TamidaI  tracts.  (See  Fig.  128.)  Occasion- 
ally, that  curious  mobile  spasm  of  the  fingers  or  other  meml)ers,  called  "  athetosis," 
is  a  sequence  of  apoplexy  and  posthemiplegic  chorea  may  develop.  This  is  most 
common  in  the  hemiplegias  of  childhood,  but  occurs  in  adults.  Full  doses  of 
strychnine  may  produce  spastic  contractions  in  old  cases  of  hemiplegia.  Next 
to  signs  of  spasm  the  most  common  sequel  is  musrular  atrophy,  which  is  due 
in  part  to  disuse  of  the  muscles  in  the  paralyzed  limbs  and  docs  not  develop  till 
some  time  after  the  acute  stage  of  the  attack.  Charcot  has  reported  instances  in 
which  true  trophic  joint  changes  took  place,  but  they  are  exceedingly  rare. 

The  symptoms  of  an  attack  of  apoplexy  in  which  the  lesion  has  been  due  to 
rupture  of  a  branch  of  the  middle  cerebral  artery  having  been  described  there  still 
remain  to  be  considered  those  additional  symptoms  which  develop  when  other 
parts  of  the  cranial  contents  are  affected  by  the  gi\ing  way  of  otiier  vessels. 

When  a  vessel  in  the  dura  mater  is  ruptured,  usually  as  the  result  of  an  injury, 
it  is  the  middle  meningeal  artery  or  vein  which  suffers  as  a  rule.  The  clot  which  is 
formed  is  either  outside  the  dura  mater  (extradural)  or  beneath  it  (subdural). 
The  noteworthy  peculiarity  of  these  cases  is  that  the  primary  unconsciousness  due 
to  a  blow  speedily  disappears,  the  patient  may  recover  his  normal  mental  state, 
and  then,  after  an  interval  varying  from  some  minutes  to  several  hours  or  days, 
becomes  heavy  and  dull,  and  finally  comatose.  Spasmodic  movements  of  the  mvscles 
on  one  side  of  the  body,  followed  by  paralysis,  may  develop.  If  the  extravasation 
of  blood  is  large,  the  pupil  on  the  paraJyzed  side  is  contracted  and  that  on  the  side 
of  the  hemorrhage  is  dilated.  This  is  called  the  "Hutchinson  pupil."  The  eyes 
are  turned  away  from  the  lesion,  whereas  in  the  acute  stage  of  an  ordinary  apoplexy 
they  are  turnetl  toward  it.  It  is  in  this  form  of  apoplexy  that  surgical  interference 
is  absolutely  essential  to  save  life.  Such  licmorrhages  sometimes  occur  in  the 
insane  without  a  history  of  injury,  particularly  in  paretics  and  in  chronic  alcoholics. 

In  hemorrhage  from  a  vessel  upon  the  cortex,  as  one  of  the  branches  of  the  Sylvian 
artery,  it  is  important  to  recall  the  fact  that  muscular  spasm,  or  a  convulsion, 
usually  ushers  in  the  attack  due  to  the  disturbance  of  the  cells  in  the  motor  area. 

When  the  blood  finds  its  way  into  the  lateral  ventricles,  a  general  convulsion 
affecting  the  entire  body  may  develop.  Such  cases  usually  pass  into  deep  coma 
and  soon  die. 

When  the  lesion  is  in  the  pons  the  temperature  is  usually  soon  hyperpyretic, 
the  pupils  are  tightly  contracted,  swallowing  is  difficult,  and  the  respiration  is  very 
slow.     Death  comes  rapidly  in  these  cases  as  a  rule. 

Under  the  name  of  "  ingravc.fccut  apoplexy"  a  condition  is  met  with  in  which  the 
symptoms  develop  very  gradually,  beginning,  it  may  be,  by  an  attack  of  vertigo 
or  aphasia,  followed  by  the  slow  development  of  the  other  symptoms  already 
described,  so  that  se\-eral  days  may  elapse  before  the  entire  s\inptom-compIex 
of  apoplexy  is  present. 

Diagnosis. — An  attack  of  apoplexy,  or  hemorrhage  into  the  brain,  must  be  separ- 
ated from  a  number  of  conditions  which  may  closely  resemble  it.  Two  conditions 
which  resemble  it  so  closely  as  to  be  inseparable  in  some  cases  are  thrombosis  and 
embolism  of  the  cerebral  vessels.  The  symptoms  produced  by  these  accidents 
will  be  found  described  below. 

An  ordinary  attack  of  synco])e  can  readily  be  differentiated  by  the  pallor,  the 
feeble  pulse,  the  weak  heart  of  a  fainting  attack,  and  the  cjuick  recovery  of  the 
patient  after  receiving  some  rapidly  acting  diffusible  stinudant. 

In  epilepsy  the  peculiar  initial  cry,  the  bloody  froth  at  the  mouth,  the  general 
convulsion,  and  the  deej)  unconsciousness  are  more  constant  and  severe  than 
in  apoplexy,  even  if  the  hemorrhage  takes  place  in  the  cortex.  Epilepsy  is  more 
common  in  the  young,  apoplexy  in  those  of  advanced  years,  and  there  may  be 


HEMORRHAGE  INTO   THE  BRAIN  793 

scars  to  indicate  previous  severe  falls  in  epileptics.  A  history  of  epilepsy  will 
practically  settle  the  diagnosis,  although  the  epileptic  is  liable  to  apoplexy.  The 
respiration  in  the  coma  of  ajjoplexy  continues  deep  and  noisy,  the  lips  and  cheeks 
of  one  side  flap  in  the  air  current,  showing  paralysis,  and  weakness  of  one  arm  and 
leg  may  be  ascertained.  In  the  coma  of  epilepsy  the  breathing  soon  becomes 
quiet.  Rarely  in  epilepsy  weakness  of  one  side  of  the  body  or  of  one  limb  may 
appear  as  the  patient  emerges  from  the  coma;  this  postepileptic  hemiplegia  is 
ascribed  to  exhaustion,  for  it  passes  off  in  a  few  hours  or  days,  but  it  may  put  the 
diagnosis  in  doubt  for  a  time. 

From  the  stupid  stage  of  acute  alcoholism  apoplexy  can  be  differentiated  by 
tlie  history  of  the  patient,  by  the  odor  of  alcohol  on  his  breath,  by  the  fact  tliat 
both  legs  are  moved  if  they  are  irritated  by  pricking,  proving  the  absence  of  hemi- 
plegia, and  by  the  cool  skin  as  compared  to  the  hot,  dry  skin  of  apoplexy.  It  is, 
however,  possible  for  an  apoplectic  to  have  induced  an  attack  by  the  use  of  alcohol, 
and  therefore  the  odor  of  alcohol  on  his  breath  is  not  of  great  importance  from  a 
diagnostic  standpoint. 

Opium  poisoning  is  differentiated  by  the  presence  of  contracted  pupils,  by  the 
fact  that  by  shouting  the  patient  can  be  aroused,  by  the  absence  of  paralysis, 
and  by  the  presence  of  the  corneal  reflexes. 

The  coma  of  uremia  and  of  diabetes  may  also  be  mistaken  for  apoplexy,  but 
in  uremia  there  may  be  edema  of  the  lower  extremities,  and  there  is  a  urinous 
odor  about  the  body  and  breath  of  the  patient.  If  the  renal  disease  is  of  the 
parenchymatous  type,  the  peculiar  waxen  appearance  of  the  patient  and  the  urine 
heavily  loaded  with  albumin  will  make  the  diagnosis  clear.  If  the  uremia  is  of 
the  type  caused  by  chronic  contracted  kidney,  these  latter  signs  will  not  be  present 
nor  will  edema  be  found,  and  as  apoplexy  often  complicates  this  disease  the  diagnosis 
may  be  most  difficult.  Unless  the  coma  is  very  deep  one  side  may  be  moved  far 
more  than  the  other,  revealing  the  hemiplegia  of  apoplexy.  However,  in  uremia 
the  cerebral  condition  may  be  more  pronounced  in  one  hemisphere,  thus  causing  a 
hemiplegia  ("uremic  apoplexy")-  In  diabetic  coma  the  sweet  odor  of  the  breath 
and  the  presence  of  sugar  and  acetone  in  the  urine  will  make  the  diagnosis  possible. 

In  sunstroke  likewise  hemiplegia  may  be  found,  which  is  not  an  apoplexy  in 
the  ordinary  sense. 

Finally,  it  must  not  be  forgotten  that  apoplectiform  attacks  not  rarely  develop 
in  the  course  of  general  paralysis  of  the  insane.  In  this  disease  the  speedy  retiu-n 
to  consciousness  and  recovery  of  power  in  the  affected  limbs,  with  the  physical 
signs  of  this  disease  and  the  mental  symptoms,  will  render  a  diagnosis  possible. 

The  separation  of  the  paralysis  due  to  hemorrhage  from  that  due  to  thrombosis 
depends  more  upon  tlie  history  of  the  patient  than  upon  the  symptoms  actually 
present.  As  already  stated,  hemorrhage  usually  follows  some  effort  and  takes 
place  during  waking  hours,  whereas  the  paralysis  of  thrombosis  develops  during 
periods  of  quiet  and  rest,  as  during  sleep,  so  that  the  patient  wakes  to  find  the 
palsy  present.  In  cases  of  hemorrhage  premonitory  sjonptoms  are  not  common, 
but  in  thrombosis  they  are  nearly  constant.  Thrombosis  is  most  frequent  in 
the  aged  or  prematurely  senile,  and  in  syphilitics.  Again,  thrombosis  does  not 
cause  such  violent  symptoms  nor  is  the  onset  of  the  symptoms  so  sudden,  but 
consciousness  is  preserved  or  is  not  so  completely  lost,  or  if  moderate  coma  is 
present  it  is  brief  in  duration  and  is  followed  by  mental  clearness.  Finally,  in 
cases  of  thrombosis,  the  recovery  of  power  in  parts  of  the  paralyzed  side  may  be 
quite  rapid,  and  at  the  end  of  a  few  days  only  a  few  mucles,  as  one  arm  or  leg,  are 
affected.  Such  cases  are,  however,  often  mentally  feeble,  emotional,  and  forgetfid 
after  the  attack.  There  is  often  to  be  found  a  history  of  syphilis,  of  arteriosclerosis, 
or  an  infectious  disease,  which  has  predisposed  the  patient  to  a  formation  of  a  clot 
by  causing  disease  in  the  lining  of  the  bloodvessel  or  producing  changes  in  the  blood. 


794  DISEASES  OF  THE  NERVOUS  SYSTE}f 

Embolism  can  be  determined  by  the  sudden  onset  of  symptoms  duriiif;  the 
waking  hours,  as  a  rule,  and  by  the  discovery  of  some  source  of  clot  or  foreign 
body,  as  in  an  endocarditis  with  vegetations  or  a  septic  focus  elsewhere.  Uncon- 
sciousness, when  it  develops,  may  be  as  profound,  l)ut  is  usually  more  transient 
than  in  hemorrhage  (Mills),  and  is  often  entirely  absent.  The  appearance  of  the 
patient  is  not  so  alarming  as  in  hemorrhage,  and  localized  or  general  twitching 
may  be  present  in  the  affected  limbs.  Not  rarely,  the  sjinptonis  ini])r()ve  with 
great  rapidity  and  after  a  few  days  may  amount  to  only  a  partial  monoplegia. 
It  must  be  recalled,  however,  that  in  some  cases  of  thrombosis  and  embolism  the 
sjTnptoms  may  be  so  like  those  due  to  hemorrhage  that  a  differentiation  is  almost 
impossible. 

The  chances  of  the  case  being  one  of  hemorrhage  rather  than  embolism  or  throm- 
bosis is  as  6  to  1,  according  to  Dana. 

Prognosis. — Many  cases  of  hemorrhage  into  the  brain  survive  the  first  rupture, 
but  if  so  they  nearly  always  fall  victims  to  subsequent  attacks.  Out  of  441  cases 
occurring  in  St.  Thomas'  and  St.  Bartholomew's  Hospitals,  London,  375  proved 
fatal,  a  mortality  percentage  of  85.  This  percentage  is,  however,  far  too  high 
for  private  practice,  where  milder  cases  are  often  seen.  In  the  severe  cases  in 
which  the  coma  is  profound,  the  temperature  low  and  then  quite  high,  the  paralysis 
severe,  and  control  of  the  bladder  or  bowels  impaired,  death,  will  probably  occur 
in  the  first  attack,  and  if  Cheyne-Stokes  breathing  is  present  death  nearly  always 
takes  place  within  a  few  hours.  If  the  hemorrhage  affects  the  pons  or  cerebelliun 
death  may  come  on  speedilj^,  but  when  the  hemorrhage  is  small  the  patient  often 
survives.  When  the  hemorrhage  is  cortical  the  prognosis  is  better  than  in  the 
other  forms  unless  the  pressure  sjonptoms  are  severe.  The  patient  not  rarely 
dies  from  pulmonary  edema  or  pneimionia  as  an  intercurrent  disease. 

Treatment. — Apoplexy,  like  other  forms  of  internal  hemorrhage,  cannot  be 
materially  benefited  by  medicinal  treatment.  If  nature  does  not  form  a  clot  to 
plug  the  bleeding  vessel,  the  hemorrhage  must  continue  until  it  has  done  so  much 
damage  that  death  is  inevitable  unless  the  vessel  is  on  the  surface  or  in  the  meninges, 
when  surgical  relief  should  be  given.  Again,  the  pressure  with  which  the  blood 
escapes  into  the  soft  textures  of  the  brain  is  so  great  that  if  the  leak  is  of  any  size 
the  mechanical  injury  to  the  cerebral  tissues  must  be  very  great,  and  for  this  reason 
the  organ  is  permanently  disabled. 

Until  the  researches  of  Gushing,  of  Baltimore,  in  regard  to  the  significance 
of  high  arterial  pressure  in  cases  of  hemorrhagic  extravasations  inside  the  skull, 
it  was  universally  taught  that  the  presence  of  a  full,  bounding  pulse  in  a  case  of 
apoplexy  indicated  venesection,  particularly  if  at  the  same  time  there  was  distinct 
venous  engorgement,  the  thought  being  that  by  this  means  the  blood  pressure 
would  be  lowered,  and  that  there  would  be  a  corresponding  decrease  in  the  leakage 
from  the  ruptured  vessel.  Cushing's  investigations  have  apparently  shown  beyond 
all  doubt  that  the  high  arterial  pressure  which  is  so  constantly  found  in  persons 
who  suffer  from  hemorrhage  inside  the  skull  is  an  effort  of  nature  to  maintain  the 
blood  supply  to  the  vital  centres  at  the  base  of  the  brain,  and  that  if  this  blood 
supply  cannot  be  maintained  because  of  a  fall  in  arterial  pressure  death  speedily 
ensues.  In  other  words,  the  maintenance  of  a  high  arterial  pressure  in  these 
cases  is  an  advantageous  sign,  and  any  marked  diminution  in  arterial  tension  is  an 
indication  that  the  vasomotor  centre  is  becoming  paralyzed  and  that  the  blood 
supply  to  the  centres  at  the  base  of  the  braiii  is  becoming  impaired.  If  Cushing's 
studies  are  correctly  interpreted  hy  him,  venesection  or  the  administration  of 
vascular  sedatives,  with  the  purpose  of  lowering  tension,  is  therefore  a  distinctly 
harmful  method  of  treatment,  and  truth  demands  that  we  should  admit  that  the 
physician  can  do  little  if  anything  in  the  way  of  controlling  the  escape  of  blood. 
For  the  purpose  of  apparently  making  an  effort  to  do  good  for  the  sake  of  the 


INFANTILE  CEREBRAL  PARALYSIS  795 

friends  who  may  demand  activity  rather  than  masterly  inactivity,  a  hot  mustard 
foot-bath  may  be  given,  and  some  diffusible  stimulant  like  Hoffmann's  anodyne 
may  be  used  if  the  patient  is  able  to  swallow  or  atropine  may  be  given  hypo- 
dermically  if  arterial  tension  falls  and  the  surface  becomes  cold  and  clammy. 

If  vomiting  occurs,  the  patient  should  be  promptly  turned  on  one  side  so  that 
free  drainage  from  the  mouth  may  take  place,  and  in  order  that  particles  of  food 
may  not  be  drawn  into  the  respiratory  passages. 

If  the  tongue  falls  back  in  such  a  manner  as  to  make  the  breathing  difficult  it 
should  be  drawn  forward  by  means  of  the  fingers  covered  with  a  towel.  If,  by 
chance,  the  patient  is  convulsed,  his  tongue  should  be  protected  from  damage  by 
placing  between  the  teeth  a  penholder  or  tooth-brush  handle  wound  around  with 
a  piece  of  muslin. 

The  patient's  body  should  always  be  put  in  that  position  in  which  breathing 
is  most  easily  carried  on. 

The  treatment  after  the  hemorrhage  has  ceased  consists  in  absolute  rest,  in 
the  application  of  an  ice-bag  to  the  head,  and  attention  to  the  bowels  and  bladder 
to  prevent  them  from  becoming  overdistended.  Gentle  jjurgation  is  probably 
advantageous  for  its  influence  upon  the  brain.  If  any  e\'idence  of  nervous  excita- 
tion exists,  it  may  be  controlled  by  small  doses  of  the  bromides  or  morphine.  If 
any  tendency  to  secondary  reaction  develops  in  the  course  of  a  few  days,  cold  to 
the  head  and  small  doses  of  aconite  to  quiet  the  circulation  may  be  administered. 
Later  on,  with  the  hope  of  diminishing  the  paralysis,  iodide  of  potassium  may  be 
given  in  moderate  doses  in  order  that  it  may  aid  in  the  absorption  of  the  extra- 
vasated  blood  and  remove  products  of  inflammation.  There  is  little  use  in  giving 
the  iodide  of  potassium  for  the  purpose  of  causing  absorption  earlier  than  two  or 
three  weeks  after  the  hemorrhage.  Strychnine  is  usually  not  valuable  in  these 
cases,  as  it  is  very  apt  to  produce  spasm  or  contracture  in  the  parts  which  are 
paralyzed  by  irritating  the  motor  tracts  in  the  spinal  cord. 

From  three  to  four  weeks  after  the  hemorrhage  it  is  often  ad-vantageous  to  apply 
a  slowly  interrupted  faradic  curreiat  to  the  paralyzed  muscles,  with  the  object  of 
maintaining  their  nutrition  by  exercise  and  keeping  them  in  the  best  possible  con- 
dition, in  the  hope  that  eventually  they  may  receive  a  sufficient  amount  of  nervous 
impulse  from  the  cerebral  centres  to  be  able  to  respond  sufficiently  to  permit  the 
patient  to  move  his  limbs.  Massage  is  another  excellent  means  to  combat  the 
loss  of  power.  Passive  and  active  movements  followed  by  a  course  of  systematic 
exercises  will  render  valuable  service  in  combating  secondary  contractures  of  the 
paralyzed  extremities.  Great  care  should  be  taken  that  all  stimulants  which 
increase  circulatory  activity,  and  all  foods  which  readily  cause  indigestion,  be 
avoided,  as  these  two  factors  tend  to  produce  that  most  unfortunate  complication, 
another  hemorrhage. 

INFANTILE  CEREBRAL  PARALYSIS. 

Definition. — ^iVs  a  result  of  injury  or  disease  of  the  brain  during  fetal  life  or  soon 
after  birth,  it  not  rarely  happens  that  certain  portions  of  the  cerebrum  fail  to 
develop,  and  as  a  consequence  a  number  of  very  characteristic  conditions  are 
produced,  which  depend  in  their  nature  upon  the  site  and  size  of  the  atrophied 
region. 

These  conditions  can  be  grouped  in  three  divisions :  In  the  first  there  is  a  spastic 
paralysis  which  may  be  limited  to  one  side  of  the  body  (spastic  hemiplegia),  or  it 
may  be  bilateral  (spastic  diplegia).  In  spastic  diplegia  the  legs  may  be  affected 
alone  or  the  arms  and  legs  may  both  be  involved.  The  second  class  is  chiefly 
characterized  by  mental  failure  varying  in  severity  from  slight  intellectual  deficiency 
to  absolute  idiocy.     In  some  instances  the  defect  is  manifested  by  epileptic  attacks.  • 


796  DISEASES  OF  THE  NERVOUS  SYSTEM 

The  tliird  class  presents  disorders  of  the  special  senses,  siidi  as  lilimlncss,  drafness, 
mutism  from  deafness,  and  it  may  be  epileptic  seizures  as  well. 

Etiojogy. — Acute  infectious  disease  occurring  in  the  mother  during  pregnancy 
may  result  in  lesions  in  the  fetal  brain.  Syphilis  may  also  act  in  this  manner. 
It  is  i)robable,  too,  that  definite  developmental  defects  may  be  hereditary,  as  when 
the  parent  or  parents  are  epileptics,  neurotic,  alcoholic,  or  otherwise  degenerate. 
Premature  labor  is  a  frequent  cause  of  diplegia.  A  very  large  proportion  of  cases 
develop  as  a  result  of  injury  during  birth  because  of  a  meningeal  or  cerebral  hemor- 
rhage. In  a  few  cases  the  damage  is  due  to  a  fall  in  early  infancy,  and  in  .still 
others  there  develops  some  time  during  the  first  tiiree  years  of  life  a  cerebral  throm- 
bosis, a  hemorrhage,  an  encephalitis,  or  a  meningitis  which  is  folhmed  by  the  brain 
s,\7nptoms  about  to  be  described.  Such  a  condition  may  arise  as  a  complication 
or  secjuela  of  any  one  of  the  acute  infectious  diseases  of  childhood.  A  convulsion 
may  be  said  to  be  the  cause  in  certain  cases,  but  it  is  probable  that  the  lesion  in  the 
brain  is  responsible  for  this  symptom  rather  than  that  it  is  the  provoking  factor. 
Finally,  there  are  certain  cases  in  which  it  is  impossible  to  discover  any  cause 
whatever. 

Pathology  and  Morbid  Anatomy. — When  spastic  paralysis  is  present  it  is  due  to  a 
lesion  which  invohes  the  motor  portion  of  the  cerebral  cortex  and  neighboring 
convolutions.  The  lesion  itself  in  long-standing  cases  is  sclerotic  or  atrophic 
in  character  and  is  associated  with  similar  changes  in  the  motor  fibres,  which  pass 
from  the  cortex,  and  occur  in  the  basal  ganglia  as  well.  In  some  cases  the  sclerotic 
change  is  limited  to  these  ganglia.  When  there  is  diplegia  both  sides  of  the  brain 
are  involved.  In  that  type  of  case  in  which  mental  impairment  is  present  the 
atrophy  and  sclerosis  afi'ect  the  anterior  convolutions  of  the  brain,  and  when 
disorders  of  special  sense  are  present  it  is  because  the  perceptive  centres  of  the 
senses  affected  are  involved  in  the  damaged  area.  It  is  readily  seen,  therefore, 
that  as  the  lesions  are  distributed  so  are  the  manifestations  of  the  disease  varied. 

The  exact  nature  of  the  cerebral  lesions  has  been  found  to  be  of  several  types: 
(1)  A  localized  atrophy,  or  failure  of  development,  may  produce  an  excavation 
of  the  surface  of  the  brain,  usually  due  to  meningeal  hemorrhage  at  birth,  with 
formation  of  a  clot  which  indents  the  delicate  cortex  permanently.  This  indenta- 
tion is  called  porencephaly  (poros,  the  Greek  word  for  "hole").  (2)  A  sclerotic 
process  with  overgrowth  of  connective  tissue  and  atrophy  of  the  nervous  protoplasm 
may  be  present.  (3)  Imperfect  development  of  the  cerebral  cells  may  be  found 
or  arrested  myelinization  of  the  nerve  fibres  of  the  motor  tract.  (4)  Atrophy 
may  follow  cerebral  softening  produced  by  the  closure  of  a  vessel  by  an  embolus 
or  thrombus.  (5)  An  inflammatory  process  in  the  pia  mater  may  cause  an  adhesion 
to  the  cerebriun  and  so  cause  atrophy  (meningo-encephalitis).  (6)  A  cerebral 
hemorrhage  may  not  only  destroy  the  cerebral  tissue,  but  cause  a  cyst  to  de\-elop. 
(7)  A  cyst  may  cause  atrophy  from  pressure.  (8)  Hydrocephalus,  in  which  state 
the  cerebral  ventricles  may  be  so  distended  that  the  brain  tissues  atrophy  from 
pressure.     (9)  Rarely  an  external  hydrocephalus  may  produce  the  same  results. 

Symptoms. — The  symptoms  in  a  child  aft'ected  by  this  accident,  like  those  of 
ordinary  apoplexy,  vary  greatly  in  speed  of  onset,  in  severity,  and  in  type.  When 
the  lesion  occurs  at  birth  there  are  often  no  symptoms  for  several  days  or  even 
weeks,  except  it  may  be  an  unusual  limpness  of  the  limbs  and  some  difficulty  in 
swallowing.  In  other  cases  iniihitrral  spasms  or  (inirral  cnnviilsions  speedily 
develop,  but  these  are  not  of  long  duration,  and  it  is  noticed  that  the  child's  head 
is  not  held  erect,  but  falls  from  side  to  sitle,  backward  or  forward.  The  convulsions 
may  affect  the  entire  iiody,  or  be  coiifined  to  the  side  in  which  paralysis  is  aliout 
to  develop.  Associated  with  these  convulsions  there  is  a  marhcd  rise  in  temperature, 
the  fever  sometimes  reaching  as  high  as  105°.  After  the  convulsion  there  may  be 
postconvulsive  coma,  which  may  last  several  days.     Gradual   improvement  now 


INFANTILE  CEREBRAL  PARALYSIS 


7sn 


takes  place,  and  as  the  child  returns  to  consciousness  it  is  found  that  there  is 
loss  of  -poioer  vpon  one  side  of  the  body.  Shortly  afterward  it  is  also  noticed  that 
the  arm  upon  the  affected  side  is  not  only  paralyzed,  but  that  it  is  in  a  somewhat 
spastic  state.  The  leg  suffers  in  a  similar  manner.  Later  on,  cluh-foot  and  a  sharply 
flexed  hand  develop  from  secondary  contractures.  The  paralyzed  lunhs  fail  to 
develop  as  they  should,  become  dirophied,  and  are  often  considerably  shorter  than 
the  limbs  upon  the  healthy  side.  The  reflexes  are  exaggerated  and  Babinski's  sign 
is  present.     Sensation  is  not  impaired. 

If  the  child  survives,  the  paralyzed  parts  gradually  become  markedly  distorted 
and  tenotomies  may  be  necessary  to  prevent  the  contracture  from  causing  so 
great  a  deformity  as  to  make  any  motion  im- 
possible. Even  these  means  may  not  make  Fig.  131 
walking  possible.  If  the  intellectual  portions 
of  the  brain  are  not  involved,  and  if  the 
patient  reaches  the  years  of  puberty,  it  not 
infrequently  happens  that  by  prolonged  train- 
ing a  very  remarkable  degree  of  ability  is  de- 
veloped in  the  nonparalyzed  side  so  that  the 
individual  can  follow  some  pursuit  which  will 
render  him  self-supporting.  In  other  instances, 
however,  the  spastic  condition  of  the  affected 
limbs  is  very  marked,  the  hand  is  sharply  flexed 
at  the  wrist,  and  athetoid  movements  of  the 
fingers  may  be  present  whenever  any  attempt 
is  made  to  move  them.  These  athetoid 
movements  occur  very  soon  after  the  para- 
lysis is  noticed  in  certain  cases.  In  others 
they  do  not  develop  for  a  long  time.  The 
state  of  the  legs  is  even  more  noticeable,  if 
such  a  thing  be  possible.  Here  we  find  that 
the  parts  are  at  once  placed  in  strong  exten- 
sion if  they  are  touched,  the  muscles  of  the 
calf  are  tightly  contracted  and  the  feet  are 
inverted  or  turned  inward.  The  thighs  are 
abducted.  When  the  attack  comes  on  after 
the  child  has  learned  to  speak,  there  may  be 
marked  aphasia  for  a  time,  but  this  sjTnptom 
often  gradually  disappears. 

Spastic  diplegia  may  affect  either  the  arms 
or  the  legs,  usually  both  arms  and  legs,  and 
is  characterized  not  only  by  loss  of  power  in 
these  parts,  but  by  rigidity,  which  is  particu- 
larly marked  in  the  lower  extremities.  The 
s\'mptoms  usually  develop  slowly,  not  acutely 
as  they  do  in  spastic  hemiplegia. 

WTien  a  hemiplegia  develops  in  a  child  of 
a  year  or  more  it  is  usually  due  to  hemor- 
rhage or  embolism   or   to   the   polio-encephalitis   of   Striimpel   rather   than   to 
meningeal  disease. 

Various  deformities  of  the  lower  limbs  occur,  and  the  muscles  of  the  trunk, 
particularly  at  the  back,  are  so  rigid  that  the  child  is  as  if  fixed  in  a  plaster  cast. 
In  other  instances  where  the  condition  has  developed  some  time  after  birth,  the 
patient  can  sometimes  walk  by  the  aid  of  a  cane  or  crutches,  but  in  those  instances 
in  which  the  lesion  is  severe  the  contractures  and  athetoid  movements,  the  exag- 


Hemiplegia.  with  contractures.  The 
patient  had  suffered  since  the  age  of  two 
years.     (Curschmaun.) 


798  DISEASES  OF  THE  NERVOUS  SYSTEM 

geration  of  tlie  reflexes,  and  the  imperfectly  developed  muscles  all  combine  to 
make  the  child  absolutely  helpless.  There  is  no  loss  in  the  control  of  the  sphincters 
nor  any  trophic  disturbances  in  the  way  of  bed-sores,  nor  are  there  any  sensory 
disturbances  or  electrical  reactions  of  degeneration. 

Both  of  these  types  not  infrequently  sufTer  from  epileptic  convulsions,  which 
may  be  of  the  Jacksonian  type.  In  those  cases  which  are  due  to  lesions  in  the 
intellectual  area  of  the  brain,  idiocy  may  be  present.  In  those  instances  in  which 
the  defect  of  mental  power  is  not  complete  the  patient  is  called  an  imbecile.  Such 
patients  are  often  subject  to  violent  outbursts  of  anger,  to  attacks  of  malicious 
mischief,  and  are  often  exceedingly  filthy  in  their  habits. 

In  the  cases  in  which  the  posterior  portions  of  the  brain  are  affected,  the  disorders 
of  special  sense  do  not  usually  make  themselves  manifest  until  the  child  is  at  least 
a  year  or  eighteen  months  old.  Often  prior  to  the  discovery  of  any  symjitoms  of 
disorder  of  special  sense,  epileptic  convulsions  have  called  attention  to  the  fact 
that  the  cerebral  development  is  imperfect.  In  some  instances  the  disorders  of 
vision  may  amount  to  nothing  more  than  a  hemianopsia.  In  others  there  may 
be  total  blindness,  or  deafness,  or  loss  of  smell  and  taste.  In  these  cases  also 
ordinary  epilepsy  and  Jacksonian  epilepsy  are  often  present.  In  some  instances 
minor  epilepsy  takes  the  place  of  major  epileptic  attacks. 

Diagnosis. — The  diagnosis  in  a  ■n'ell-de\'eloped  case  of  infantile  cerebral  paralysis 
is  not  difficult.  The  early  development  of  the  malady  (after  a  hard  labor  it  may 
be),  the  marked  arrest  of  normal  development,  and  the  epileptic  convulsions,  with 
the  spastic  state  of  the  muscles,  all  separate  this  form  of  infantile  paralysis  from 
those  forms  which  depend  for  their  existence  upon  lesions  in  the  spinal  cord,  for 
in  the  latter  the  paralyzed  parts  are  flaccid.  There  are,  however,  two  forms  of 
spinal  spastic  palsy  of  childhood  with  which  this  condition  can  be  confused,  one 
of  which  is  the  so-called  "hereditary  spastic  spinal  paralysis,"  but  in  this  disease 
the  mental  s.^Tnptoms  are  lacking  and  the  condition  is  progressive.  The  second 
state  which  resembles  this  disease  is  "amaurotic  family  idiocy,"  but  in  this  malady 
the  paralysis  may  be  flaccid  or  spastic  and  blindness  is  an  early  symptom.  There 
is  also  a  characteristic  change  in  the  fundus;  a  cherry-red  spot  in  the  region  of  the 
fossa  centralis,  surrounded  by  a  whitish  areola.  The  very  rarity  of  these  diseases 
serves  to  exclude  them. 

Prognosis. — It  must  be  evident  that  the  prognosis  as  to  complete  recovery  in 
severe  cases  is  anything  but  good.  In  those  cases  in  which  the  mental  powers 
are  feeble  and  convulsions  frecjuently  recur,  the  outlook  is  bad  both  as  to  recovery 
and  a  long  duration  of  life.  If  they  live  they  are  hopeless  mibeciles  or  idiots. 
When  the  affection  is  confined  chiefly  to  one  side  of  the  brain — that  is,  when  there 
is  hemiplegia — adult  years  may  be  reached  and  ordinary  mental  pursuits  followed 
in  many  cases. 

Some  of  these  patients,  moreover,  can  be  materially  improved  by  proper  training, 
in  which  instance  special  centres  which  are  not  impaired,  or  intellectual  centres  which 
have  escaped  the  wreck,  may  be  developed  to  such  an  extent  that  a  fair  degree  of 
comfort  and  intelligence  may  be  attainable.  The  con\-ulsions  cannot  be  cured, 
as  they  depend  upon  faulty  development,  but  they  may  be  modified  by  skilful 
treatment,  consisting  in  the  administration  of  nervous  sedatives,  the  avoidance 
of  all  causes  of  nervous  excitement  and  irritation,  and  the  moderate  emplo,Mnent 
of  the  bromides.  As  a  rule,  better  results  can  be  obtained  from  hygienic  methods 
and  from  mental  training  in  an  institution  devoted  to  this  pur])ose  than  can  be 
obtained  at  home.  At  one  time  it  was  considered  that  o])erative  interference  might 
be  of  very  great  value  in  these  cases,  but  we  now  know  that  little  can  be  expected 
from  such  a  plan  of  treatment.  In  those  cases  in  which  the  skull  has  seemed 
to  be  abnormally  small  it  was  proposed  that  the  skull  should  be  cut,  or  bone  should 
be  removed,  in  such  a  way  as  to  permit  expansion  of  the  brain.     But  the  smallness 


APHASIA  799 

of  the  skull  is  probably  more  dependent  upon  the  size  of  the  brain  than  is  the  size 
of  the  brain  upon  the  condition  of  the  skull.  In  some  instances  the  parents  prefer 
running  the  risk  of  the  child's  death  as  the  result  of  such  a  grave  operation  ratlier 
than  to  have  it  continue  a  hopeless  invalid,  and  in  such  cases,  if  there  are  distinct 
localizing  symptoms,  epileptic  or  otherwise,  the  question  of  cerebral  localization 
and  operation  must  be  carefully  considered. 

Little's  Disease. — The  name  "Little's  disease"  has  heen  applied  by  some  writers 
to  the  cerebral  palsies  of  childhood;  but  is  probably  best  restricted  to  cases  in 
which  there  is  congenital  spastic  rigidity  of  the  limbs,  particularly  of  the  legs, 
tending  to  improvement.  In  Little's  disease,  thus  defined,  there  is  normal  mental 
capacity  and  no  epilepsy  or  athetosis.  The  condition  is  purely  motor  from  defective 
development  of  the  pyramidal  system  in  the  brain  or,  according  to  Dejerine,  in 
the  spinal  cord. 

APHASIA. 

Deftnitlon  and  Symptoms. — Aphasia  is  a  condition  in  which  the  function  of  speech 
becomes  impaired  or  arrested  as  the  result  of  disease  involving  those  parts  of  the 
brain  which  are  concerned  with  the  expression  of  ideas  in  words.  For  the  power 
of  speech  it  is  necessary  that  the  individual  shall  huve  not  alone  the  motor  centres 
which  will  cause  the  proper  muscular  movements  which  give  rise  to  certain  sounds, 
but  in  addition  there  must  be,  in  close  association  with  these  centres,  others  in 
which  the  conception  of  an  idea  must  originate,  and  still  others  in  which  a  sense  of 
the  appearance  of  words,  or  sounds  of  words,  is  stored.  When  a  child  is  learning 
to  talk,  an  object,  such  as  a  horse,  is  pointed  out  to  him,  and  the  word  "horse"  is 
frequently  repeated  at  the  same  moment.  He  therefore  learns  to  associate  a 
certain  shape  and  form  with  the  word  "horse."  For  him  to  do  this  it  is  necessary 
that  his  visual  apparatus  shall  carry  to  his  brain  a  certain  form,  and  that  his  brain 
should  store  up  that  form  as  typifying  a  certain  object.  It  is  also  necessary  that 
his  auditory  apparatus  shall  carry  to  his  brain  a  certain  sound  or  sounds,  and  that 
his  brain  shall  associate  this  sound  with  the  form  that  he  has  seen.  In  addition 
it  may  be  that  he  has  touched  or  stroked  the  horse,  and  so  his  sense  of  touch  has 
conveyed  to  his  brain  a  certain  model,  or  form,  which  is  associated  with  those 
received  by  means  of  his  eyes  and  ears.  When,  therefore,  he  sees  a  horse  a  second 
time  the  memories  or  imprints  derived  from  these  various  sources  are  utilized,  and 
he  attempts  to  reproduce  the  word  "horse"  by  a  process  which  calls  into  play 
certain  muscles  which  are  necessary  for  making  this  sound.  Speech  is  therefore 
in  one  sense  a  complicated  function,  closely  connected  with  the  organs  of  special 
sense,  of  intellection,  and  with  the  motor  neurones  as  well.  This  is  perhaps  made 
more  clear  by  the  following  diagram : 


A,  pathways  for  receiving  imprints  or  models;  B,  centre  for  storage  of  models;  C,  centre  for  storage  of 
motor  memories;  D,  concept  centre;  B.  motor  centres  for  controlling  muscles  of  speech  at  F. 

A  visual  impulse,  an  auditory  impulse,  a  touch  impulse,  an  olfactory  impulse, 
or  a  taste  impulse,  or  all  of  them  together,  pass  to  the  centre  B,  where  they  are 
received  and  stored.  From  B  these  memories  or  imprints  are  transmitted,  when- 
ever they  are  needed,  to  those  centres  in  the  brain  which  are  concerned  with  the 


800  DISEASES  OF  THE  NERVOUS  SYSTEM 

power  of  the  conccjrtion  of  an  idea,  or  they  may  he  transferred  directly  to  C,  which 
may  transform  them  into  speech  by  mimicry,  without  any  idea  or  higher  intellectual 
process  than  that  concerned  with  imitation.  If  the  child  thinks  of  a  horse  at  D, 
he  receives  memories  of  the  character  of  a  horse  from  li  and  sends  from  1)  an  impulse 
which  causes  C'to  send  impulses  to  the  organs  of  speech.  It  is  evident,  tlierefore, 
that  if  the  sensory  tracts  are  diseased  before  the  centres  for  storing  the  record 
are  developed,  or  if  any  part  of  the  mechanism  described  in  the  diagram  is  unde- 
veloped or  damaged,  the  entire  chain  fails  because  one  of  its  links  is  broken. 

This  process  may,  however,  he  even  more  comi)licated  than  that  described. 
Thus,  there  may  be  stored  in  the  storage  centre  not  only  the  mode!  or  imprint 
of  a  horse  Init  also  the  additional  memory  of  the  appearance  of  the  word  "horse" 
when  in  tyj)e,  and  in  addition  tliere  may  be  stored  the  memory  of  certain  move- 
ments which  are  characteristic  of  a  horse,  so  that  the  child  can  imitate  its  movements 
or  perhaps  draw  an  outline  of  its  appearance.  While  pantomine  and  drawing 
are  not  speech,  they  are  so  nearly  related  to  it  as  to  really  form  part  of  it.  Again, 
it  is  necessary  that  there  should  be  stored  at  C  the  models  or  memories  of  those 
muscular  movements  which  will  give  rise  to  the  sound  of  the  word  hf)rse,  for  this 
is  part  of  learning  how  to  talk. 

In  certain  cases  in  which  the  brain  is  diseased  the  patient  may  see  and  feel  and 
hear  a  horse,  and  his  concept  centres  may  know  perfectly  that  a  horse  is  before  him, 
or  that  the  word  "horse"  is  in  print,  but  he  cannot  say  the  word  "horse"  because 
the  centres  concerned  with  the  storage  of  memories  of  the  muscular  movements 
necessary  to  speak  the  word  "horse"  are  destroyed.  He  may  write  the  word 
"horse"  or  draw  a  horse,  but  he  cannot  say  "horse."'  To  this  form  of  motor 
aphasia  the  word  aphemia  is  applied.  If  the  centre  in  which  the  memories  of 
how  to  write  the  word  "hor.se"  are  destroyed  the  condition  is  called  nrjraphia, 
and  if  those  in  which  the  muscular  movements  required  to  describe  a  horse  by 
gesture  are  diseased  it  is  said  to  be  amimia.  When  the  tracts  that  associate  the 
storage  centres  for  memories  of  words  are  interfered  with,  the  patient  skips,  or 
jumbles,  or  repeats  his  words,  and  this  is  called  conduction  aphasia;  and  if  he  .speaks 
one  word  when  he  means  another,  it  is  called  paraphasia. 

On  the  other  hand,  when  the  sensory  portion  of  the  speech  mechanism  is  diseased 
the  patient  may  be  able  to  say  the  word  "horse,"  but  if  he  sees  a  horse  he  cannot 
say  that  he  has  seen  it  because  he  has  lost  the  memories  of  the  horse;  or  if  he  sees 
the  word  "liorse"  in  print,  he  may  be  able  to  reproduce  tlie  letters  in  writing,  in 
their  order,  but  he  is  entirely  unable  to  read,  for  he  has  lo.st  the  memory  of  the 
significance  of  these  letters  when  so  joined.  This  is  called  alexia,  or  word  blindness 
an  unfortunate  term,  as  blindness  would  indicate  failure  of  visual  power,  which 
does  not  exist.  Again,  in  certain  cases  there  is  loss  of  memory  of  sounds.  The 
voice  of  a  speaker  may  be  heard  and  even  imitated,  but  the  patient  understands 
nothing  more  than  if  an  unknown  language  was  spoken.  It  conveys  no  idea  to 
his  mind.  This  is  called  word  deafness — another  unfortunate  term,  because  hearing 
in  tlie  ordinary  sense  of  that  word  is  perfect.  Apra.ria  is  still  another  nearly 
related  state  in  which  the  patient  fails  to  appreciate  the  purposes  or  uses  of  an 
object.  He  may  see,  hear,  and  touch  a  knife  or  a  coin,  but  his  mind  cannot  grasp 
its  uses. 

When  we  come  to  study  the  lesions  which  produce  these  disturbances  in  the 
ability  to  express  an  idea,  we  find  that  when  the  patient  has  aphemia  or  motor 
aphasia  the  damage  has  been  done  to  the  third  left  frontal  convolution  (Broca's 
convolution).  In  such  a  case  he  also  cannot  write  either  his  own  ideas  or  the  words 
that  he  hears  spoken,  but  he  can  copy.  If  the  lesion  is  a  severe  one,  his  power  of 
understanding  words  he  sees  written  or  hears  spoken  is  usually  impaired.     In 

•  As  a  matter  of  fact,  these  powers  are  usually  lost. 


'TUMORS  OF   THE  BRAIS  A.XD  ITS  MEMBRANES  >^01 

other  words,  he  also  suffers  from  word-bliiidness  and  word-deafness.  When  he 
has  word-bhndness  or  alexia,  the  lesion  is  at  the  left  angular  gyrus.  If  there  is  a 
pure  alexia  the  lesion  is  in  the  subcortical  substance  of  the  left  angular  gyrus.  In 
word-deafness  the  lesion  is  in  the  posterior  part  of  the  first  temjjoral  convolution 
on  the  left  side.  Aphasia  also  develops  when  a  lesion  takes  place  from  hemorrhage, 
embolism,  or  thrombosis  in  the  knee  of  the  internal  capsule,  for  at  this  point  the 
fibres  which  convey  speech  impulses  are  destroyed. 


TUMORS  OF  THE  BRAIN  AND  ITS  MEMBRANES. 

Intracranial  tumors  arise  from  the  substance  of  the  brain  itself  or  from  the 
membranes  which  surround  it.  A  great  variety  of  these  growths  ha\-e  been  recorded, 
but  by  far  the  most  common  are  tubercle,  gumma,  glioma,  and  sarcoma.  Cancer, 
fibroma,  neuroma,  and  vascular  tumors  also  rarely  occur.  Echinococcus  cysts 
may  develop. 

Etiology  and  Frequency. — The  causes  of  these  morbid  growths  are  not  understood 
except  in  the  case  of  tubercle  and  gumma.  Sex  seems  to  exercise  a  very  distinct 
influence,  for  we  find  that  males  suffer  very  much  more  frequently  than  females. 
Gowers  states  that  out  of  650  cases  of  brain  tumor  440  occurred  in  males  to  210 
in  females.  Dana  gives  the  figures  at  644  to  320,  and  Starr's  figures  are  nearly 
identical  in  their  proportions.  This  great  preponderance  in  males  is  not  explained 
by  either  syphilis  or  injury,  for  there  is  no  greater  frequency  of  giunma  in  men  than 
in  women.  On  the  contrary,  tubercle  and  glioma  are  the  groMhs  that  are  particu- 
larly frequent  in  men.  Gowers  has  shown  that  after  the  first  six  months  of  life 
till  old  age  all  ages  suffer  about  equally.  Thus,  the  percentage  in  the  first  decade 
is  18.5,  in  the  second  14,  in  the  third  20,  in  the  fourth  decade  18.5,  and  in  the  fifth 
14.  Most  of  the  growths  in  childhood  are  tuberculous,  and  indeed  they  form  53 
per  cent,  of  all  growths  at  all  ages,  if  gumma  be  excluded. 

Pathology  and  Morbid  Anatomy. — Tumors  of  the  brain  affect  its  tissues  in  its 
different  areas  as  follows,  according  to  Gowers:  In  the  hemispheres  297,  in  the 
cerebellum  179,  in  the  base  of  the  brain  76,  in  the  pons  59,  in  the  central  ganglia 
48,  in  the  medulla  31,  in  the  corpora  quadrigemina  13,  and  in  the  crus  10. 

Tuberculous  tumors  occur  as  solid,  firm,  round  masses  which  are  not  rarely 
multiple.  Their  size  varies  from  that  of  a  pea  to  a  hen's  egg  or  even  larger.  The 
growth  starts  from  the  lymphoid  sheaths  of  the  vessels,  and  rapidly  obliterates 
them.  For  this  reason  it  is  devoid  of  vessels  and  its  tissue  soon  undergoes  necrosis, 
so  that  on  section  it  is  cheesy  and  shows  spots  of  softening.  As  the  surface  is  soft, 
and  the  surrounding  brain  substance  is  also  softened,  the  mass  is  clearly  outlined, 
hence  the  name  tuberculoma.  Finally,  the  growth  may  become  calcified  or  undergo 
suppuration.  Tuberculous  growths  are  often  found  in  the  cerebellum,  and  they 
also  occur  in  the  pons  and  cerebrum.  When  in  the  cerebrum  they  are  usually 
found  along  the  great  vessels  in  the  interpeduncular  space  or  in  the  fissure  of 
Sylvius ;  not  rarely  the  growth  is  near  a  Pacchionian  body,  but  it  may  be  found  in 
the  depths  of  the  centrum  ovale. 

Gummata  of  the  brain  rarely  reach  a  size  greater  than  that  of  a  hickory-nut. 
They  are  also  somewhat  cheesy  in  appearance  and  have  an  irregular  surface, 
which  may  be  gelatinous,  or  indurated  and  hard,  and  enclosed  in  a  fibrous  cap- 
sule. These  growths  are  thought  to  spring  from  the  bloodvessels  of  the  dura 
mater. 

Sarcomata  occur  as  round,  oval,  or  spindle-cell  tumors  which  destroy  the  tissues 

of  the  brain  as  they  grow.     When  they  are  of  the  gliomatous  type  they  differ 

greatly  from  all  the  growths  so  far  described,  for  they  are  not  round,  but  extend 

by  a  process  of  infiltration  between  the  nerve  cells.     They  may  be  soft  and  mucoid 

51 


802  DISEASES  OF  THE  NERVOVS  SYSTEM 

(myxoglioma),  or  firm  and  fibrous  (fibroglioma).  Gliomas  of  tlic  soft  variety  are 
liable  to  hemorrhage.  A  cystic  form  of  glioma  due  to  softening  is  not  rare.  Glio- 
mata  are  usually  single. 

The  secondary  changes  produced  by  these  growths  are  of  importance  and  depend 
chiefly  upon  the  pressure  of  the  tumor  upon  healthy  tissues  which  in  this  way  are 
destroyed.  The  very  growth  of  the  tumor  inside  the  skull  also  increases  intracranial 
pressure,  and  if  it  be  so  situated  that  it  prevents  the  free  passage  of  cerebrospinal 
fluid  from  the  choroid  plexus  in  the  lateral  ventricle  through  the  third  ventricle 
and  the  ifer  a  fertio  ad  quartum  ventrmdwn,  then  distention  of  the  lateral  ventricles 
or  internal  hydrocephalus  develops.  A  tiunor  of  the  pons,  of  the  corpora  cjuad- 
rigemina  of  the  middle  lobe  of  the  cerebelhun,  or  in  the  third  ventricle  may  cause 
such  obstruction.  A  third  result  of  the  intracranial  tumor  is  irritation  of  the  nerve 
cells  of  the  brain  and  inflammation  in  them  or  in  the  meningeal  membranes,  and 
lastly  it  may  cause  actual  thinning  of  the  skull  by  the  pressure  induced. 

Symptoms. — By  far  the  most  common  symptom  of  brain  tumor  is  headache, 
constant  in  type  like  all  headaches  of  organic  origin.  This  headache  is  usually 
severe  and  is  characterized  by  sharp  exacerbations.  In  some  instances  it  is  dull 
and  boring  in  character.  In  others  it  is  sharp,  stabbing,  and  tearing.  By  reason 
of  its  constancy  it  prevents  sleep,  and  in  its  most  severe  paroxysms,  may  produce 
temporary  aberration  of  mind.  The  pain  is  widely  dift'used,  and  is  particularly 
severe  if  it  encroaches  on  the  dura  which  is  supplied  with  sensation  by  the  fifth 
nerve.  If  the  pain  is  localized  it  does  not  necessarily  indicate  that  the  growth 
is  in  that  neighborhood,  although  in  those  cases  in  wdiich  the  tumor  is  superficial 
the  locality  of  the  growth  and  of  the  pain  is  often  identical. 

Next  to  headache  in  constancy  as  a  symptom  is  vomiting.  The  expulsion  of 
the  stomach  contents  is  usually  spoken  of  as  "projectile,"  and  in  this  respect  it 
resembles  the  vomiting  of  certain  forms  of  intestinal  obstruction.  Although  the 
vomiting  is  severe,  nausea  is  often  absent.  This  symptom  is  supposed  to  be  most 
frequent  and  severe  when  the  growth  is  rapidly  progressing.  Vertigo  also  occurs 
and  varies  from  slight  dizziness  to  a  degree  which  causes  the  patient  to  fall.  Not 
infrequently  this  vertigo  causes  the  patient  to  walk  in  the  direction  in  which  it  is 
not  his  intention  to  go.  Vertiginous  symptoms  are  more  common  in  tumor  of 
the  cerebellum  than  in  lesions  elsewhere,  and  often  the  patient  falls  to  one 
side.  Another  very  important  symptom  of  brain  tumor  is  optic  neuritis,  which 
occurs  in  a  large  proportion  of  cases  and  which  often  enables  us  to  make  a 
diagnosis  of  brain  tumor  with  the  aid  of  the  ophthalmoscope  when  the  other 
symptoms  are  so  obscure  that  it  is  difficult  to  determine  the  nature  of  the  patient's 
disease. 

Optic  neuritis  is  usually  most  marked  in  cases  of  tumor  of  the  cerebellum,  of 
the  midbrain,  and  of  the  great  ganglia  near  the  base.  It  occurs  less  frequently 
when  the  tumor  is  in  the  cortex  or  springs  from  one  of  the  membranes,  but  the 
localizing  value  of  neuritis  is  really  not  great.  Nearly  always  both  optic  nerves 
are  involved,  although  sometimes  the  lesion  develops  in  one  before  it  attacks  the 
other.  Gowers  gives  three  reasons  for  this  optic  neuritis:  First,  irritation  of  the 
nerve  fibres  produced  by  the  pressure  which  finally  causes  inflammation.  Second, 
distention  of  the  nerve  sheaths  and  the  lymphatic  spaces  of  the  papilla  h\  sub- 
arachnoid fluid,  which,  perhaps,  contains  irritating  poisons.  The  third  cause  is 
thought  to  be  inflammation  of  the  meninges,  which  is  so  frequently  present,  and 
which  may  extend  to  the  optic  nerve. 

Slowness  of  thought  and  gradual  mental  failure  are  not  infrequently  present. 
Sometimes  aphasia  develops.  All  these  three  SNTiiptoms  are  prone  to  occur  when 
the  tumor  afi'ects  the  frontal  lobe,  and  the  SATiiptom  of  aphasia  is,  of  course,  most 
frequently  developed  when  the  left  frontal  lobe  is  involved.     F,pil(>])tiform  con- 


'TUMORS  OF  THE  BRAIN  AND  ITS  MEMBRANES  SOZ 

vulsioiis  occur  in  about  one-quarter  of  the  cases  of  brain  tumor,  and  are  especially 
marked  in  those  instances  in  which  the  growth  directly  or  indirectly  produces  irrita- 
tion of  the  cortex.  So,  too,  there  may  be  symptoms  which  for  a  time  resemble  the 
early  stages  of  an  apoplexy.  Quite  rarely  actual  rupture  of  a  bloodvessel  occurs, 
and  so  the  symptoms  are  really  apoplectic. 

Paralysis  due  to  brain  tumor  may  be  unilateral  or  bilateral.  When  unilateral 
it  may  manifest  itself  as  a  monoplegia  or  as  a  hemiplegia.  It  is  usually  gradual 
in  onset,  and  when  hemiplegic  in  type  is  due  to  the  presence  of  a  growth  in  the  upper 
part  of  the  pons,  in  the  crus,  or  in  the  internal  capsule,  or  over  a  wide  area  in  the 
cortex.  Localized  paralysis,  such  as  monoplegia,  may  be  due  to  a  growth  involving 
the  cortex  or  the  subcortex  before  the  fibres  have  come  together  so  closely  that 
even  a  small  tumor  must  affect  the  whole  bundle  and  produce  widespread  paralysis. 
Such  a  monoplegia  involving  the  arm  or  leg  is  not  infrequently  associated  with 
epileptiform  attacks,  limited  to  the  paralyzed  part.  If  the  growth  is  in  the  lower 
third  of  the  pons  the  ordinary  form  of  crossed  paralysis  may  be  present,  the  face 
being  paralyzed  on  the  side  of  the  lesion,  while  the  arm  and  leg  are  paralyzed  on  the 
opposite  ^ide. 

A  rarer  form  of  crossed  paralysis  (Weber's  syndrome)  may  result  from  tumor 
of  one  crus  involving  the  third  nerve.  The  eyes  are  deviated  to  the  side  opposite 
the  lesion  and  the  pupil  dilated  on  the  side  of  the  lesion,  while  the  arm  and  leg, 
as  in  ordinary  hemiplegia,  are  paralyzed  upon  the  opposite  side. 

Bilateral  paralysis  due  to  brain  tumor  can  only  occur  when  the  growth  is  multiple 
and  presses  upon  both  sides  of  the  brain,  or  when  it  is  so  situated  that  it  can  at 
once  cut  off  fibres  from  both  sides  as  they  approach  the  middle  area,  as  in  the  pons 
or  in  the  medulla.  Under  these  circimistances  the  legs  are  usually  more  affected 
than  the  arms,  even  though  the  face  as  well  as  the  arms  be  included  in  the  paralysis. 
Contractures,  tonic  spasms,  or  convidsions,  either  generalized  or  Jacksonian,  may 
also  occur.  They  usually  indicate  that  the  growth  is  situated  somewhere  near  the 
cortex,  where  it  produces  other  irritations. 

If  the  tiunor  is  in  the  frontal  area  and  grows  forward  it  may  cause  protrusion 
of  the  eyeballs  and  paralysis  of  the  extrinsic  muscles  of  the  eye,  while  if  it  grows 
backward  it  may  cause  spasm  and  epileptiform  convulsions  by  the  irritation  of 
the  motor  area  of  the  cortex. 

The  development  of  a  cortical  growth  in  the  posterior  part  of  the  frontal  lobe 
along  the  fissure  of  Rolando  produces  symptoms  which  are  more  definite  than 
those  which  are  found  in  association  with  growths  elsewhere,  because  it  is  the 
motor  area  of  the  brain.  Not  infrequently  localized  convulsions,  or  Jacksonian 
epilepsy,  occur  in  such  cases  and  paralysis  limited  to  the  same  muscles  may  follow 
such  an  attack.  The  part  in  which  the  convulsion  begins  and  the  subsequent 
paralysis  indicate  the  presence  of  the  tumor  in  or  beneath  the  centre  supplying  the 
centres  controlling  these  muscles.  Disorders  of  sensation  in  the  affected  limb  may 
be  present,  consisting  of  numbness,  tingling,  and  even  hemianesthesia. 

When  a  tiunor  involves  the  parietal  region  the  sj^mptoms  are  not  definite,  but 
pertain  chiefly  to  common  sensation  and  "muscle  sense." 

If  the  superior  parietal  lobule  be  invaded  there  is  more  or  less  loss  of  "muscle 
sense,"  and  often  the  symptom  astereognosis  is  present.  When  the  angular  gyrus 
on  the  left  side  is  involved,  word  blindness  may  be  present. 

When  that  portion  of  the  parietal  area  near  the  longitudinal  fissure  is  invaded 
we  not  infrequently  have  spasms  or  convulsions  in  the  lower  extremities  on  the 
side  opposite  the  lesion,  because  the  growth  begins  to  invade  the  part  of  the  leg 
centre  which  is  on  the  inner  surface  of  the  hemisphere. 

Tumors  of  the  occipital  lobe,  if  in  the  cuneus  or  otherwise  near  the  calcarine 
fissure,  produce  lateral  homonymous  hemianopsia.     If  the  growth  in  the  occipital 


<S()4 


i)ish:Asi-:s  OF  THE  xkrvdcs  systkm 


lobe  is  sufficiently  far  forward  to  involve  some  of  the  j)arietal  area,  and  so  do 
damage  to  the  angular  gyrus,  word-blindness  and  hemianopsia  may  develop,  and 


'^^o      s  p  H  B 


Showing  the  areas  of  the  hrain  concerned  with  special  functions.     1.  Prefrontal  area.    2.  Central 
area.    3.  Parietal  area.    4.  Occipital  area.    5.  Temporal  area.     (Modified  from  Fuller.) 


6.  Corpus  callosum.    7.  Thalamus  opticus.     10.  Corpora  quadrigemina.     11.  Crus.     12.  Pons. 
13.   Medulla  oblongata.     It.   CVrchclluni.     l.i.   Fourth  ventricle.     (Modified  from  Reirhert.) 


if  the  invasion  extends  still  tartluT,  lu'inititit.xia,  hemianesthesia,  and  even  some 
heiniple<;ia  due  to  involvement  of  some  of  the  fibres  of  the  internal  capsule  may 
be  present. 


TUMORS  OF   THE  BRAIN  AND  ITS  MEMBRANES 


80') 


In  the  first  left  temporal  convolution  brain  tumor  produces  word-deafness, 
a  form  of  sensory  aphasia.  Occasionally  large  tumors  in  the  temporal  area  produce 
vertigo. 

Tumors  of  the  corpus  callosum  are  not  only  very  unusual,  but  i)r()duce  symptoms 
which  are  not  vi;ry  definite,  being  primarily  those  of  mental  failure  and  secondarily 
those  due  to  encroachment  upon  neighboring  parts.  In  addition  to  the  general 
symptoms  of  brain  tumor,  the  growth  in  this  region  produces  hemiplegia,  ultimately 
developing  into  paraplegia,  great  mental  duiness,  and  finally  coma. 


10.  Corpora  quadrigemina.     11.  Crus.     12.  Pons.     13.  Medulla  oblongata. 
(Modified  from  Reichert.) 


14.  Cerebellum. 


When  a  tumor  involves  the  great  basal  ganglia  or  the  fibres  of  the  internal  capsule, 
hemiplegia  is  the  most  prominent  symptom,  and  hemianesthesia  and  choreic 
movements  may  be  present. 

If  the  posterior  part  (pulvinar)  of  the  optic  thalamus  and  nearby  tissues,  particu- 
larly one  of  the  optic  tracts,  are  involved  by  the  growth,  hemianopsia  may  be 
present,  but  this  hemianopsia  may  be  separated  from  that  which  is  due  to  a  lesion 
in  the  occipital  lobe  by  the  presence  of  Wernicke's  sign  (hemianopic  pupillary 
inaction) . 

Having  from  these  several  symptoms  determined  that  a  brain  tumor  is  present, 
it  still  remains  for  the  physician  to  definitely  determine  its  locality,  and  this  can 
only  be  done  by  his  knowledge  of  cerebral  localization.  For  this  study  the 
brain  can  best  be  divided  into  fifteen  parts,  most  of  which  can  be  seen  on  the 
accompanying  diagrams  (Figs.  133,  1.34,  and  135). 

The  numbers  in  the  text  refer  to  the  numbers  in  the  figures  and  show  where  the 
growth  would  be  situated. 


806 


DISEASES  OF  THE  NERVOUS  SYSTEM 


Tumors  of  the  prefrontal  area 
(See  Fig.  133.) 


2-  ,1 

Tumors  of  the  central  area     .    .   ■ 

(See  Fig.  133.) 


Tumors  of  the  parietal  area        .   • 
(See  Fig.  133.) 


Tumors  of  the  occipital  lobe 
(See  Fig.  133.) 


Tumors  of  temporal  area 
(See  Fig.  133.) 


u. 
Tumors  of  corpus  callosum 
(Very  rare.) 
(See  Fig.  134.) 


7,  8,  9. 
Tumors  of  the  great  basal  ganglia  ( 

and  capsule. 
(See  Fig.  134,  for  7  and  Fig.  130 
for  8  and  9.) 


10. 
Tumor  of  the  corpora  quadri- 
gemina  (vermis  of  the  cerebel- 
lum) and  spinal  gland. 
Additional  information  as  to 
these  lesions  can  be  had  by 
studying  Figs.  130  and  135. 

11. 

Tumors  of  cms 

(Verj'  rare.) 


12. 
Tumors  in  the  pons 


Table  of  Cekebkal  Localizino  Symptoms.' 


No  symptoms,  or 

Stupidity. 

Silliness. 

Emotionalism. 

Loss  of  smell  on  one  side  or  both  sides. 

Hemianopsia  and  optic  neuritis. 

Protrusion  of  the  eyeball. 

Paralysis  of  the  extrinsic  ocular  muscles. 

Jacksonian  epilepsy. 

Sensory  disorders,  tingling  or  hemianesthesia. 

Impaired  muscle  sense. 

Motor  aphasia  and  agraphia. 

Local  palsy  after  spasm. 

No  symptoms,  or 

Loss  of  muscle  sense  if  supramarginal  gyrus  is  affected. 

Word-blindness  if  angular  gyrus  and  inferior  lobule  are  affected. 

Paralysis  or  spasm  of  the  lower  limbs  if  the  upper  margin  of  the 
cerebral  area  is  invaded. 

Perhaps  slight  paralysis  of  the  sixth  nerve  if  the  angular  gyrus  is 
affected. 

Homonymous  hemianopsia  if  the  cuneus  or  the  neighborhood  of  the 
calcarine  fissure  and  first  occipital  convolution  are  involved. 

Failure  to  grasp  meaning  of  surrounding  objects  (mind-blindness)  if 
cuneus  escapes. 

Word-blindness  and  some  hemianopsia  if  the  angular'gyrus  is  affected. 

Hemiataxia,  hemianesthesia,  and  partial  hemiplegia  if  the  internal 
capsule  is  slightly  involved  in  the  posterior  part,  and  also  homony- 
mous hemianopsia  from  involvement  of  the  optic  radiations. 

No  symptoms  if  on  right  side. 

Word-deafness  if  the  posterior  part  of  the  first  and  second  temporal 
convolution  is  involved. 

Vertigo  and  forced  movements,  if  the  growth  is  low  down,  due  to 
irritation  of  internal  ear. 

Gradually  developing  hemiplegia  followed  by  paraplegia. 

Dulness  and  other  mental  symptoms  suggesting  paresis. 

Stupor    "I  and  various  symptoms  due  to  pressure  upon  neighboring 

Coma     /      structures. 

Death. 

Progressive  hemiplegia. 

Anesthesia  (?) 

Choreic  movements  if  tumor  involves  optic  thalamus  (7)  and  nearby 
part  of  capsule  (8) .     Starr  thinks  that  these  movements  are  cortical. 

No  localizing  symptoms  if  the  tumor  involves  the  caudate  or  lenticu- 
lar nucleus  (9). 

Hemianopsia  and  the  hemianopic  pupillary  inaction  of  Wernicke,' 
if  the  optic  tract  or  its  endings  near  the  posterior  part  of  the  optic 
thalamus  and  adjacent  tissues  are  involved.  If  this  pupillary  in- 
action of  Wernicke  is  absent  hemianopsia  indicates  a  lesion  in  the 
occipital  lobe  involving  the  cortex  or  the  optic  radiations. 

Cerebellar  inco-ordination. 

Forced  movements. 

Ocular   palsies,   often   sjTnmetrical. 

Hemianopsia  if  primary  optic  centres  of  one  side  are  destroyed; 
blindness  if  destroyed  on  both  sides. 

Deafness  or  partial  deafness  if  posterior  tubercles  of  corpora  quadri- 
gemina  are  affected. 

Hemiplegia. 

Hemianesthesia  (?) 

Paralysis  of  oculomotor  nerve  upon  same  side  as  tumor  (crossed 
paralysis) . 

Facial  palsy  on  same  side  as  tumor;  hemiplegia  on  opposite  side 
(crossed    paralysis) . 

Trifacial  paralysis  on  same  side  as  tumor  if  below  middle  of  pons; 
hemianesthesia  on  opposite  side  (crossed  sensory  paralysis) . 

Hemianesthesia  and  hemiplegia  if  tumor  is  large  and  above  middle 
of  the  pons. 

Conjugate  deviation  of  eyes  away  from  the  lesion. 


'  In  the  preparation  of  this  table  much  use  has  been  made  of  the  facts  stated  by  Dana  in  his  work 
on  Nervous  Diseases. 

'  A  ra.v  of  light  thrown  on  the  blind  half  of  the  retina  will  not  produce  reflex  pupillary  contraction, 
though  the  pupils  react  normally  if  the  light  strikes  the  other  half  of  the  retina. 


'TUMORS  OF  THE  BRAIN  AND  ITS  MEMBRANES  807 


13. 

Tumors  in  medulla 


14. 
Cerebellar  tumor      .      .      ,      .     ■ 


Tumor  in  anterior  fossa 


Hemiplegia  and  hemianesthesia  with  hypoglossal  paralysis  or  other 
cranial  norve  palsy  on  side  of  lesion.    Glj'cosuria  and  vasomotor 
disturbance. 
^  Symptoms  of  bulbar  paralysis  if  growth  is  large. 

Headache  ] 

Ver't^go"^  [  "^"''"y  ^'''"'^^- 

Optic  neuritis    J 

Reeling  gait  if  in  middle  lobe. 

Glycosuria  and  cranial  nerve  palsies  if  pressing  upon  or  in  middle 

lobe. 
Bulbar  symptoms  (i.  e.,  cranial  nerve  palsies). 
Hydrocephalus  if  tumor  presses  on  aqueduct  of  Sylvius. 
Same  symptoms  as  prefrontal  tumors. 
Loss  of  smell,  sight,  and  oculomotor  paralysis.     Acromegaly,  optic 

neuritis,  and  temporal  hemianopsia  if  the  tumor  is  in  middle  fossa 

and   involves   optic   chiasm. 

Diagnosis. — ^As  already  stated,  the  important  sjTnptoms  in  the  diagnosis  of 
brain  tumor  are  headache,  vertigo,  optic  neuritis,  convulsions,  and  paralysis. 
It  must  be  remembered,  however,  that  these  sjTuptoms  are  none  of  them  pathog- 
nomonic of  brain  tumor,  and  that  each  of  them  is  often  present  in  other  maladies. 
It  is  the  combination  of  s\Tiiptoms  rather  than  any  one  of  them  alone  that  indicates 
or  establishes  the  diagnosis.  Headache  and  vertigo  are  due  to  a  host  of  causes,  as 
convulsions  and  paralysis  are  common  .conditions;  it  is  the  localization  of  the 
convulsions  and  of  the  paralysis,  pointing  to  a  distinct  focus,  that  is  signiiicant. 
Hysteria  may,  however,  cause  localized  palsies  and  localized  anesthesia,  but  they 
are  not  associated  with  optic  neuritis  and  the  hysterical  sensory  stigmata  would  be 
conspicuous.  Sometimes,  too,  localized  convulsions  are  not  only  due  to  tumor, 
but  are  symptomatic  of  a  general  condition  such  as  poisoning,  or  of  a  widespread 
nervous  disease  such  as  paresis.  The  most  valuable  sign  of  brain  tumor,  optic 
neuritis,  may  be  present  in  chronic  contracted  kidney,  chronic  lead  poisoning,  and 
severe  anemia,  etc.,  but  these  conditions  can  be  eliminated  from  the  case  by  the 
absence  of  the  other  signs  and  sjTnptoms  of  these  maladies. 

Among  the  pathological  states  that  may  produce  sjmptoms  of  brain  tumor 
is  to  be  mentioned  localized  meningitis  due  to  tuberculosis  or  sj-philis.  (See 
Meningitis.)  In  tuberculosis  the  degree  of  optic  neuritis  is  usually  slight;  there 
is  a  primary  tuberculous  focus  existing  elsewhere,  and,  as  the  case  progresses, 
evidences  of  a  general  meningeal  inflammation  may  develop.  Sj^Dhilitic  meningitis 
is  usually  diffuse,  not  localized,  and  when  localized  is  to  be  considered  as  a  gumma 
or  tumor.  Another  cause  of  such  symptoms  is  abscess.  This  may  be  differentiated 
by  its  rapid  development  and  by  the  presence  of  a  septic  focus  elsewhere,  as  in  the 
ear  or  in  other  parts  of  the  body.     (See  Brain  Abscess.) 

The  question  as  to  the  character  of  the  growth  is  determined  by  the  following 
facts  in  many  cases.  Tuberculous  growths  are  frequently  met  with,  particularly 
in  children.  The  presence  of  tuberculous  infection  elsewhere  also  points  to  this 
form  of  tumor.  So,  too,  the  presence  of  a  malignant  growth  in  some  other  part 
of  the  body  suggests  that  the  lesion  in  the  brain  is  of  the  same  character.  A 
historj^  or  the  presence  of  the  scars  of  syphilis  and  a  positive  Wassermann  test  will 
indicate  the  existence  of  a  giunma.  Gowers  states  that  if  the  tiunor  be  in  the 
cerebellum  or  pons,  there  is  some  probability  "  of  its  being  tubercle  or  glioma,  and 
if  it  is  in  the  cortex  the  probability  that  it  is  sj'philitic  is  considerable."  "A  tumor 
outside  the  brain  tissue  is  probably  sarcoma."  So,  too,  the  disappearance  of  the 
symptoms  under  active  antisyphilitic  treatment  point  to  syphilis  as  the  cause. 
"  A  tumor  which  grows  rapidly  at  the  onset  and  then  becomes  stationary  is  probably 
tuberculous." 

Prognosis. — The  prognosis  in  all  forms  of  brain  tumor  is  grave.  It  is  least  so 
in  gumma  and  next  best  in  tubercle,  for  in  the  former  active  treatment  may  cure, 
and  in  the  second  a  long  period  of  arrest  may  ensue.     A  growth  in  the'  pons  or 


808  DISEASES  OF  THE  NERVOUS  SYSTEM 

medulla  is  more  dangerous  as  to  life  than  one  in  the  cortex,  but  the  presence  of 
severe  symptoms  of  brain  tumor,  be  the  seat  of  the  growth  what  it  may,  is  always 
of  grave  omen. 

Treatment. — From  what  has  been  said  of  the  etiology  and  ])atiioiogy  of  i)rain 
tumor  it  nuist  be  evident  that  medicinal  treatment  can  do  nothing  more  than 
palliate  the  j)atient's  suffering,  unless  the  growth  be  syphilitic.  For  the  relief 
of  the  headache  the  various  coal-tar  products,  such  as  acetaniiid,  phenacetin,  or 
antipyrin,  may  be  employed,  and  their  efficiency  is  usually  much  increased  In- 
giving  simultaneously  1  or  2  grains  of  caffeine  and  10  or  20  grains  of  one  of  the 
bromides,  preferably  the  bromide  of  strontium  or  bromide  of  sodium.  In  those 
cases  in  which  the  headache  becomes  so  severe  as  to  be  insupportable,  hypodermic 
injections  of  morphine  may  be  employed,  but  it  is  an  interesting  therapeutic  fact 
that  this  drug  gives  less  relief  in  the  pain  of  brain  tumor  than  in  almost  any  other 
affection  characterized  by  pain.  Excessive  vomiting  is  to  be  checked  by  aflmini.s- 
trations  per  rectum  of  10  or  20  grains  of  chloral  with  60  grains  of  bromide  of  sodium, 
to  which  may  be  added  30  to  60  minims  of  deodorized  tincture  of  opium.  So, 
too,  epileptiform  convulsions,  if  they  are  severe,  may  be  prevented,  at  least  in 
part,  by  the  use  of  the  bromides,  or,  if  an  aura  is  present,  by  inhalations  of  nitrite 
of  amyl. 

In  those  eases  in  which  there  is  tbe  history  of  syphilis,  the  administration  of 
salvarsan  or  mercury  and  the  iodide  of  potassium  is,  of  course,  strongly  indicated, 
and  if  a  gumma  is  producing  symptoms  such  as  convulsions,  which  may  in  them- 
selves endanger  the  patient's  life,  the  mercury  should  be  pushed  as  actively  as 
possible,  being  given  by  the  mouth,  by  inunction,  by  hypodermic  injection — 
that  is,  by  every  avenue  of  entrance — in  the  hope  that  it  may  exercise  its  influence 
upon  the  syphilitic  growth  before  a  convulsion  sufficiently  violent  to  cause  death 
ensues.  In  other  instances,  when  there  are  no  acute  symjjtoms  which  demand 
immediate  interference,  protiodide  of  mercury  may  be  alternated  with  iodide  of 
potassium,  iodide  of  sodium,  or  iodide  of  strontium.  Salvarsan  seems  less 
efficacious  in  these  cases  than  mercury. 

When  the  growth  is  due  to  tuberculosis  the  administration  of  cod-liver  oil,  iron, 
and  arsenic,  and  residence  in  a  climate  in  which  plenty  of  fresh  air  and  sunshine 
can  be  constantly  obtained,  is  essential.  In  such  cases  great  improvement  in  the 
general  heafth  may  do  something  toward  arresting  the  local  process. 

In  those  forms  of  brain  timior  which  are  not  tuberculous  or  syphilitic,  the  use 
of  drugs,  except  to  relieve  pain,  is  practically  useless,  and  operative  interference 
offers  the  patient  the  best  chance  of  recovery.  Surgical  procedures  can,  however, 
only  be  resorted  to  in  those  cases  in  which  a  definite  localization  of  the  tumor  can 
be  made,  and  where  that  locality  is  so  situated  that  the  surgeon  can  reach  it  without 
doing  damage  to  vital  parts.  The  earlier  the  operation  is  performed  the  better 
is  the  outlook.  J\I.  Allen  Starr  has  collected  400  cases  of  brain  tumor  which  were 
operated  upon.  In  154  instances  tumor  of  the  cerebrum  was  successfully  removed, 
and  the  patients  recovered.  In  52  cases  the  patients  died.  In  Hi  instances  in 
which  the  timior  was  in  the  cerebellum  it  was  removed  and  the  patients  recovered. 
In 8  instances  death  followed  remo\al.  It  is  interesting  to  note  that  in  91  instances 
of  supposed  cerebral  tumor  the  growth  could  not  be  found  on  operation.  The 
same  failure  to  discover  a  growth  was  met  with  in  22  instances  of  supijo.sed  cere- 
bellar tumor. 

Of  the  cases  which  recovered  52  were  sarcoma,  29  were  cy.sts,  S  were  gunnnata, 
19  were  tuberculous,  and  15  were  gliomas. 

The  operation  of  cerebral  decompression,  consisting  in  the  removal  of  an  area 
of  bone,  usually  in  the  subtemporal  region,  is  indicated  as  a  palliative  measure 
when  the  swelling  of  the  optic  disks  threatens  loss  of  vision. 

F'or  the  measures  which  are  to  be  pursued  in  the  removal  of  l)raiii  tumor,  the 
reader  is  referred  to  the  modern  works  on  surgery. 


ABSCESS  OF  THE  BRAIN  809 


ABSCESS  OF  THE  BRAIN. 

Definition. — Abscess  of  the  brain  is  a  condition  in  which  an  accumulation  of 
pus  takes  place  in  the  cerebrum,  or  the  cerebellum,  or  between  these  parts  and  their 
covering  membranes.  In  the  latter  case  the  brain  substance  forms  one  wall  of  the 
abscess  and  the  membranes  the  other  wall.  The  latter  type  of  abscess  difi'ers  from 
purulent  meningitis  in  that  the  inflammatory  process  is  primarily  in  the  nervous 
tissues,  and  that  it  is  limited  to  a  comparatively  small  area.  Abscess  of  the  brain 
without  involvement  of  the  membranes  is  much  the  more  common  form,  and  the 
white  matter  suffers  very  much  more  frequently  than  the  gray  substance.  Abscess 
rarely  occurs  in  the  central  ganglia,  the  pons,  the  medulla,  or  the  middle  lobe  of  the 
cerebellum. 

Etiology. — Abscess  of  the  brain  is  always  due  to  an  infection  by  some  pathogenic 
organism.  In  some  instances  the  process  is  excited  by  an  injury  which  aflords 
a  nidus  in  which  the  organism  may  develop;  in  other  cases  a  septic  embolus  is 
carried  from  another  part  of  the  body  in  which  there  is  an  infected  area ;  in  still 
others  the  infection  takes  place  more  directly,  as  in  those  instances  in  which  by 
fracture  of  the  skull  injury  and  infection  both  occur,  or,  as  in  the  case  of  abscess 
of  the  middle  ear  and  mastoid  disease,  the  infection  spreads  by  ^way  of  the 
sinus. 

Middle-ear  disease  is  the  cause  in  a  great  proportion  of  cases,  about  45  per  cent, 
arising  from  this  primary  focus  of  infection  and  25  per  cent,  from  injury.  The 
remaining  causes  are  infection  of  the  other  cranial  bones  than  the  mastoid  or  septic 
foci  elsewhere. 

Males  are  affected  far  more  frequently  than  females,  in  the  proportion  of  .3  to  1 . 
This  is  largely  due  to  the  fact  that  males  are  so  much  more  exposed  to  injury  than 
females.  If  the  cases  of  abscess  due  to  middle-ear  disease  are  studied  by  themselves, 
the  proportion  is  almost  equal ;  but  if  those  due  to  trauma  are  considered  by  them- 
selves, the  proportion  is  5  of  men  to  1  of  women. 

The  disease  is  most  frequent  between  the  tenth  and  twentieth  years  of  life. 
In  the  second  decade  ear  disease  is  the  common  cause,  and  in  the  third  decade  ear 
disease  and  injury,  or  a  distant  focus  of  infection,  are  about  equal  in  frequency  as 
causes. 

Pathology  and  Morbid  Anatomy. — A  majority  of  cases  of  brain  abscess  affect 
the  right  side  of  the  brain.  Out  of  71  cases  collected  by  Oppenheim  55  were  in  the 
temporal  lobe,  13  in  the  cerebellum,  2  in  the  pons,  and  1  in  the  crus. 

The  pathological  process  which  results  in  abscess  consists  primarily  of  an  enceph- 
alitis which  speedily  goes  on  to  the  stage  of  suppuration.  This  encephalitis  may 
be  due  to  any  organism  capable  of  causing  an  active  inflammatory  process.  Thus, 
the  Streptococcus  pyogenes,  the  Staphylococcus  pyogenes  aureus,  and  the  pneumo- 
coccus  may  be  the  provoking  factors.  In  other  cases  the  typhoid  bacillus  may 
be  the  cause,  and  even  the  streptothrix  may  produce  such  a  lesion,  as  in  a  case 
seen  by  me  in  consultation  with  the  late  Dr.  J.  H.  Musser.  The  abscess  is  nearly 
always  single,  but  two  or  more  pockets  of  pus  may  be  present.  The  size  of  the 
abscess  varies  greatly.  In  some  cases  it  is  so  small  as  scarcely  to  be  recognized,  a 
small  collection  of  pus  being  found  in  the  centre  of  an  area  of  softening;  whereas 
in  other  cases  the  quantity  of  pus  may  be  very  large,  varying  in  quantity  from 
a  drachm  to  several  ounces. 

The  abscess  may  be  surrounded  by  an  inflammatory  fibrous  wall  which  serves 
to  separate  it  from  the  neighboring  white  matter,  or  it  may  be  contained  in  a  cavity 
without  any  such  well-defined  margin,  the  walls  of  the  abscess  being  composed  of 
softened  brain  tissue.  The  latter  form  is  prone  to  spread  more  rapidly  than  the 
abscess  which  has  been  walled  oft'.     On  the  other  hand,  the  wall  of  the  abscess  may 


810  DISEASES  OF  THE  NERVOUS  SYSTEM 

rupture  and  produce  sudden  death.  Not  rarely  the  extension  of  tlie  inflammatory 
process  produces  a  meningitis  if  the  abscess  is  situated  near  the  surface  of  tlie  l)rain, 
and  a  septic  thrombosis  of  the  nearby  vessels  may  occur. 

Symptoms. — It  is  of  interest  to  note  that  cerebral  abscess  may  occur  without 
producing  symptoms  sufficiently  typical  to  lead  to  an  antemortem  diagnosis. 
In  the  great  proportion  of  cases,  however,  the  symptoms  of  its  existence  are  well 
developed.  The  most  constant  of  these  is  headache,  general  or  localized;  it  is  often 
excruciating  when  associated  with  middle-ear  disease;  next  in  constancy  is  mental 
disturbance,  the  patient  being  alternately  irritable  and  dull,  and  often  seeming  to 
be  exceedingly  ill.  The  temperature,  unlike  that  of  septic  processes  elsewhere,  is 
usually  normal  or  subnormal,  unless  the  abscess  ruptures,  when  it  may  be  hj^jer- 
pyretic.  A  persistent  low  temperature,  associated  with  a  slow  pulse  rate,  is  very 
characteristic  of  the  affection. 

The  blood  may  show  no  change,  but  usually  there  is  a  moderate  degree  of  leuko- 
cytosis with  a  relative  increase  of  the  polymorphonuclear  leukocytes  to  85  per 
cent,  or  higher.  The  surface  of  the  skull  is  often  hypersensitive,  and  in  some  cases 
it  has  been  possible  to  localize  the  abscess  by  the  dulness  on  percussion  produced 
by  its  presence.  Optic  neuritis  is  often  present.  None  of  these  symptoms  is 
in  any  sense  pathognomonic,  since  all  may  occur  in  other  states  of  disease;  but 
when  they  are  taken  into  consideration  in  connection  with  a  history  of  middle-ear 
disease,  injury,  or  the  presence  of  a  septic  focus  elsewhere,  they  possess  great 
diagnostic  value.  The  deafness  due  to  destruction  of  the  auditory  centre  is  masked 
by  the  deafness  due  to  the  disease  in  the  ear.  Parali/sis  of  one  side  of  the  face  is 
not  of  much  diagnostic  value,  since  this  symptom  is  often  due  to  the  inflammation 
about  the  facial  nerve  as  it  passes  tlirough  the  stylomastoid  foramen. 

The  value  of  localizing  symptoms  depends,  of  course,  upon  the  part  of  the  brain 
which  happens  to  be  affected.  When  the  infection  spreads  from  the  mastoid  bone 
after  or  during  otitis  media,  and  infects  the  temporal  lobe,  there  are  no  localizing 
nervous  sjonptoms  because  we  are  in  the  dark  as  to  the  function  of  the  temporo- 
sphenoidal  lobe.  In  a  few  cases  a  lesion  in  the  left  temporosphenoidal  lobe  has 
caused  aphasia.  When  the  association  tracts  between  the  occipital  lobe  and  the 
speech  centre  are  involved  the  patient  may  present  the  symptom  described  by 
Freund  as  optical  aphasia.  Starr  has  observed  a  case  of  this  character.  The 
patient  knows  an  object  when  it  is  placed  before  him,  but  cannot  name  it.  The 
lesion  would  be  in  the  left  temporal  lobe,  and  it  may  likewise  cause  hemiplegia  or 
hemianesthesia  by  pressure  upon  the  internal  capsule.  Hemianopsia  may  also 
be  caused  in  this  manner. 

When  the  abscess  is  in  the  cerebelhun  the  symptoms  are  those  characteristic 
of  cerebellar  tumor,  viz.,  a  staggering  gait,  vertigo,  and,  it  may  be,  vomiting, 
diplopia,  and  nystagmus.  •  In  some  instances  the  patient  staggers  toward  the 
diseased  side.  If  pressure  is  brought  to  bear  by  the  abscess  upon  the  crus  or  pons 
there  may  be  paralysis  of  the  oculomotor  or  facial  nerves  on  the  side  of  the  lesion, 
with  increase  in  the  knee-jerks  on  the  opposite  side. 

Diagnosis. — The  diagnosis  of  brain  abscess  is  not  difficult  if  the  s.Muptoms  just 
described  have  been  preceded  by  a  history  of  injury  or  of  a  septic  process  elsewhere, 
near  or  remote.  There  are  two  other  states  with  which  it  may  be  confused,  namely, 
meningitis  and  thrombosis  of  the  lateral  sinus.  In  the  former  condition  the  onset 
is  usually  more  abrupt,  the  headache  is  prone  to  be  more  severe  in  the  early  stages, 
and  a  sharp  febrile  movement  is  usually  present;  whereas,  as  has  already  been 
pointed  out,  in  cerebral  abscess  fever  is  often  absent  imless  the  abscess  ruptures. 
The  pressure  of  abscess  produces  a  slow  pulse  like  that  of  cerebral  compression, 
but  in  meningitis  the  pulse  is  usually  very  rapid.  Additional  symptoms  of  menin- 
gitis, which  are  of  great  value,  are  the  stifTness  of  the  muscles  of  the  neck,  the 
muscular  twitchings,  the  early  development  of  squint,  a  marked  leukocytosis 


ACUTE  CEREBRITIS  OR  ENCEPHALITIS  811 

(above  15,000  or  20,000),  and,  last  of  all,  the  presence  of  a  pathological  state  of  the 
cerebrospinal  fluid  obtained  by  lumbar  puncture.     (See  Cerebrospinal  Fever.) 

When  thrombosis  of  a  lateral  sinus  is  present  the  febrile  movement  is  sharp 
and  severe,  with  marked  remissions  and  exacerbations  as  in  sepsis.  There  is 
swelling  of  the  jugular  vein  on  the  affected  side  and  of  the  conjunctiva  as  well, 
associated,  it  may  be,  with  exophthalmos.  Swelling,  edema,  and  pain  on  pressure 
over  the  mastoid  may  also  be  present.  The  use  of  the  ophthalmoscope  also  reveals 
choked  disk  in  many  cases  as  an  early  symptom. 

Prognosis. — This  depends  very  largely  upon  the  site  of  the  abscess  and  the  ability 
of  the  surgeon  to  evacuate  and  drain  it.  In  all  cases  the  prognosis  is  necessarily 
grave.  That  many  patients  may  recover  if  promptly  relieved  is  shown  by  recent 
statistics,  which  show  that  60  per  cent,  of  traumatic  abscess  recover  after  operation, 
and  about  50  per  cent,  of  abscess  due  to  ear  disease  do  likewise. 

Treatment. — ^The  treatment  is  purely  surgical,  and  for  the  necessary  procedures 
reference  must  be  had  to  surgical  treatises. 

ACUTE  CEREBRITIS  OR  ENCEPHALITIS. 

Definition. — ^Acute  cerebritis,  sometimes  called  "acute  encephalitis,"  is  a  con- 
dition in  which  there  is  an  acute  inflammation  of  the  brain  arising  as  a  primary 
disease  not  secondary  to  meningitis. 

[;  Etiology. — ^The  cause  of  acute  cerebritis  is  always  an  infection  due  to  the  entrance 
of  a  micro-organism  into  the  body,  and  in  most  instances  the  condition  arises  as  a 
complication  of  measles,  scarlet  fever,  smallpox,  or  ulcerative  endocarditis,  or  in 
the  convalescence  from  influenza.  Acute  alcoholism  and  other  forms  of  poisoning 
may,  by  diminishing  vital  resistance  in  the  brain,  predispose  to  this  condition. 
Possibly  trauma  may  have  a  like  result.  Whatever  may  be  the  cause,  this  con- 
dition as  a  primary  acute  disease  is  very  rare. 

Pathology  and  Morbid  Anatomy. — The  inflammatory  process  is  not  widely  diffused, 
as  a  rule,  but  is  found  to  exist  chiefly  in  the  distribution  of  one  or  more  nearly 
related  bloodvessels.  At  times  it  affects  the  same  areas  on  both  sides  of  the  brain. 
In  some  instances  only  the  cortex  is  involved,  while  in  others  the  process  chiefly 
affects  the  white  matter.  A  limited  form  of  this  condition  is  the  acute  inflammation 
of  the  medulla,  pons,  or  midbrain  (polio-encephalitis  inferior  of  Wernicke  or  acute 
bulbar  paralysis) . 

The  changes  found  in  the  affected  parts  are  those  characteristic  of  acute  inflam- 
mation in  all  the  nervous  tissues,  and  indeed  in  any  acute  inflammation,  namely, 
hyperemia,  out-wandering  of  blood  cells,  and  minute  hemorrhagic  extravasations, 
followed  by  the  ordinary  degenerative  changes  in  the  nerve  cells  produced  by  an 
interference  with  their  normal  blood  supply  and  the  effects  of  toxemia.  The 
nerve-ceil  body  or  ganglion  cell  itself  suffers  from  cloudy  swelling,  loses  its  sharp 
outlines,  and  its  nucleus  becomes  indistinct  or  disappears.  The  axones  and  den- 
drites also  undergo  a  similar  change.  The  interstitial  tissues  are  at  first  filled  with 
small  cells,  and  ultimately  there  is  an  overgrowth  of  the  neuroglia  cells,  so  that 
patches  of  sclerosis  are  produced.  This  last  result  is,  of  course,  permanent,  and 
if  it  takes  place  to  any  great  extent  may  seriously  impair  the  function  of  the  brain. 
If  the  inflammatory  process  is  in  the  cortex,  adhesions  to  the  meninges  may  take 
place. 

Symptoms. — The  symptoms  of  acute  cerebritis  depend  to  a  large  extent  upon 
the  portion  of  the  brain  which  is  chiefly  affected,  although  the  general  manifesta- 
tions of  an  acute  inflammatory  process  in  the  brain  are  present  in  all  cases.  The 
patient  is  seized,  after  a  few  hours  of  general  distress,  with  headache  and  dizziness, 
followed  by  a  chill  and,  it  may  be,  vomiting.  These  symptoms  are  in  turn  speedily 
followed  by  fever  and  rapidity  of  the  fidse  and  respirations,  and  these  in  turn  in 


812  DISEASES  OF  THE  XERVOIS  SYSTEM 

some  instances  by  delirivm  of  a  violent  type.  If  the  case  is  severe  tiie  patient  may 
now  pass  into  coma,  and  then  gradually  pass  to  death,  or,  after  several  days,  or  even 
weeks,  of  these  symptoms,  c(»i,s'ciousness  (iraduaUy  returnx,  the  temi)pratiire  falls, 
and  recovery  takes  place,  although,  as  already  stated,  permanent  impairment  of 
s(jme  of  the  cerebral  functions  may  persist. 

The  special  symptoms  which  depend  upon  the  areas  of  the  brain  which  are 
affected  consist  in  liciniplfc/ia,  iiionople(/ia,  aphasia,  or  in  trord-hluulncfin  anfl  word- 
deafness,  heinianop.sia,  or  invtism.  Any  of  these  may  l)ecome  permanent.  In  still 
other  cases  the  patient  suffers  from  impairment  of  the  intellectual  jjowers  or  the 
changes  in  the  motor  cortex  j^roduce  epileptic  attacks,  and  in  other  in.stances  the 
development  of  the  sclerotic  patches  already  named  results  in  the  production  of  a 
condition  identical  with  disseminated  sclerosis  with  nystagmus,  tremor,  and  peculiar 
speech.  The  very  rare  condition  called  "polio-encephalitis  superior  of  Wernicke" 
is  manifested  by  the  presence  of  ptosis,  strabismus,  nystaqmus,  and  even  opAic 
neuritis  with  vertigo  and  a  staggering  gait.  In  addition  there  may  be  difficult  speech 
and  facial  paralysis. 

Diagnosis. — Acute  encephalitis  may  be  confused  with  brain  tumor  when  e])ilepti- 
form  convidsions  and  paralyses  are  prominent,  but  the  absence  of  choked  disk 
and  the  rapid  onset  will  distinguish  the  former.  In  its  "  comatose"  and  "  epileptic" 
forms  it  may  resemble  apoplexy  or  epilepsy,  and  a  close  study  of  the  entire  clinical 
picture  is  necessary,  with  the  history,  to  differentiate  such  cases. 

Prognosis. — That  the  prognosis  in  acute  encephalitis  in  the  early  course  of  the 
malady  must  be  uncertain  is  manifest  when  we  consider  the  character  of  the  lesions 
which  are  present.  Even  after  the  active  stage  of  the  disease  is  passed  the  outlook 
as  to  complete  restoration  to  health  is  still  clouded  because  it  is  not  possible  to  tell 
what  secondary  changes  may  develop  in  the  brain  or  its  membranes.  All  cases 
of  acute  encephalitis  are  to  be  regarded  as  of  much  gravity.  A  high  temperature, 
convulsions,  profound  and  prolonged  coma  are  all  ^'ery  unfavorable  symjitoms. 
Even  in  the  very  grave  cases  a  remarkable  degree  of  recovery  may  occur. 

Treatment. — This  consists  in  the  application  of  an  ice-bag  to  the  head,  and  in 
the  use  of  moderate  doses  of  tincture  of  aconite  if  there  is  circulatory  excitement. 
If  the  bowels  are  confined,  an  active  saline  purgative  is  useful  to  move  them  and  to 
deplete  the  bloodvessels.  A  hot  foot-bath  may  also  be  used.  I'henacetin  and 
acetanilid  may  be  employed  for  the  relief  of  pain,  but  they  usually  fail.  On  the 
other  hand,  the  use  of  opium  or  morphine  often  makes  the  pain  worse.  Absolute 
rest  in  a  darkened  room  is  essential.  After  the  acute  process  is  over  iodide  of 
potassiimi  may  be  given  in  the  dose  of  10  grains  three  times  a  day,  with  the  hope 
that  in  this  manner  inflammatorv  exudates  and  adhesions  mav  be  absorbed. 


THROMBOSIS  OF  THE  VENOUS  SINUSES. 

Etiology. — Thrombosis  of  the  venous  sinuses  is  due,  as  are  cases  of  thrombosis 
elsewhere,  to  an  inflammation  of  the  endothelium  which  lines  these  vessels.  This 
inflammation  may  be  the  result  of  a  septic  iTitVction  in  remote  or  in  neighboring 
tissues,  as,  for  examjile,  in  suj)])urative  otitis  media.  Where  the  cause  is  sepsis 
the  thromlius  usuall\-  contains  micro-organisms.  The  vast  majority  of  instances 
depend  u]nm  suj)puration  in  the  ear. 

Pathology  and  Morbid  Anatomy. — The  size  of  the  thrombus  varies  very  greatly. 
Beginning  as  a  small  clot  in  one  sinus,  it  may  gradually  increase  in  size  until  the 
sinus  is  filled,  and  may  even  extend  to  adjacent  sinuses  and  into  neighboring  veins. 
If  sejjtic  in  origin  it  may  be  purulent  in  character.  The  longitudinal  sinus  is  very 
rarely  affected.  The  lateral  sinus  is  the  one  most  commonly  invoKed,  and  after 
it  the  cavernous  sinus. 


CEREBRAL  MENINGITIS  813 

Symptoms. — The  symptoms  of  thrombosis  of  the  lateral  sinus  are  congestion 
of  the  veins  in  the  neighborhood  of  the  mastoid,  with  swelling  of  the  tissues  covering 
it.  There  is  often  pain  and  tenderness  on  pressure.  Not  rarely  the  cervical  glands 
are  enlarged  from  infection,  and  wryneck  may  be  present.  Choked  disk  is  frequently 
present  upon  both  sides.  With  the  infection  of  the  sinus  there  is  usually  a  history 
of  a  rigor  followed  by  high  fever,  with  headache,  vomiting,  delirium,  and  finally 
coma.  The  fever  not  rarely  follows  a  septic  course,  rising  and  falling  sharply. 
Other  evidences  of  septicemia  may  also  be  present,  such  as  sweatiruj,  diarrhea,  and 
the  occurrence  of  infarctions  in  such  organs  as  the  lungs,  spleen,  and  kidneys. 

In  thrombosis  of  the  cavernous  sinus  there  is  local  swelling,  congestion  of  the 
face  about  the  eyes,  epistaxis,  and  undue  fulness  of  the  retinal  veins.  Occasionally 
squint  develops  as  a  result  of  interference  with  the  function  of  the  oculomotor  and 
abducens  nerve. 

Thrombosis  of  the  longitudinal  sinus  is  manifested  by  intense  venous  congestion 
in  the  scalp,  and  indeed  of  the  entire  head.  Choked  disk  may  be  present  and 
epistaxis  may  occur. 

Prognosis. — This  is  unfavorable  unless  surgical  interference  gives  relief,  and 
surgical  interference  is  practically  limited  to  cases  of  disease  of  the  lateral  sinus. 

Treatment. — This  is  purely  surgical,  and  consists  in  trephining  or  otherwise 
opening  both  the  source  of  infection  and  the  sinus  and  thus  removing  the  focus  and 
the  clot.  For  details  as  to  the  method  of  operation,  and  as  to  the  statistics  of 
recovery  following  such  operations,  the  reader  is  referred  to  books  on  surgery. 

CEREBRAL  MENINGITIS. 

Definition  and  Etiology. — By  meningitis  is  meant  an  inflammation  of  the  mem- 
branes covering  the  brain  or  spinal  cord.  From  an  anatomical  standpoint  there 
are  three  of  these — the  dura  mater,  the  arachnoid,  and  the  pia  mater — but  from 
the  standpoint  of  the  clinician  and  pathologist  these  membranes  may  be  di^'ided 
into  two  parts,  the  dura  mater  on  the  one  hand  and  the  arachnoid  and  pia  mater 
(pia-arachnoid)  on  the  other,  for  the  dura  is  often  inflamed  by  itself,  but  the  pia 
and  arachnoid  are  always  affected  together.  When  the  dura  is  alone  involved  it 
is  called  pachymeningitis,  and  when  the  other  membranes  are  affected  it  is  called 
leptomeningitis. 

Pachymeningitis. — Pachymeningitis  may  occur  in  an  internal  form,  when  the 
smooth  inner  layer  of  this  membrane  is  inflamed  (pach^Tueningitis  interna),  and 
in  an  external  form,  in  which  the  outer  layer  is  chiefly  affected  where  it  is  in  contact 
with  the  bone  (pachymeningitis  externa).  The  latter  is  the  more  common  type 
by  far. 

Pachymeningitis  externa  is,  in  the  greater  proportion  of  cases,  secondary  to 
some  traumatism  or  to  disease  of  the  bone.  Thus,  a  blow  on  the  head  which 
fractures  the  skull,  or  necrosis  of  the  skull,  may  so  result.  A^ery  much  more  rarely 
an  acute  infection  arises,  as  in  an  infectious  and  septic  malady  such  as  erysipelas. 

Pathology  and  Morbid  Anatomy. — The  inflammatory  process  resembles  that  seen 
in  anj'  inflammation,  namely,  hj^Deremia  followed  by  swelling  and  cellular  infiltra- 
tion, and  this  in  turn  by  the  formation  of  pus  which  is  found  between  the  skull 
and  the  dura  mater,  or,  in  extraordinary  cases,  between  the  layers  of  this  membrane. 
When  the  inflammatory  process  does  not  go  on  to  suppuration,  the  external  layer 
of  the  dura  becomes  thickened  and  adherent  to  the  skull.  If  the  inflammation 
is  very  severe  the  inner  layer  of  the  dura  is  affected,  and  the  pia  mater  may  become 
involved  and  adherent  to  it. 

Symptoms. — These  consist  in  those  characteristic  of  the  cause,  as  the  primary 
unconsciousness  from  a  blow,  or  the  pain  of  bone  disease,  and  in  the  development, 
as  direct  symptoms,  of  headache,  confusion  of  mind,  delirium,  and  in  severe  cases, 


814  DISEASES  OF  THE  NERVOUS  SYSTEM 

convulsive  seizures.  Fever  may  or  may  not  be  present.  If  pus  collects,  sxinjjtoms 
of  pressure  on  the  brain  may  develop,  and  paralysis  of  the  opposite  side  of  the  body 
may  ensue  (hemiqjlegia) . 

Diagnosis. — The  history  of  injury,  of  bone  disease,  or  of  some  focus  of  infection 
makes  the  diafjnosis  possible. 

Prognosis. — This  is  bad  in  direct  proportion  to  the  severity  of  the  inflammatory 
process  and  the  degree  to  which  the  pia  mater  is  involved.  External  pachymenin- 
gitis is  less  grave  than  leptomeningitis. 

Treatment. — This  consists  in  the  use  of  saline  purgatives  to  relieve  cranial  con- 
gestion, in  applying  an  ice-cap  to  the  head,  rest  in  bed  in  a  darkened  room  to 
secure  perfect  quiet,  and  in  the  employment  of  aconite  as  a  cardiovascular  sedative 
if  the  pulse  is  excited.  If  s,^'mptoms  of  cerebral  compression  develop,  as  coma  or 
paralysis,  the  fluid  or  pus  must  be  evacuated  by  operation. 

Pachymeningitis  Interna. — Pachymeningitis  interna  occurs  in  a  purulent  and 
in  a  hemorrhagic  form,  the  purulent  being  very  rare.  To  the  hemorrhagic  type 
the  terms  "hemorrhagic  internal  pachAineningitis"  or  "hematoma  of  the  dura 
mater"  are  sometimes  applied.  Even  this  type  is  rarely  met  with,  and  its  existence 
is  rarely  recognizable  before  autopsy.  It  affects  males  far  more  commonly  than 
females  (4  to  1,  Gowers),  and  is  generally  met  with  after  the  fiftieth  year.  It  is 
also  met  with  more  commonly  in  the  first  twelve  months  of  life  than  in  childhood 
or  early  manhood.  As  a  rule,  in  adults  it  develops  in  the  course  of  some  form  of 
chronic  insanity,  particularly  in  the  course  of  general  paralysis  of  the  insane,  or  in 
cases  of  chronic  inebriety.  Very  rarely  it  has  complicated  the  course  of  one  of  the 
acute  infectious  diseases,  such  as  typhoid  fever  or  smallpox.  In  children  it  may 
complicate  scurvy. 

Pathology  and  Morbid  Anatomy. — The  exact  method  or  process  by  which  the 
hemorrhagic  extravasation  takes  place  is  not  known.  The  autopsy  reveals  a 
bilateral,  and  rarely  a  unilateral,  extravasation  between  the  layers  of  the  dura 
and  between  the  dura  and  the  arachnoid.  Not  only  is  a  bloody  fluid  formed  in 
these  spaces,  but  a  pseudomembrane  is  also  present;  it  may  be  in  se^•eral  layers. 
These  layers  are  at  first  red  and  later  may  be  pallid,  and,  by  adhering  together 
at  spots,  form  pockets  in  which  the  bloody  fluid  is  found.  When  the  condition 
has  existed  a  long  time  this  fluid  may  be  decolorized  and  contain  crystals  of  choles- 
terin.     Very  rarely  suppuration  takes  place. 

Symptoms. — The  sjnnptonis  are  in  many  cases,  if  the  disease  complicates  chronic 
insanity,  so  suppressed,  or  absent,  that  no  suspicion  of  the  state  just  described  is 
harbored.  In  some  cases  the  patient  develops  attacks  which  resemble  those  of 
apoplexy,  which  are  supposed  to  be  due  to  fresh  extravasations  of  blood.  In 
other  instances  there  are  signs  of  cerebral  compression,  as  shown  by  stupor,  or 
coma,  or  optic  neuritis.  Headache  and  vomiting  may  be  present.  Partial  hemi- 
plegia may  develop. 

The  prognosis  is  very  unfavorable.  Treatment  is  almost  useless.  Quiet  and 
rest,  with  cold  to  the  head,  is  all  that  can  be  done.  In  cases  with  strictly  localized 
s.Mnptonis  surgical  intervention  is  justifiable. 

Leptomeningitis. — Leptomeningitis  is  the  form  of  meningitis  which  compli- 
cates the  course  of  all  of  the  acute  infections,  notably  pnemnonia,  erysipelas, 
septicemia,  and  less  frequently  variola,  scarlet  fever,  typhoid  fever,  and  measles. 
INIeasles  produces  it  very  commonly  because  this  malady  is  often  followed  by 
otitis  media,  and  because  otitis  media  not  rarely  causes  mastoid  abscess,  and,  from 
this  focus,  infection  involves  the  meninges  or  the  lateral  sinus.  It  is  probable, 
too,  that  a  very  considerable  proportion  of  cases  of  leptomeningitis  are  caused  by 
infection  which  takes  place  through  the  nose.  It  can  be  readily  understood  that 
any  infectious  micro-organism  which  can  gain  access  to  the  meninges  through  the 
openings  in  the  skull  or  in  the  blood  may  cause  such  an  inflammation,  and,  in 


CEREBRAL  MENINGITIS  815 

addition,  that  the  possibility,  or  probability,  of  infection  is  greatly  increased  by 
any  disease  which  lowers  vital  resistance,  such  as  nephritis.  It  must  not  be  thought, 
however,  that  all  cases  of  leptomeningitis  due  to  the  pneumococcus  are  complica- 
tions of  croupous  pneumonia,  for  this  micro-organism  may  produce  a  meningitis 
by  direct  infection,  without  the  lung  being  affected  in  the  least.  It  is  probable, 
too,  that  the  typhoid  bacillus  may,  in  a  case  which  has  long  since  convalesced 
from  the  fever,  act  in  a  similar  manner.  (For  the  relationship  of  leptomeningitis 
to  pneumonia  and  typhoid  fever  the  reader  is  referred  to  the  articles  on  those 
diseases.    Also  to  that  on  cerebrospinal  meningitis.) 

Meningitis  is  more  common  in  children  during  the  first  decade  of  life  than  at 
any  other  period,  but  in  these  cases  the  inflammation  usually  involves  the  meninges 
at  the  base,  wliereas  in  adults  that  part  of  the  meninges  which  covers  the  convexity 
is  chiefly  afl'ected. 

Morbid  Anatomy  and  Pathology. — The  inflammatory  process  may  involve  the 
whole  membrane  or  be  quite  limited.  The  limited  cases  are  those  which  arise 
from  direct  infection  from  a  nearby  focus  of  disease.  Thus,  in  cases  which  are 
secondary  to  middle-ear  disease  the  lesion  is  often  unilateral,  whereas  in  those 
cases  in  which  the  pneumococcus  is  the  infecting  agent  the  entire  con^vexity  on 
both  sides  is  usually  affected.  In  the  latter  tj-pe  of  case  the  effusion  which  develops 
is  often  large  in  quantity  and  purulent.  If  the  cause  is  tuberculous  the  base  is 
usually  affected.  (See  Tuberculous  Meningitis.)  The  actual  lesions  found  in 
the  meninges  in  these  cases  are  noteworthy.  Beginning  with  hj-peremia  and 
congestion  they  pass  on  to  cloudiness  of  the  membranes  affected,  which  is  particu- 
larly well  marked  along  the  course  of  the  bloodvessels  because  of  the  engorgement 
of  the  accompanying  IjTuph  vessels.  Small  spots  of  purulent  material  are  dotted 
along  these  vessels  which,  as  they  increase  in  size,  coalesce,  and  so  considerable 
areas  are  covered  by  pus.  When  the  process  is  severe  the  dura  mater  and  the  cere- 
bral cortex  may  be  involved  by  the  inflammatory  changes. 

Symptoms. — In  studying  the  sjTiiptoms  of  leptomeningitis  it  must  be  recalled 
that  the  manifestations  of  involvement  of  the  cortical  area  are  by  no  means  pathog- 
nomonic. Every  physician  of  experience  has  seen  cases  of  typhoid  fever  or 
croupous  pneiunonia  present  apparent  evidences  of  meningitis,  yet  the  autopsy 
has  revealed  no  such  lesion  present.  In  other  words,  as  pointed  out  when  these 
diseases  were  discussed,  toxins  produced  by  the  specific  organisms  may  cause 
sj-Tuptoms  identical  with  those  of  meningeal  inflammation.  This  is  exceedingly  com- 
mon in  the  pneiunonia  of  children,  and  is  termed  pseudomeningitis  or  meningismus. 

There  are,  however,  certain  sjTuptoms  of  meningitis  which  are  certainly  indicative 
of  either  inflammation  or  irritation  of  the  meninges,  particularly  if  they  are  asso- 
ciated with  a  disease  or  an  injury  qualified  to  produce  meningeal  involvement. 
These  consist  in  fever,  headache,  vomiting,  retraction  of  the  head,  and  rarely  convulsions. 
Grindimj  of  the  teeth,  obstinate  co7istipation,  and  an  excessive  hyperesthesia  of  the 
skin  of  the  arms  and  legs  are  also  common  symptoms.  When  the  inflammatory 
process  is  basilar  the  symptoms  are  much  more  definite  and  reliable.  In  addition 
to  those  just  named  we  find  that  optic  neuritis  is  present,  and  strabismus  and  ptosis, 
due  to  the  pressure  exercised  upon  the  cranial  nerves,  develop.  The  pupils  may 
be  contracted  in  the  early  stages  because  of  irritation  of  the  oculomotor  nerves, 
and  later  widely  dilated  by  reason  of  paralysis  of  these  nerves.  Fever  may  or  may 
not  be  present,  and  the  pulse  is  usually  slow  even  if  the  temperature  is  raised. 
Kernig's  sign  may  be  present.  (See  Cerebrospinal  Meningitis.)  A  rapid  loss  of 
flesh  takes  place  in  nearly  all  cases. 

Diagnosis. — The  sjonptoms  of  basilar  leptomeningitis,  whatever  its  cause,  are 
usually  unmistakable.  A  very  useful  aid  to  diagnosis  is  lumbar  puncture,  already 
described  under  Cerebrospinal  Meningitis.  If  the  cerebrospinal  fluid  escapes  with 
a  spurt  from  the  needle,  it  is  indicative  of  the  presence  of  tuberculous  meningitis, 


816  niSI'JASKS  OF   THE   SKRVOI'S  SYSTEM 

but  by  no  means  positive  of  this  condition,  for  it  sometimes  happens  that  a  similiir 
high  pressure  exists  in  cases  of  purulent  meningitis  and  of  spina!  tumor.  If  disin- 
tegrated blood  is  present  in  the  cerebrospinal  fluid  it  is  an  indication  of  the  jjrcsence 
of  paclmneningitis  or  injury.  Fresh  blood,  on  the  other  hand,  is  probai)ly  due  to 
the  puncture.  If  the  fluid  is  perfectly  clear,  every  inflammatory  affection  of  the 
meninges  except  tuberculosis  may  be  excluded.  In  tuberculosis  it  may  be  clear, 
but  is  often  cloudy,  and  toward  the  end  of  the  case  even  purulent.  The  normal 
proportion  of  albumin  in  it  is  0.2  to  0.5  per  mille  (Quincke),  and  if  more  than 
0.5  per  mille  is  present  an  inflammatory  process  is  probably  going  on.  If  the 
small  quantity  of  sugar  which  is  normally  present  is  absent,  this  is  a  sign  that 
inflannnation  is  present. 

Treatment. — Aside  from  the  employment  of  rest  and  colfl  to  tiie  head,  if  fever  is 
jiR'scnt  or  i)ain  is  suffered,  we  can  do  little  for  this  coiiflition  except  we  resort  to 
lumbar  jjuncture  for  the  purpose  of  relieving  pressure. 

The  cerebrospinal  fluid  may  also  give  us  valuable  information  as. to  the  ])rescnce 
or  absence  of  meningitis,  if  it  "be  examined  microscopically  and  a  cjuantitative 
estimation  of  its  leukocytes  is  made.  As  a  general  rule,  there  is  a  marked  increase 
in  lymphocytes  if  the  inflammatory  process  is  tuberculous,  and  of  polymorpho- 
nuclear cells,  if  it  is  non-tuberculous.  Exceptions  to  this  rule  occur,  and  therefore 
the  presence  of  either  one  of  these  forms  of  leukocytes  in  increased  number  is  not 
pathognomonic. 

Microscopic  examination  of  the  cerebrospinal  fluid  may  also  be  made  for  the 
purpose  of  discovering  tubercle  bacilli,  or  the  diplococcus  of  pneumonia,  or  other 
pathogenic  micro-organisms.  The  fluid  for  this  purpose  should  be  kept  on  ice 
for  not  less  than  twelve  hours,  until  a  small  clot  is  formed.  The  web-like  fibres  of 
this  clot  are  transferred  to  a  co\er-glass,  spread  in  as  thin  a  film  as  possible,  and 
stained  by  the  methods  commonly  employed  for  staining  the  tubercle  bacillus. 
Where  the  examination  must  be  performed  at  once,  the  fluid  may  be  put  in  a 
centrifuge,  and  the  sediment  examined  by  the  staining  methods  already  described. 
As  with  examinations  of  the  sputum  in  su.spected  tuberculosis,  the  finding  of  tubercle 
bacilli  is  a  positive  sign  of  great  value,  but  the  failure  to  find  them  by  no  means 
proves  that  the  disease  is  not  tuberculous.  Reference  to  the  presence  of  the 
Diplococcvs  inierceJhdaris  meningitidis  has  already  been  made  in  the  article  upon 
Cerebrospinal  ]\Ieningitis.  Occasionally  the  streptococcus  and  staphylococcus 
are  found.  In  African  "sleeping  sickness"  trypanosomes  have  frccpiently  been 
found  in  the  cerebrospinal  fluid. 

DEMENTIA  PARALYTICA. 

Definition. — Dementia  paralytica,  often  called  "  meniugo-encephalitis,"  "  paresis," 
or  "general  i^aralysis  of  the  insane,"  is  a  state  characterized  anatomically  by  a 
widely  diffused  process  of  degeneration  in  the  central  nervous  system,  particularly 
in  the  cerebral  cortex,  with  morbid  changes  in  the  pia  mater.  The  chief  symptoms 
in  the  early  stages  are  the  de\elopment  of  great  irritability  of  temper,  forgetfulness, 
carelessness  as  to  habits,  and  later  delusions  of  grandeur.  C^linically  it  is  character- 
ized by  a  progressive  paralysis  of  the  body,  associated  with  certain  physical  signs, 
and  a  progressive  loss  of  mental  power  of  a  peculiar  kind.  The  most  striking 
sjTiiptom  of  this  disease  is  the  "delusion  of  grandeur." 

Etiology. — Without  doubt  syphilis  is  a  provoking  cause  in  a  large  proportion  of 
cases.  This  view  is  sui)ported  by  the  finding  of  the  specific  spirochete,  the  con- 
stancy of  the  Wassermaim  reaction  in  the  cerebros])inal  fluid,  a  sign  of  active 
syphilis,  not  of  the  refiitUs  of  syphilis.  It  is  like  locomotor  ataxia,  in  that  its  symp- 
toms develop  from  five  to  twenty  years  after  the  initial  lesion.  At  one  time  it 
was  thought  that  it  resulted  from  an  infection  long  since  past,  but  recent  investi- 


DEMENTIA  PARALYTICA  817 

gations  have  shown  that  in  many  instances  the  spirocheta  pallida  exist  in  large 
numbers  in  the  perivascular  spaces.  These  discoveries  are  of  the  greatest  impor- 
tance in  early  cases  since  the  use  of  salvarsan  or  neosalvarsan  may  arrest  the  malady, 
particularly  if  the  antibodies  engendered  in  the  blood  can  be  injected  into  the  cere- 
brospinal canal  and  so  get  at  the  spirochetse  hidden  in  the  nervous  system  into 
which  the  specific  remedy  cannot  enter,  when  given  intravenously,  because  its  mole- 
cule is  too  large  to  pass  through  the  cells  lining  the  arachnoid.  Alcoholism,  exces- 
sive sexual  indulgence,  and,  indeed,  excesses  of  every  kind,  are  also  without  doubt 
predisposing  factors  of  importance.  The  disease  is  a  common  one  among  roues. 
It  affects  males  more  frecjuently  than  females  10  to  1.  Like  locomotor  ataxia 
its  age  incidence  is  between  thirty  and  fifty  years  of  age. 

The  disease  is  one  of  the  middle  period  of  life,  between  thirty  and  fifty  years, 
but  a  number  of  cases  have  been  recorded  as  occurring  in  children  who  have  usually 
had  hereditary  syphilis. 

Pathology  and  Morbid  Anatomy. — The  brain  changes  consist  in  a  chronic  parenchy- 
matous encephalitis  produced  by  the  invading  spirochetes.  The  primary  change 
in  cases  of  this  disease  takes  place  in  an  increased  blood  supply  to  the  pia  mater 
and  in  the  smaller  vessels  of  the  cerebral  cortex,  associated  with  degenerative 
changes  in  the  bloodvessel  walls.  The  progress  of  these  degenerati^•e  changes 
results  in  the  development  of  fusiform  dilatations  of  the  bloodvessels  and  the  filling 
of  the  Ij-mph  spaces  with  serum,  intimately  the  quantity  of  Ij-mph  present  in 
the  perivascular  spaces  is  so  great  that  a  true  cerebral  edema  is  produced.  There 
is  an  overgrowth  of  the  neuroglia  about  the  A-essels,  and  this  newly  formed  con- 
nective tissue  sends  fibrils  down  between  the  cells  of  the  cortex,  with  the  result 
that  true  sclerosis  de^'elops.  Associated  with  these  connective-tissue  changes 
there  are  degenerative  changes  in  the  cerebral  neurones.  The  body  of  the  neurone 
undergoes  hyaline  and  then  fatty  degeneration,  pigmentation,  and  finally  atrophy. 
Mantles  of  IjTnphoid  and  plasma  cells  are  seen  about  the  vessels  in  the  cortex. 
When  the  disease  has  been  present  for  a  long  tune,  autopsy  reveals  the  presence 
of  small  cysts  in  the  white  and  gray  matter,  and  so  marked  a  decrease  in  the  size 
of  the  convolutions  and  of  the  entire  brain  that  it  is  found  to  be  much  smaller 
than  is  normal.  Its  surface  is  harder  than  is  natural,  pigmented,  and  adherent 
to  the  pia  mater,  which  is  also  found  to  be  the  site  of  overgrowth  of  connective 
tissue.  The  ventricles  contain  an  excess  of  fluid,  and  their  lining  membrane,  the 
ependjTna,  is  thickened.  It  is  noteworthy  that  the  left  hemisphere  is  usually 
more  affected  than  the  right,  and  that  the  changes  already  described  affect  the 
frontal  lobes  and  the  areas  of  the  motor  cortex  before  the  rest  of  the  brain  is  involved. 

In  most  cases  of  paresis  degeneration  is  found  in  the  spinal  cord,  so  that  spinal 
sjTnptoms  are  added  to  the  cerebral  signs  and  form  part  of  the  clinical  picture  of 
the  disease.  The  lateral  and  posterior  tracts  are  usually  affected,  producing 
sjTnptoms  of  ataxic  paraplegia.  Sometimes  the  posterior  columns  alone  are 
degenerated,  presenting  sjTnptoms  of  locomotor  ataxia.  Rarely,  disseminated 
sclerosis  is  found;  and  recently  the  spinal  cord  in  a  case  of  paresis  is  found  to  be  suf- 
fering from  syringomyelia.  In  a  few  cases  of  locomotor  ataxia  (tabes  dorsalis),  fully 
developed  and  tj^pical,  the  cerebral  signs  of  paresis  came  on,  as  if  the  disease  had 
finally  "risen"  to  the  brain.    These  cases  constitute  the  "ascending  tj-pe"  of  paresis. 

Some  authorities  believe  that  paresis  is  identical  in  nature  with  tabes — that 
it  is  a  "tabes  of  the  brain."  A  clinical  picture  of  paretic  dementia  with  tabes  is, 
therefore,  met  with.  Rarely  the  spinal  symptoms  precede  the  cerebral  sjTiiptoms 
in  the  development  of  the  disease.  So,  too,  sjTnptoms  of  spastic  paraplegia  may 
develop.  Sometimes  autopsy  reveals  the  fact  that  pachjTiieningitis  and  hematoma 
have  occurred  as  the  result  of  the  aneurysmal  dilatations  of  the  cerebral  and  pial 
vessels,  already  described,  leaving  behind  them  an  organized  membrane  beneath 
the  dura,  or  a  mass  of  encysted  blood  clot. 
52 


818  DISEASES  OF  THE  NERVOUS  SYSTEM 

Symptoms. — When  the  symptoms  of  demeiitiii  ])aralvtica  are  well  developed, 
they  are  so  eharacteristic  and  ol)trusi\e  that  there  ean  he  little  difficulty  in  reaching 
a  correct  diagnosis  in  regard  to  the  condition  from  which  the  patient  is  suffering. 
It  is  only  wJien  the  disease  is  in  its  stage  of  onset,  or  in  an  atypical  form,  tliat  any 
doubt  can  be  present. 

As  a  rule,  the  early  symptoms  are  recognized  in  retrospect  rather  than  at  the 
time  at  which  they  occur,  unless,  perchance,  these  symptoms  are  very  strongly 
developed.  It  is  noticed  that  the  patient  seems  to  be  nervousli/fatif/ued  or  mentally 
fncif/cd,  and  often  this  condition  is  ascribed  to  the  excesses  which  have  been  com- 
mitted in  connection  with  venery,  wine,  and  other  forms  of  nervous  stress.  The 
iemjxr  is  usually  irritable,  and  the  friends  notice  that  the  patient  takes  offense  at 
remarks  which  ordinarily  he  would  not  notice.  At  times  he  is  remarkably  forgetful. 
Naturally  tidy  as  to  his  habits  and  dress,  he  becomes  careless  and  slovenly.  Occa- 
sionally sleeplessness  will  be  complained  of. 

Although,  before  the  onset  of  the  symptoms,  he  may  be  apparently  kind  and 
faithful  to  his  family,  he  begins  to  be  brutal  in  his  conduct  toward  his  wife  and 
children,  and  perhaps  returns  to  the  alcoholic  and  sexual  excess  which  laid  the 
foundation  for  his  disease  many  years  before.  The  speech  becomes  indistinct, 
hesitating,  and  if  the  tongue  is  protruded  a  very  fine  tremor  may  be  seen  in  it. 
There  is  also  a  very  marked  tremor  of  the  hands.  Ataxia  of  station  (Romberg's 
sign)  is  a  common  s.^^nptom.  The  impils  are  generally  uneciual  and  irregular, 
and  the  pupillary  light  reflex  may  be  lost,  while  reaction  to  accommodation  is 
maintained.  In  other  words,  the  Argyll-Robertson  pupil  is  present,  for  the  same 
reason  that  it  is  present  in  cases  of  locomotor  ataxia,  because  !\Ieynert's  decussation, 
or  other  fibres,  involved  in  the  light  reflex  arc  are  affected  by  the  degenerative 
process  already  described.  The  loss  of  consensual  reflex  is  also  frequently 
observed. 

The  sj-mptoms  of  onset  are  often  prolonged  over  the  period  of  many  months, 
and  sometimes  for  several  years,  depending  upon  the  rapidity  with  which  the 
pathological  changes  in  the  brain  develop.  The  disease  is  progressive  and  ulti- 
mately the  symptoms  of  the  later  stages  are  developed.  These  symptoms  may 
consist  in  delusions,  which  are  usually  composed  of  extravagant  ideas.  Thus,  the 
patient  may,  on  the  one  hand,  believe  that  he  is  some  great  historical  character, 
or  that  he  is  a  ruling  potentate,  or,  again,  that  he  is  possessed  of  fabulous  riches. 
In  one  instance,  for  example,  within  the  writer's  knowledge,  the  patient  took  a  room 
at  a  prominent  hotel,  after  having  provided  himself  with  large  sums  of  money, 
and  from  the  balcony  outside  of  the  room  showered  the  crowd  beneath  with  coins 
of  different  values,  with  the  idea  that  his  wealth  was  limitless.  In  another  instance, 
the  manager  of  a  small  plant  for  making  steel  became  imbued  with  the  idea  that 
his  company  had  obtained  and  could  fill  contracts  for  the  delivery  of  manufactured 
steel  on  a  scale  far  beyond  those  ever  attempted  by  any  corporation,  although  as  a 
matter  of  fact  the  business  of  the  concern  was  at  its  last  ebb,  and  his  delusions  aided 
in  causing  its  final  financial  collapse,  through  its  inability  to  carry  out  the  agree- 
ments which  he  made  with  other  concerns.  In  this  instance  the  stress  of  business 
worry  combined  with  previous  excess  was  an  active  factor  in  producing  the  disease. 

As  the  degenerative  process  in  the  brain  continues,  the  patient's  judgment 
becomes  profoundly  impaired.  He  rarely  is  capable  of  continuous  thought,  and 
no  longer  adheres  for  hours  at  a  time  to  his  delusions.  He  frequently  becomes 
exceedingly  emotional,  and  laughs  and  cries  without  adequate  cause.  At  times 
he  is  excessively  depressed;  at  other  times  exalted,  and  he  may  occasionally  become 
frenzied  with  rage,  during  which  time  he  may  commit  some  crime. 

The  handwriting  is  often  characteristic.  It  may  become  illegible,  either  because 
the  letters  are  badly  formed  or  because  important  words  are  dropped  out.  Still 
later,  loss  of  power  occurs  in  the  limbs  until  total  paralysis  may  be  present.    Sensa- 


DEMENTIA   PARALYTICA  MO 

tion  is  not  so  markedly  disturbed,  hut  areas  of  anesthesia  and  analgesia  may  Ije 
found.     The  reflexes  may  he  mar1<ediy  inereased  or  entirely  lost. 

Naturally,  there  is  an  impairment  of  the  general  health  with  the  progress  of 
the  disease.  Epileptiform  attacks  or  sudflen  periods  of  unconsciousness  (apoplecti- 
form attacks)  develop,  accompanied  hy  paralysis  of  one  limh,  or  hy  hemijjlegia. 
Death  usually  ends  the  case  by  the  end  of  the  third  to  the  sixth  year,  the  patient 
dying  of  exhaustion  or  of  some  intercurrent  disease,  such  as  pneumonia,  obstruction 
of  the  bowels,  or  of  one  of  the  epileptiform  or  apoplectiform  attacks. 

Cases  of  paresis  in  which  the  delusion  of  grandeur  is  prominent  are  the  earliest 
recognized,  and  constitute  the  classic  form  of  the  disease.  There  are  many,  how- 
ever, in  which  depression  simulating  melancholia  is  present  throughout;  that  is, 
the  depressed  form  of  paresis.  But  in  a  large  proportion  of  all  cases  the  mental 
symptoms  are  mainly  those  of  progressive  mental  loss,  without  distinct  delusions 
(the  simple  or  demented  form  of  paresis).  An  alternation  of  excitement  and 
depression  (circular  form  of  paresis)  is  observed  rarely;  delusions  similar  to  those 
of  paranoia  or  of  alcoholic  insanity  may  mask  the  underlying  condition. 

Diagnosis. — ^Dementia  paralytica  must  be  separated  in  its  early  stages  from 
neurasthenia.  The  patient  sufTering  from  ner\'ous  exhaustion  usually  studies 
his  own  sjTiiptoms  in  the  greatest  detail,  and  usually  considers  that  he  is  an  ill 
man,  while  the  paretic  has  a  very  much  more  optimistic  view  and  often  insists 
that  he  is  more  than  usually  well,  when  it  is  manifest  that  his  ill  health  is  extreme. 
So,  too,  the  neurasthenic  rarely  has  complete  lapses  of  memory  and  defects  of 
speech.  From  cerebral  syphilis  paresis  is  separated  by  the  fact  that  the  former 
usually  manifests  severe  pain  in  the  head  and  true  aphasia  due  to  a  syphilitic 
arteritis  in  the  neighborhood  of  the  speech  centre.  The  fine  tremor  of  the  tongue 
and  of  the  hand  in  paresis  is  absent  in  cerebral  syphilis.  Optic  neuritis  is  usually 
present  in  cerebral  syphilis,  but  not  very  common  in  paresis.  So,  too,  the  mental 
state  is  one  of  constant  depression  in  syphilis,  and  not  that  of  excitation.  From 
multiple  sclerosis  paresis  is  separated  by  the  presence  in  sclerosis  of  nystagmus  and 
intention  tremor  and  by  the  absence  of  delusions. 

While  the  blood  may  give  a  negative  Wassermann  reaction  the  spinal  fluid 
often  gives  a  positive  reaction.  An  examination  of  the  cerebrospinal  fluid  shows 
an  enormous  increase  in  the  nmnber  of  small  lymphocytes,  ranging  from  .30  to 
300  to  the  cubic  millimetre.  This  is  also  true,  however,  of  tuberculous  meningitis. 
The  fluid  also  contains  a  great  excess  of  globulin. 

Prognosis. — This  is  very  unfavorable.  Cases  rarely  if  ever  recover,  although 
temporary,  and  it  may  be  prolonged;  remissions,  which  cause  encouragement  on 
the  part  of  the  friends,  may  occur,  particularly  if  salvarsanized  serum  is  injected 
intraspinally. 

Treatment. — It  must  be  evident,  from  the  pathological  condition  already 
described,  that  treatment  can  do  little.  But  it  must  be  remembered  that  this 
disease  is  directly  due  to  syphilis,  and  therefore  antisyphilitic  remedies  should 
be  employed.  Their  general  tendency  is  favorable,  and  they  may  perhaps  arrest 
for  the  time  being  the  progress  of  the  vascular  changes,  but  they  cannot  cure 
those  in  existence.  Salvarsan  may  be  given  intravenously,  or  better,  the  more 
recent  method  of  Swift  and  Ellis  of  injecting  salvarsanized  blood  serum  intraspinally 
should  be  tried.  This  method  of  treatment  is  still  "on  trial"  and  while  it  is  as 
yet  too  early  to  know  its  real  value,  certainly  marked  improvement  has  in  many 
instances  followed  its  use.  That  the  improvement  observed  in  a  given  case  will 
eventually  prove  to  be  but  a  more  or  less  prolonged  remission,  is  however,  probable. 
Mercury  and  the  iodides  should  also  be  used  freely  in  connection  with  hot  baths. 
If  the  patient  is  difficult  to  control,  it  is  far  better  both  for  himself  and  his  friends 
that  he  should  be  committed  to  an  asylimi  where  he  can  be  properly  cared  for,  not 
only  in  the  sense  of  being  properly  controlled,  but  of  being  well  fed,  as  the  main- 


820  DISEASES  OF  THE  NERVOUS  SYSTEM 

tenance  of  health  and  fjeneral  nutrition  is,  of  course,  of  importance.  Sleeplessness 
may  be  treated  by  any  one  of  the  good  hypnotics,  of  which  chloral,  trional,  and 
veronal  are  the  best.  Occasionally,  hyoscine  may  be  used.  Care  must  be 
taken  that  the  carelessness  of  the  patient  in  regard  to  his  bowels  does  not  result  in 
obstinate  constipation,  which  may  be  difficult  to  relieve.  For  this  reason,  active 
purgatives  are  often  necessary.  If  outbreaks  of  excitement  come  on,  yj^  of  a 
grain  of  hyoscine  may  be  given  hypodermically. 

DISSEMINATED  SCLEROSIS. 

Denfiition. — Disseminated  sclerosis  is  characterized  by  the  development  of 
irregularly  distributed  patches  of  sclerosis  in  different  parts  of  the  brain  and  spinal 
cord.  Similar  changes  also  take  place  in  the  cranial  nerves.  It  is  sometimes 
called  "insular  sclerosis"  or  "multiple  sclerosis."  By  the  French  it  is  called 
sclerose  en  ylaqves  disseminees.  It  has  only  been  recognized  as  a  distinct  disease 
for  a  little  more  than  fifty  years. 

Etiology. — The  essential  cause  of  multiple  sclerosis  is  not  known.  It  affects 
both  sexes  equally,  and  occurs  chiefly  in  young  adults,  appearing  infrequently 
in  childhood  and  rarely  after  forty-five  years  of  age.  Its  most  common  period 
of  existence  is  from  the  twenty-fifth  to  the  thirty-fifth  year.  Occasionally  it 
has  been  known  to  follow  one  of  the  acute  infectious  diseases,  and  has  been  regarded 
as  a  consequence  of  disseminated  myelitis  of  infectious  origin  (Marie);  but  it  is 
doubtful  whether  this  malady  has  any  direct  productive  effect  in  the  case.  Syphilis, 
that  great  cause  of  organic  nervous  disease,  does  not  seem  to  be  frequently  present 
as  an  etiological  factor.  The  disease  has  been  known  to  follow  shock,  trauma, 
and  severe  exposure,  but  in  the  majoritj'  of  cases  no  causal  factor  can  be  traced. 

Pathology  and  Morbid  Anatomy. — The  lesions  of  disseminated  sclerosis  consist, 
as  already  stated,  in  irregularly  distributed  patches  in  which  the  nervous  tissues 
have  undergone  sclerotic  change.  These  patches  are  found  chiefly  in  the  white 
matter  of  the  brain,  being  comparatively  rare  in  the  gray  substance  of  the  cortex. 
They  are  irregular  in  outline  and  in  distribution  and  vary  in  size.  In  appearance 
they  are  reddish-gray  and  translucent.  The  surface  of  a  patch  is  usually  even 
with  the  surrounding  brain  tissue,  but  it  may  be  slightly  depressed.  A  sharp  line 
of  demarcation  separates  the  diseased  area  from  the  healthy  tissues.  When  touched , 
the  patches  seem  harder  than  normal  gray  matter,  but  they  are  not  usually  met  with 
until  section  of  the  brain  or  cord  is  made,  when  they  appear  in  strong  contrast 
to  the  surrounding  white  tissue.  They  may  be  found  in  considerable  number  in 
the  lateral  ventricle,  in  the  corpus  collosum,  crura,  and  pons.  The  patches  in  the 
spinal  cord  are  not  so  reddish  in  hue  as  in  the  brain,  but  are  more  gray  in  color  and 
extend  vertically  rather  than  transversely;  but  this  rule  is  not  absolute,  and  at 
times  the  transverse  extension  of  a  patch  may  embrace  the  entire  thickness  of  the 
cord.  When  one  of  the  cranial  nerves  is  involved;  it  is  found  to  be  gray  in  color 
and  sclerotic  for  a  certain  portion  of  its  length.  In  some  instances  the  entire 
thickness  of  the  nerve  is  involved.  The  olfactory,  optic,  oculomotor,  trifacial, 
and  facial  nerves  are  the  ones  which  are  most  commonly  affected,  and  in  tlie  case 
of  the  oj)tic  nerve  the  fa^'oritc  scat  is  the  chiasm. 

The  sclerotic  process  in  this  disease  does  not  differ  very  materially  from  that 
met  with  in  sclerotic  processes  occurring  in  other  organs  of  the  body;  there  is  an 
overgrowth  of  the  true  neuroglia  or  connective  tissue,  and  side  by  side  with  this 
overgrowth  a  corresponding  atrophy  or  disappearance  of  the  nerve  cells  and  fibres 
themselves  takes  place.  When  the  degenerative  process  is  well  advanced,  we  find 
scattered  through  the  connective-tissue  fatty  granules  and  nerve  cells  which  show 
evidence  of  degenerative  change.  In  the  nerve  fibres  the  chief  change  takes  place 
in  the  myelin,  but  after  the  disease  is  far  advanced  the  axis  cylinder  also  becomes 


DISSEMINATED  SCLEROSIS  821 

affected  and  finally  is  completely  destroyed.  In  the  central  nervous  system  it  is 
usually  found  that  secondary  degeneration  in  the  nerve  fibres  above  or  below  the 
seat  of  the  original  sclerotic  patch  is  only  met  with  when  the  disease  has  been 
sufficiently  severe  to  destroy  the  axis  cylinders.  On  this  account  secondary 
degenerations  are  not  common  in  disseminated  sclerosis,  the  axis  cylinders  surviving 
in  the  midst  of  fully  developed  sclerotic  patches. 

Symptoms. — The  symptoms  of  disseminated  sclerosis  depend  almost  entirely 
upon  the  areas  of  the  nervous  system  which  are  chiefly  affected  by  the  pathological 
changes  just  described.  Among  the  earliest  symptoms  in  many  cases  is  a  loss 
of  fower  in  the  extremities.  In  the  legs  the  symptoms  may  be  ataxic,  but  usually 
simulate  those  of  spastic  paraplegia  in  a  striking  degree.  When  spastic  paraplegia 
is  present,  this  indicates  that  the  sclerotic  process  has  involved  the  pyramidal 
tracts;  the  knee-jerks  are  found  to  be  exaggerated,  and  Babinski's  sign  is  present. 
In  other  instances  inco-ordination  of  the  hands,  or  of  one  hand,  may  be  the  first 
manifestation  of  the  malady,  and  in  still  others  sensory  disturbances  in  the  legs 
or  arms  are  first  complained  of  by  the  patient.  The  inco-ordination  of  the  muscles 
of  the  arms  is  often  very  marked  indeed.  Often  it  is  impossible  for  a  patient  to 
carry  a  glass  of  water  to  his  lips  wi  thout  spilling  it  (intention  tremor) .  The  co-ordi- 
nated movements  which  are  necessary  in  writing  are  impossible  because  of  the 
quick  or  spasmodic  contractions  of  the  mi'scles  employed  for  this  purpose.  The 
cause  of  these  irregular  movements  is  not  known.  According  to  some  it  is  depen- 
dent upon  the  fact  that  certain  fibres  are  affected,  and  impulses  going  along  certain 
channels,  particularly  the  motor,  are  delayed  in  passing  through  sclerotic  areas, 
or  that  those  which  pass  along  fibres  still  unaffected  are  made  inadequate  and, 
as  it  were,  embarrassed.  By  others  it  is  thought  that  the  sclerotic  patches  have 
involved  afferent  fibres  of  the  cerebellar  system  which  are  concerned  with  muscular 
sense. 

If  sensory  fibres  in  the  dorsal  columns  are  involved,  areas  of  anesthesia  or  hemi- 
anesthesia, also  ataxia  of  the  extremities,  will  develop,  the  severity  of  these  sjonptoms 
depending,  of  course,  upon  the  area  involved  in  the  sclerotic  process.  The  eye 
symptoms  are  usually  well  marked.  One  of  the  earliest  and  most  constant  of 
these  is  nystagmus.  Eyesight  fails  through  involvement  of  the  optic  nerve  or 
because  of  a  sclerotic  patch  at  the  optic  chiasm.  As  the  disease  advances  pallor 
of  the  optic  disk,  particularly  its  temporal  half,  and  sometimes  optic  atrophy  can 
be  recognized  on  ophthalmoscopic  examination.  One  eye  is  often  much  more 
affected  than  the  other,  and  loss  of  accommodation  may  occur.  In  other  instances 
the  pupillary  reflex  may  be  lost,  yet  the  pupil  will  react  to  accommodation.  In 
other  words,  the  Argyll- Robertson  pupil  is  present.  The  affection  of  the  external 
ocular  muscles,  aside  from  the  production  of  nystagmus,  consists  most  frequently 
in  a  failure  in  convergence  and  in  conjugate  deviation.  More  rarely  a  single 
muscle  is  affected  and  squint  is  produced.  When  the  facial  nerve  is  affected,  the 
symptoms  in  the  early  stages  may  consist  in  clonic  spasm  of  the  muscles  of  the  face, 
followed  eventually  by  paralysis.  The  lesions  of  the  cranial  nerves,  which  produce 
these  results,  may,  as  already  pointed  out,  occur  in  the  nerves  themselves  or  involve 
their  nuclei. 

Of  all  the  sjTuptoms  of  disseminated  sclerosis  perhaps  the  most  characteristic 
and  most  frequent  is  the  peculiar  disorder  of  speech  in  which  syllables  are  enunciated 
in  a  measured  manner.  To  this  mode  of  speech  the  term  staccato  or  scanning  is 
applied.  The  exact  cause  of  this  is  not  clear.  It  does  not  seem  to  be  dependent 
entirely  upon  paralysis  involving  the  tongue  or  the  lips. 

The  mental  condition  of  the  patient  is  usually  not  materially  altered.  The 
memory  may  be  slightly  impaired  and  the  patient  seems  somewhat .  emotional. 
Uncontrolled  laughter,  as  first  shown  by  Oppenheim,  is  an  occasional  symptom. 
Very  occasionally  actual  insanity  develops.     Paroxysmal  attacks  of  vertigo  and 


822  DISEASES  OF  THE  NERVOUS  SYSTEM 

vomiting  are  occasionally  met  with,  and  in  some  cases  the  patient  is  seized  with 
attacks  which  closely  resemble  an  ordinary  apoplexy.  These  attacks,  it  will  be 
remembered,  sometimes  develop  in  patients  who  suffer  from  general  paralysis  of 
the  insane,  and  they  appear  either  as  ordinary  coma,  as  Jacksonian  epilepsy,  or  as  a 
hemiplegia  which  is  fleeting  in  character.  All  these  symptoms  of  an  apoplectiform 
type  may  recur  frequently,  and  are  usually  recovered  from,  but  occasionally  death 
comes  on  during  coma.  It  is  a  fact  worthy  of  note  that,  notwithstanding  the 
profound  changes  which  take  place  in  different  portions  of  the  nervous  system, 
trophic  changes  in  the  muscles  are  rarely  met  with,  even  in  advanced  cases. 

Diagnosis. — The  most  characteristic  sjinptoms  of  disseminated  sclerosis,  as 
just  stated,  consist  in  the  intention  tremor,  the  staccato  speech,  the  nystagmus, 
the  peculiar  jerking,  inco-ordinated  movements  of  the  muscles  of  the  arms  and 
sometimes  of  the  legs,  weakness  of  the  legs,  and  the  gradual  invohement  of  the 
cranial  nerves,  especially  the  optic. 

The  disease  is  to  be  separated  from  locomotor  ataxia  by  the  jerking  character 
of  the  inco-ordinated  movements;  and  by  the  exaggeration  of  the  reflexes,  which 
are  in  contrast  to  the  absent  reflexes  of  ataxia.  From  paralysis  agitans  it  is  sepa- 
rated by  the  fact  that  in  the  latter  disease  there  is  a  finer  tremor  of  the  hand,  or 
of  the  parts  of  the  body  which  may  be  affected  (the  tremor  is  passive),  by  the 
peculiar  attitude  of  the  patient  in  paralysis  agitans,  and  by  the  absence,  as  the 
disease  progresses,  of  the  characteristic  symptoms  just  spoken  of  as  peculiar  to 
multiple  sclerosis.  General  paralysis  of  the  insane  is  distinguished  by  the  presence, 
in  the  classic  type  of  this  disease,  of  delusions  of  grandeur,  by  the  twitching  of  the 
muscles  of  the  lips  and  tongue,  which  are  more  constant  and  severe  than  they  are 
in  multiple  sclerosis,  and  by  the  other  evidences  of  mental  change.  In  a  case  of 
disseminated  sclerosis,  in  which  the  lateral  columns  of  the  spinal  cord  are  involved, 
it  may  be  difficult  to  differentiate  multiple  sclerosis  from  spastic  paraplegia,  but 
as  the  disease  progresses  the  development  of  the  other  s^Tiiptoms  of  disseminated 
sclerosis  makes  the  diagnosis  easy.  From  hysteria  disseminated  sclerosis  is  to  be 
separated  by  the  fact  that  nystagmus,  optic  atrophy  and  Babinski's  sign  do  not 
appear  in  this  functional  nervous  disorder,  and  by  the  inconstancy  of  the  symptoms 
in  many  cases  of  hysteria.  The  other  characteristic  stigmata  of  hysteria  may  also 
be  found.     (See  article  on  Hysteria.) 

Prognosis. — The  prognosis  in  a  case  of  disseminated  sclerosis  is  absolutely  unfavor- 
able as  to  ultimate  recovery.  The  disease  is  characterized  by  various  remissions 
or  periods  of  arrest,  so  that  death  is  sometimes  postponed  for  a  considerable  period 
of  time.  The  prognosis  as  to  duration  of  life  is  worse  in  those  cases  in  which  the 
lesions  involve  nervous  tissues  closely  associated  with  vital  functions,  as  when 
sclerotic  changes  take  place  in  the  pons,  or,  above  all,  when  they  occur  in  the 
medulla.  It  is  noteworthy  that  pregnancy  or  trauma  increases  the  rajjidity  with 
which  the  disease  progresses. 

Treatment. — E\erywhere  in  this  book,  when  we  have  considered  the  treatment 
of  diseases  depending  upon  sclerotic  changes  or  overgro^\i;h  of  connective  tissue 
it  has  been  pointed  out  that  our  therapeutic  resources  are  inadequate.  We  do 
not  know  the  causes  of  this  connecti\-e-tissue  oA'ergrowth,  and  so  are  unable  to 
combat  it,  nor  do  we  know  why  the  cells  degenerate.  Neither  \vA\e  we  any  reason 
to  believe  that  in  the  future  we  will  discover  any  remedy  which  will  cause  the 
absorption  of  connective  tissue  when  it  is  once  formed,  and  it  is  certain  that  fibres 
which  ha\'e  once  degenerated  and  have  been  destroyed  cannot  be  regenerated  by 
the  a(ti()n  of  anv  medicine. 


PLATE    XII 


The  Cervical  and  Sacral  Enlargements  of  the  Spinal  Cord, in 
Cross-section,  showing  the  various  neurones  in  the  gray  matter, 
the  direction  of  their  axones,  and  the  varieties  of  fibres  in  the 
different  columns  of  the  eord  (Starr).  Blue,  motor-;  red,  sensory-; 
purple,  association-neurones  and  axones. 

I.  Ant.  median  column.  II.  Anterolateral  column.  III.  Gowers'  anterolateral  ascending 
column.  IV.  Marginal  column.  V.  Lateral  pyramidal  column.  VI.  Direct  cerebellar  column. 
VII.  Lissauer*s  tract.  VIII.  Ext.  portion  of  column  of  Burdach.  IX.  Root  zone  of  the  column 
of  Burdach.  X.  Descending  comma-shaped  bundle  of  Schultze.  XI.  Post,  commissural  tract. 
XII.  Column  of  Goll.     XIII.  Septomarginal  tract. 


LOCOMOTOR  ATAXIA  823 


DISEASES  IN  WHICH  THE  CHIEF  MANIFESTATIONS  ARE  IN  THE 
SPINAL  CORD. 

LOCOMOTOR  ATAXIA. 

Definition. — Locomotor  ataxia  is  a  disease  characterized  chiefly  by  inco-ordination 
of  gait  and  station,  loss  of  muscle  and  joint  sense,  and  loss  of  the  deep  reflexes. 
It  is  often  accompanied  by  pain.  The  most  noteworthj^  loss  of  reflexes  is  in  the 
patellar  tendon  and  iris.  Pathologically,  it  is  characterized  by  slow  progressive 
degeneration  which  aft'ects  chiefly  the  sensory  nerve  roots  and  the  posterior  or 
dorsal  columns  of  the  spinal  cord.  It  is  sometimes  called  tabes  dorsalis,  or  pos- 
terior spinal  sclerosis. 

History. — Cases  of  locomotor  ataxia  were  recorded  as  a  form  of  paralysis  many 
years  ago,  but  it  was  not  till  1847  that  Todd  clearly  separated  this  malady  from 
other  states  of  paralysis.  In  1840  Stanley  had  recognized  that  the  affection  was 
associated  with  changes  in  the  posterior  colimins  of  the  spinal  cord.  In  1855 
Reynolds  first  showed  that  the  disease  was  essentially  a  state  in  which  the  symptoms 
were  due  to  a  loss  of  muscle  sense,  and  not  to  loss  of  power  in  the  motor  nerves 
or  muscles — a  view  confirmed  by  Tiirck,  who  made  a  microscopic  demonstration 
of  the  site  of  the  lesions. 

Etiology. — Males  suffer  more  than  females  in  the  proportion  of  10  to  1.  In  a 
large  general  hospital  experience  of  more  than  thirty  years  I  have  seen  but  one 
case  in  a  woman.  Half  the  cases  develop  in  the  decade  of  life  between  thirty  and 
forty  years,  and  80  per  cent,  between  thirty  and  fifty  years.  Gowers  states  that 
it  rarely  develops  after  fifty  years. 

By  far  the  most  common  cause  of  the  disease  is  acquired  sj^Dhilis.  Rarely 
the  syphilis  is  hereditary.  Some  writers  have  gone  so  far  as  to  state  that  locomotor 
ataxia  is  due  to  this  cause  in  over  90  per  cent,  of  the  cases  (Sachs).  Gowers  gives 
the  rather  moderate  proportion  of  77  per  cent.;  Starr  70  per  cent.  The  more 
acute  methods  of  diagnosticating  syphilis  seem  to  indicate  that  it  is  the  cause  in 
100  per  cent.  C.  J.  White  has  recorded  a  patient  twenty-one  years  old  who 
developed  tabes  three  months  after  infection.  Rarely  the  ataxic  sjTnptoms  develop 
within  five  years  of  the  primary  sore.  In  226  tabetics  he  found  the  disease  developed 
in  11  per  cent,  in  the  first  five  years,  25  per  cent,  in  the  first  ten  years,  and  61 
per  cent,  in  the  first  fifteen  years;  76  per  cent,  developed  the  disease  between 
thirty  and  fifty  years  of  age.  In  many  instances  the  ataxic  symptoms  develop 
so  many  years  after  syphilitic  infection  that  the  patient  cannot  believe  that  the 
two  maladies  have  any  relationship  of  cause  and  effect,  the  more  so  as  ataxia 
is  more  frequently  met  with  in  patients  who  have  presented  very  mild  secondary 
symptoms  than  in  those  who  have  had  severe  s\Tnptoms  in  the  early  stages. 

Severe  falls,  or  blows  upon  the  spine,  have  been  followed,  months  or  years  later, 
by  tabes  dorsalis,  but  it  is  impossible  to  tell  just  what  relation  the  trauma  has  to 
the  malady. 

Pathology  and  Morbid  Anatomy. — In  studying  the  morbid  anatomy  and  pathology 
of  locomotor  ataxia  it  is  important  for  the  student  to  recall  the  fact  that  the  primary 
lesion  of  the  disease  is  in  the  posterior  ganglia  and  posterior  roots  of  the  spinal 
cord,  and  in  the  ganglia  of  the  cranial  nerves,  and  not  in  the  posterior  columns  of 
the  spinal  cord,  as  was  thought  at  one  time.  The  sensory  cells  in  the  posterior 
ganglia,  outside  of  the  cord,  are  flask-shaped  bodies,  each  of  which  has  a  process 
which  divides  into  two  axones.  One  of  these  goes  by  the  posterior  nerve  root  to 
the  spinal  cord,  and  the  other  goes  to  the  afferent  nerve,  which  extends  to  the 
peripheral  portions  of  the  body.  (See  Plate  XII.)  Degenerative  changes  take 
place  in  the  proximal  axone  as  well  as  in  the  peripheral  portion  of  the  distal  axone. 


824  DISEASES  OF  THE  NERVOUS  SYSTEM 

These  changes  are  sclerotic  and  are  carried  into  the  cord,  so  to  speak,  by  the  proximal 
axone.  Therefore,  locomotor  .ataxia  consists  primarily  in  disease  of  the  proximal 
axone,  secondarily  in  disease  of  the  distal  axone,  and  finally  in  disease  of  those 
fibres  in  the  posterior  portion  of  the  spinal  cord  which  have  their  origin  in  the 
proximal  axone  just  described.  While  it  is  true  that  the  primary  lesion  is  not  in 
the  cord,  it  is  nevertheless  a  fact  that  the  chief  manifestations  of  the  pathological 
process  are  to  be  found  in  this  portion  of  the  ner\'ous  system.  Indeed,  the  changes 
in  the  spinal  cord  are  so  well  developed  in  typical  cases  that  the  macroscopic 
examination  suffices  for  the  diagnosis  at  the  autopsy. 

The  affected  portions  of  the  cord  are  smaller  than  normal  and  more  grayish 
in  appearance.  The  distribution  of  those  areas  varies  greatly.  In  some  instances 
the  disease  is  so  moderate  in  degree  and  in  distribution  as  to  be  difficult  of  recogni- 
tion, except  by  the  microscope.  In  others,  if  the  malady  is  far  advanced,  the  whole 
length  of  the  posterior  columns  may  be  affected.  There  arc  certain  parts  of  the 
cord  which  are  particularly  prone  to  the  development  of  the  disease.  Thus,  the 
lesions  are  usually  well  deve'oped  in  the  posterior  columns  in  the  lumbar  regions 
particularly  in  the  neighborhood  of  the  posterior  root  zones,  and  this  accounts 
for  the  fact  that  the  legs  show  the  earliest  and  most  severe  symptoms.  As  we 
ascend  the  cord,  howe-ver,  the  lesions  are  chiefly  found  in  the  posteromedian 
columns. 

In  instances  in  which  the  disease  affects  the  arms  as  well  as  the  legs  and  is  well 
developed,  the  postero-external  co  umns  are  affected  even  in  the  cervical  region 
(Fig.   134). 

Under  the  microscope  it  is  found  that  the  connective  tissue  in  the  posterior 
columns  of  the  cord  has  undergone  hyperplasia  or  overgrowth.  The  fibrous 
sheath  of  the  bloodvessels  is  particularly  affected  and  is  seen  to  be  thickened  and 
to  project  connective-tissue  fibrils  into  nearby  parts.  The  nerve  fibres  may  have 
disappeared  entirely  or  be  represented  by  atrophied  or  wasted  fibres.  In  some 
cases  the  vessels  of  the  pia  mater  are  also  thickened,  particularly  in  the  part  covering 
the  posterior  columns,  and  these  vessels  may  also  give  off'  fibrils  of  connective 
tissue  which  add  to  the  connective-tissue  overgrowth  in  the  superficial  part  of 
the  cord. 

The  changes  which  are  found  in  the  posterior  ner\"e  roots  vary  greatly  in  their 
degree.  In  some  instances  they  are  so  slight  that  they  can  be  recognized  only 
by  carefu  microscopic  examination;  in  other  instances  they  are  so  well  marked 
that  the  naked  eye  can  detect  them.  Under  these  circumstances  they  appear 
atrophied  and  the  connective-tissue  elements  may  be  somewhat  increased.  The 
root  fibres  in  the  cord  are  more  affected  than  those  outside  of  the  cord  The  ganglia 
are  also  affected  by  an  o\-ergrowtli  of  connective  tissue,  and  by  an  atrophy  of  their 
nerve  cells.  Beyond  the  ganglia  pathological  changes  in  the  mixed  nerve  are 
rarely  seen  as  a  continuation  of  the  process  found  in  the  nerve  roots,  but  it  is  a 
well-recognized  fact  that  marked  primary  changes  are  to  be  found  in  the  peripheral 
nerves,  and  especially  in  the  cutaneous  branches.  These  changes  consist  in  an 
atrophy  of  the  myelin  sheath  followed  by  degeneration  and  segmentation  of  the 
axis  cylinder  and  they  occur  at  the  distal  extremity  of  the  nerve  in  greater  degree 
than  higher  up.  The  main  nerve  trunks  are  rarely  affected.  It  is  largely  because 
of  these  neural  lesions  that  sensation  in  the  skin  and  in  the  joints  and  the  mu.scular 
sense  are  lost. 

In  certain  cases  the  changes  of  locomotor  ataxia  may  be  well  marked  in  the  cord 
and  slight  in  the  nerve  roots,  and  in  others  the  nerves  are  chiefly  involved.  It  is 
important  that  this  fact  be  remembered  because  it  serves  to  fix  in  the  mind  of  the 
student  the  fact  that  locomotor  ataxia  is  not  solely  a  disease  of  the  posterior  columns 
of  the  cord. 

While  locomotor  ataxia  chiefly  aflects  the  spinal  cord  and  its  ner\'e  roots,  it  also 


LOCOMOTOR  ATAXIA 


825 


attacks  quite  frequently  the  cranial  nerves,  and  of  these  the  optic  nerve  suffers 
most  severely  and  most  frequently.  Its  nerve  fibres  atrophy  and  its  connective 
tissue  undergoes  proliferation. 

By  no  means  rarely  marked  degenerative  changes  are  found  in  the  joints.    The 
articulating  cartilages  are  eroded,  the  joint  may  become  filled  with  fluid,  and  for 
these  reasons  dislocations  may  occur.    Trophic 
changes  also  occur  elsewhere.   (See  Symptoms.)  Fig.  136 

Symptoms.  —  In  a  case  of  locomotor  ataxia 
which  is  typical  in  its  course  the  following 
symptoms  are  present,  and  if  they  are  weU  de- 
veloped it  is  not  difficult  to  make  a  diag- 
nosis; 

The  patient  often  states  that  his  feet  feel 
"mvffled,"  that  is,  as  if  he  had  on  several  pairs  of 
thick  socks.  In  other  cases  he  notices  that  on 
arising  at  night  he  has  difficulty  in  getting  a 
proper  "purchase"  with  his  feet  on  the  floor,  or 
the  floor  may  feel  as  if  its  plane  is  at  a  different 
angle  from  that  pictured  in  his  mind.  These 
awkward  sensations  are  due  to  the  interference 
with  the  sensory  nerve  fibres,  that  is,  with  con- 
duction of  sensation  to  the  spinal  cord.  He  also 
has  difficulty  in  walking  in  the  dark,  not  only 
because  his  tactile  sense  is  disturbed,  but  because 
his  muscle  sense  is  also  impaired,  wdth  the  result 
that  he  is  in  doubt  as  to  the  position  of  his  limbs 
and  as  to  the  relative  tonicity  of  opposing 
muscles.  This  loss  of  muscle  sense  depends  upon 
the  fact  that  the  sensory  nerves  supplying  the 
joints,  tendons,  and  fasciae  are  impaired  in  func- 
tion and  the  tracts  in  tlie  spinal  cord  which 
carry  these  impulses  which  reflexly  co-ordinate 
movement  are  also  involved.  If  the  impulse 
passes  this  area  of  damage  and  reaches  the  cord 

it  passes  up  the  posteromedian  cohunns  without     anterior     cervical    region)     pyramidal 

decussation,  and  probably  goes  directly  to  the    t''^<=t«' ^'i*  slight  degeneration  of  the 

,     ,,  ,  .   1  .  ,  "^     °         ,     ,  mi  anterior  cornua.    .4,  cervical;  B,  dorsal; 

cerebellum,  which  presides  over  balance,    ihese    c,  lumbar  sections.    (After  Gowers.) 
columns   are   always   diseased   if  the   ataxia  is 

marked,  but  cutaneous  sensibility  is  often  preserved,  proving  that  the  muscular 
and  cutaneous  sensations  are  carried  by  different  tracts. 

Closely  related  to  the  disorder  of  muscle  sense  is  inco-orclination,  which  produces 
the  ixculiar  gait.  In  the  ataxic  gait  the  foot  is  raised  awkwardly  and  then  thrown 
down  in  front  of  the  other  foot  with  a  characteristic  uncertain  movement,  the  whole 
under  surface  of  the  foot  striking  the  ground  at  once.  This  uncertainty  of  move- 
ment becomes  still  more  marked  if  the  surface  over  which  the  patient  has  to  walk 
is  uneven,  or  if  a  rug  upon  the  floor  requires  that  the  feet  shall  be  lifted  slightly 
to  clear  it.  In  other  cases  the  edge  of  the  foot  rests  on  the  floor  instead  of  the 
plantar  surface,  and  in  the  effort  to  correct  this  position  another  clumsy  movement 
is  made.  If  the  light  is  poor  or  if  the  patient  closes  his  eyes,  the  difficulty  in  muscu- 
lar co-ordination  may  be  so  great  that  he  staggers  and  falls.  As  the  involvement 
of  the  sensory  pathways  becomes  more  marked,  support  by  means  of  a  cane,  nearby 
objects,  or  another  person,  is  needful  for  locomotion,  and  finally  all  attempts  at 
walking  have  to  be  given  up.  In  cases  in  which  the  upper  portions  of  the  cord 
suffer,  there  is  a  similar  inco-ordination  of  the  arms,  so  that  the  patient  cannot 


Sclerosis  of  the    lateral  and  (in   the 


820  DISEASES  OF  THE  XERVOCS  SYSTEM 

carry  food  to  his  mouth  if  the  eyes  are  closed.  In  other  instances,  Ikiwcncp,  even 
when  the  legs  are  practically  useless,  the  arms  entirely  escape.  If  citlRT  the  arms 
or  the  legs  arc  extended  the  muscles  do  not  remain  steady,  hut  alternately  contract 
and  relax,  as  the  patient  vainly  endeavors  to  maintain  his  balance.  There  is  no 
actual  loss  of  muscle  strength  until  tiic  disease  has  lasted  so  long  tiiat  the  muscles 
waste  from  disuse. 

The  same  cause  that  produces  the  difficulty  in  gait  also  causes  a  disturbance  of 
"station."  That  is  to  say,  the  patient  cannot  stand  steadily,  but  sways  in  the 
endeavor  to  keep  his  balance.  If  his  eyes  are  closed  or  if  he  is  blindfolded  he  sways 
so  widely  that  there  is  danger  of  his  falling,  and  he  may  actually  fall  if  he  cannot 
co-ordinate  his  muscles  by  the  use  of  his  eyes,  which  will  give  him  a  conception  of 
the  relative  position  of  surrounding  objects.  This  instal)ilit\'  is  often  very  marked 
when  the  patient  attempts  to  suddenly  assume  the  erect  jxisture  after  sitting  in  a 
chair  for  some  time.  As  Romberg  first  called  attention  to  this  loss  of  station,  the 
term  "  Romberg's  symptom"  is  applied  to  this  manifestation  of  the  malady. 

Still  another  indication  of  the  disease  in  the  sensory  pathways  in  locomotor 
ataxia  is  the  diminution  and  final  total  loss  of  the  knee-jerks  when  the  patellar  tendon 
is  tapped.     This  is  called  "WestphaVs  symptom." 

The  diminished  tonicity  of  the  muscles  and  ligaments  in  tabes  causes  them  to 
relax.  This  "hypotonia"  can  easily  be  demonstrated  by  having  the  patient  lie 
on  liis  back  on  a  flat  surface,  the  examiner  pressing  the  knee  down  and  elevating 
the  heel.  It  will  be  found  that  in  tabes  the  point  to  which  the  heel  can  be  raised 
will  be  much  higher  than  can  be  reached  when  the  test  is  applied  to  a  normal 
individual. 

So  far  only  those  disorders  of  motion  which  result  from  the  loss  of  muscle  sense 
have  been  discussed.  There  yet  remain  to  be  considered  the  characteristic  sensorj'^ 
symptoms  themselves.  These  consist  in  pain  and  /o.?.s  of  sensibility.  Pain  is  a 
very  frequent  and  often  a  very  early  symptom,  occurring  in  about  90  per  cent,  of 
all  cases,  and  it  may  be  \'ery  severe.  It  occurs  chiefly  in  the  legs  as  sharp  dartings 
called  "  lightning  pains."  Unlike  the  motor  symptoms,  these  pains  are  not  confined 
to  the  legs  and  arms,  but  are  often  present  in  the  body  and  even  in  the  head,  where 
other  symptoms  of  this  disease  are  rare,  except  in  the  eyes.  The  pains  are  often 
agonizing  and  occur  chiefly  at  night.  In  most  instances  they  occur  in  periodic 
attacks,  then  ceasing  for  weeks  or  even  months.  They  may  develop  in  different 
parts  of  the  body  at  each  attack.  They  rarely  have  their  seat  in  large  nerve  trunks, 
but  exist  in  the  more  minute  fibres  of  the  nerves.  When  they  attack  the  stomach 
they  are  called  "gastric  crises,"  a  term  also  applied  to  severe  attacks  of  vomiting 
in  this  disease.  So,  too,  attacks  of  intense  pain  may  suddenly  de^•clop  in  the 
bladder,  "vesical  crises,"  and  in  the  rectmn,  "  rectal  crise.'i."  There  may  be  marked 
"girdle  sensations"  in  the  trunk. 

The  pains  are  described  as  darting,  rending,  or  burning,  and  the  jjatient  may  speak 
of  "burning  toes"  as  his  most  troublesome  symptom.  Inten^se  hyperesthesia  of  the 
skin  in  the  jjainful  areas  may  also  be  present.  These  pains  are  to  some  extent 
affected  by  atmospheric  states.  I  have  more  than  once  known  them  to  be  produced 
or  exaggerated  by  constipation,  probably  because  of  the  absorption  of  intestinal 
toxins. 

It  is  important  to  bear  in  mind  the  fact  that  i)ain  may  be  one  of  the  earliest 
signs  of  this  malady,  and  may  vary  from  tingling  to  an  agony  without  any  of  the 
disorders  of  the  gait  being  as  yet  present.  On  the  other  hand,  very  severe  ataxia 
may  be  present  without  any  j)ain.  In  addition  to  these  painful  disorders  various 
other  disturbances  of  sensation  also  develop,  such  asforniiraflon,  tickling,  pricking, 
creeping,  .s-ensatio7is  of  heat  and  cold,  or  hyperesthesia.  When  the  disease  is  well 
advanced,  diminution  of  sensation  in  the  skin  or  even  complete  anesthesia  may 
appear.     The  sense  of  pain  and  of  touch  may  both  be  impaired.     The  pain  sense 


LOCOMOTOR  ATAXIA  827 

may  be  lost  and  the  heat  sense  retained,  or,  again,  the  tactile  sense  may  be  inter- 
preted by  the  patient  as  pain  or  heat.  A  very  interesting  perversion  of  the  function 
of  sensation  is  the  delay  in  the  transmission  of  the  sensory  impulses,  so  that  a  very 
appreciable  interval  occurs  between  the  moment  at  which  the  foot  is  pricked 
and  the  moment  at  which  the  patient  appreciates  the  fact  that  the  injury  has  been 
sustained.  Obersteiner  has  recorded  a  case  in  which  the  interval  was  twenty-five 
seconds.  So,  too,  the  patient  is  unable  to  readily  indicate  the  part  touched.  He 
may  even  assert  that  it  is  the  left  foot  when  it  is  really  the  right  one  that  is  irritated. 
To  this  symptom  the  term  allochiria  is  applied.  All  these  tests  must  be  made, 
of  course,  with  the  patient  blindfolded.  The  deeper  portions  of  the  body  may  be 
as  anesthetic  as  the  skin,  and  injury  to  a  testicle,  pleurisy,  and  severe  muscular 
inflammation,  as  after  a  deep  injection  of  mercury,  may  be  painless.  Biernacki 
has  shown  that  the  ulnar  nerve  is  often  insensitive  to  pressure  at  the  elbow,  h-exual 
power  may  or  may  not  be  lost. 

The  changes  which  take  place  in  the  eyes  in  locomotor  ataxia  are  so  constantly 
met  with  and  are  so  valuable  to  us  from  a  diagnostic  standpoint,  that  they  are 
worth  remembering.  In  about  80  per  cent,  of  the  cases  the  Argi/II- Robertson 
inrpil  is  present,  that  is,  the  pupil  reacts  to  accommodation,  but  not  to  light.  This 
state  depends  upon  a  lesion,  somewhere  in  the  path  of  the  light  reflex,  which  includes 
the  optic  nerve  on  the  one  hand  and  the  oculomotor  nerve  and  nucleus  on  the 
other,  with  a  connection  between  these  two  nerves  which  is  not  known,  h'ome  have 
taught  that  Meynert's  decussation,  between  the  primary  optic  centres  in  which  the 
optic  nerve  ends  and  the  third  nerve  nucleus,  forms  this  connection  and  is  the  seat 
of  lesion  determining  the  Argyll-Eobertson  pupil.  Recent  studies  indicate  that 
the  fibres  concerned  pass  from  the  optic  tract  to  the  third  nerve  nucleus  before 
the  former  has  reached  the  primary  optic  centres. 

There  may  be  loss  of  accommodation  in  some  cases.  The  pupils  are  usually 
myotic;  they  may  be  unequal  and  uneven,  especially  during  contraction;  they  may 
also  be  irregular  in  shape. 

The  second  important  ocular  symptoms  are  those  which  depend  upon  the  nen-e 
supply  of  the  extrinsic  muscles  of  the  eye.  Diplopia  may  develop  as  a  fleeting 
or  permanent  symptom  due  to  insufficiency  of  one  of  the  ocular  muscles,  the  external 
rectus  muscle  being  the  one  most  commonly  affected,  although  there  is  diversity 
of  opinion  as  to  this  point.  So,  too,  single  or  double  ptosis  may  develop  and  be 
transient  or  permanent.  In  some  cases  all  the  extraocular  muscles  become  par- 
alyzed so  that  a  comp)lete  ophthalmoplegia  may  be  present.  The  third  ocular  sign  of 
importance  is  atrophy  of  the  optic  nerve,  which  takes  place  in  about  10  per  cent,  of 
all  cases.  It  is  often  present  before  any  difficulty  of  the  gait  deA'elops,  and  for  this 
reason  the  presence  of  the  disease  may  be  first  recognized  by  the  ophthalmologist 
rather  than  by  the  general  practitioner.  It  is  thought  by  some  writers  that  this 
manifestation  of  locomotor  ataxia  is  more  prone  to  develop  in  the  instances  in 
which  the  arms  are  involved  than  in  those  cases  in  which  the  lower  portions  of  the 
cord  are  affected.  Not  rarely  the  presence  of  optic  7ierve  atrophy  seems  to  be 
accompanied  by  an  arrest  of  the  sclerotic  process  elsewhere.  The  field  of  vision 
is  primarily  duninished,  there  may  be  loss  of  color  vision,  but  sometimes  the  failure 
is  marked,  even  from  the  onset,  in  the  neighborhood  of  the  macula.  The  impair- 
ment of  vision  which  ensues  may  progress  to  total  blindness  or  become  arrested 
and  consist  in  more  or  less  severe  impairment.  Usually  the  process  is  slow,  but 
occasionally  it  is  so  rapid  that  even  a  few  days  produce  great  changes  in  the  visual 
acuity.  As  is  easily  understood,  when  we  consider  the  nature  of  the  lesions  which 
are  characteristic  of  the  disease  the  loss  of  vision  is  not  always  unilateral. 

When  the  optic  nerve  is  examined  by  the  ophthalmoscope  in  such  cases  the  disk 
is  seen  to  be  pale  and  shrunken,  but  at  times  the  degree  of  blindness  is  in  excess 
of  the  changes  in  the  disk.     Finally,  the  disk  becomes  a  pale  gray. 


828 


DISEASES  OF  THE  NERVOUS  SYSTEM 


Occasionally  deafness  gradually  or  suddenly  develops.  It  may  be  transient  or 
fleeting. 

The  bladder  in  locomotor  ataxia  is  often  greatly  impaired  in  its  functions.  The 
urine  is  often  imperfectly  expelled  and  as  a  result  residual  urine  jjroduces  cysiitis. 
More  rarely  retention  of  urine  ensues.  The  sijliincter  an!  is  also  weakened,  and 
so  control  of  the  feces  is  diminished. 

There  still  remain  to  be  considered  two  results  of  the  disease  which  arc  of  interest 
and  diagnostic  importance.  The  first  of  these  is  the  so-called  "Charcot  joint," 
to  which  reference  has  already  been  made.  Owing  to  the  changes  in  the  elbow, 
shoulder,  hip,  and  knees  the  landmarks  of  these  parts  may  be  completely  obliterated, 
and  great  swelling  often  is  present.  The  second  of  these  trophic  changes  is  the 
so-called  perforating  ulcer  of  the  foot,  which  may  or  may  not  be  accompanied  by 
ulcerations  about  the  toe-nails.  In  addition  to  these  trophic  symptoms  the  bones 
are  sometimes  abnormally  brittle,  so  that  fractures  result  spontaneously  or  from 
trivial  causes. 

Diagnosis. — As  already  intimated,  the  most  valuable  diagnostic  sjinptoms  and 
signs  of  locomotor  ataxia  are  the  loss  of  the  knee-jerk,  the  swaying  station,  the 
Argyll-Robertson  pupil,  the  optic  atrophy,  and  the 
lightning  pains.  No  one  of  these,  however,  enables 
us  to  make  a  diagnosis  because  of  its  presence.  The 
disease  must  be  differentiated  from  peripheral  neuritis 
due  to  alcohol,  lead,  and  arsenic,  and  from  that  due 
to  typhoid  fever  and  diphtheria.  In  these  conditions 
there  is  loss  of  knee-jerk,  swaying  station,  and  often 
severe  pains  or  anesthesia,  but  the  Argyll-Robertson 
pupil  is  absent  and  the  history  of  the  patient  as  to 
exposure  to  alcohol,  lead,  or  arsenic  aids  us  greatly  in 
the  differentiation.  To  these  states  the  term  pseudo- 
tabes has  been  well  applied.  A  positive  Wassermann 
reaction,  given  by  the  cerebrospinal  fluid  which  con- 
tains an  excess  of  lymphocytes  of  from  10  to  100  to  the 
cubic  millimetre,  an  excess  of  globulin,  and  which  reduces 
Fehling's  solution,  practically  decides  the  diagnosis. 

Locomotor  ataxia  is  separated  from  the  various 
forms  of  paraplegia  by  the  loss  of  the  knee-jerk,  which 
is  usually  exaggerated  in  other  spinal  states,  and  by 
the  actual  loss  of  power  in  paraplegia.  From  the 
spastic  paraplegia  due  to  lateral  sclerosis  true  loco- 
motor ataxia  is  separated  by  the  spastic  state  of  the  muscles  and  the  greatly 
increased  knee-jerk. 

From  general  paralysis  of  the  insane  locomotor  ataxia  may  be  difficult  of  separa- 
tion, for  in  this  disease  the  Argyll-Robertson  pupil  and  other  physical  signs  of 
locomotor  ataxia  may  be  present.  As  the  case  advances  the  predominance  of  the 
cerebral  symptoms  over  the  spinal  symptoms  becomes  marked  and  so  renders  the 
diagnosis  possible.     (See  Paretic  Dementia.) 

The  fact  that  in  rare  cases  of  locomotor  ataxia  severe  jKuns  are  felt  in  the  trunk 
should  never  be  forgotten,  for  it  has  ha])])ened  not  infrequently  that  they  have 
misled  the  physician  into  a  belief  that  caries  of  the  vertebric  was  present. 

The  staggering  gait  of  cerebellar  tumor  can  scarcely  be  mistaken  for  locomotor 
ataxia.  If  there  is  doubt  as  to  its  cause  it  can  be  dispelled  by  the  absence  of  shooting 
pains,  by  the  presence  of  headache  and  of  nystagmus. 

Prognosis. — The  prognosis  of  locomotor  ataxia  may  be  best  considered  in  two 
parts.  So  far  as  complete  recovery  is  concerned,  this  is  out  of  the  cjuestion.  So 
far  as  rapidity  of  progress  is  concerned,  we  must  always  be  guarded  in  expressing 


Perforating  ulcer  of  the  foot 
in  locomotor  ataxia.  (Ober- 
stcinor.) 


LOCOMOTOR  ATAXIA  829 

an  opinion.  In  the  great  majority  of  cases  the  disease  lasts  for  years  and  is  ciiar- 
acterized  not  only  by  periods  of  arrest,  but  of  actual  improvement  of  a  very  marked 
character  in  some  cases.  In  cases  not  too  far  advanced,  with  proper  care  and 
treatment,  a  useful  life  may  be  had  for  twenty  years.  The  use  of  the  proper 
specific  remedies  may  arrest  the  malady,  but  they  cannot  cure  the  damage  already 
done.  Cases  which  attack  those  young  in  years  and  progress  rapidly  are  most 
unfavorable,  but  even  these  cases  make  remarkable  "stops"  in  the  advance  of 
the  affection. 

Treatment. — There  is  probably  no  grave  disease  of  the  nervous  system  of  an 
organic  nature  which,  in  some  instances  at  least,  yields  such  good  results  from 
treatment  as  does  this  one. 

As  may  be  gathered  from  the  discussion  of  the  pathology  of  locomotor  ataxia, 
it  must  be  evident  that  the  physician  can  only  palliate  the  symptoms  of  this  disease, 
and  that  a  complete  cure  is  practically  impossible.  The  most  that  we  can  do  is 
to  prevent  further  progress  of  the  malady.  Nevertheless,  in  a  large  proportion 
of  cases,  benefit  is  obtained  by  the  pursuance  of  a  plan  of  treatment  which  consists 
largely  in  the  administration  of  mercury  and  salvarsan  (see  Sj-philis),  and  possibly 
iodide  of  potassiiun.  If  the  specific  infection  is  of  comparatively  recent  date, 
the  salvarsan  should  be  used,  but  in  many  instances  this  is  not  the  case,  and  mercury 
is  the  remedy  of  choice.  In  almost  all  cases  salvarsan  first  and  mercury  afterwards 
should  be  the  plan,  and  under  their  conjoint  use  the  specific  manifestations,  already 
described,  in  the  cerebrospinal  fluid  disappear  and  the  sj-mptoms  moderate  unless 
the  morbid  change  in  the  nerve  roots  and  cord,  be  so  far  gone  as  to  be  permanent. 
Usually  four  doses  of  salvarsanized  serum  are  given  within  the  first  four  weeks. 
The  repeated  use  of  salvarsan  depends  upon  the  findings  in  the  cerebrospinal  fluid. 
If  they  clear  up  it  may  be  stopped  and  repeated  if  they  return.  The  mercury  is 
best  used  intramuscularly  in  the  form  of  the  salicylate  or  the  gray  oil.  The 
Swift-Ellis  method  of  injecting  salvarsanized  blood  serum  intraspinally  is  of 
recent  introduction  and  seems  to  be  of  distinct  value,  especially  in  relieving  the 
lightning  pains  and  visceral  crises,  ^''ery  often  the  best  results  are  obtained  if  in 
addition  inunctions  with  mercurial  ointment  are  practised  twice  or  thrice  a  week. 

While,  on  the  one  hand,  it  should  be  our  endeavor  to  use  these  two  specific 
remedies  very  freely,  it  must  also  be  remembered  that  the  patient's  vitality  must 
be  kept  at  the  highest  possible  level  by  every  means  in  our  power.  Poor  health 
and  digestive  disturbance  produced  by  the  unwise  emplo^Tnent  of  mercury  probably 
does  the  patient  more  harm  than  the  drugs  do  him  good.  Starr  asserts  that  the 
use  of  mercury  hastens  the  process  of  optic  nerve  atrophy,  and  in  those  cases  in 
which  this  sjinptom  is  present  mercurial  treatment  should  not  be  resorted  to. 
In  those  cases  in  which  there  is  no  syphilitic  history,  or  in  which  the  mercurials 
are  badly  borne,  arsenic  may  be  given  as  a  nerve  tonic  particularly  in  the  form  of 
cacodylate  of  sodium.  Nitrate  of  silver  was  at  one  time  thought  to  be  ad^-antage- 
ous,  but  there  is  nothing  in  our  knowledge  of  this  drug  or  of  the  disease  wliich  makes 
its  emplojTiient  in  any  way  specific. 

For  the  relief  of  the  pains  in  the  peripheral  nerves,  the  coal-tar  products  are 
our  best  remedies,  acetanilid,  phenacetin,  and  antipjTin  being  commonly  employed. 
In  other  instances  the  salicylates  are  useful.  If  the  pain  is  excessive,  morphine 
must  be  used. 

For  the  twitching  of  the  limbs,  the  bromides,  which  quiet  the  sensory  portions 
of  the  cord,  may  be  employed  in  sufficiently  large  doses  to  produce  sedation. 

A  method  of  treating  these  cases  which  is  of  some  value  is  that  introduced  by 
Fraenkel,  of  Berlin.  This  method  is  not  curative  in  the  sense  that  it  is  supposed  to 
influence  the  lesions  in  the  cord,  but  is  employed  with  the  object  of  training  other 
nerve  fibres  than  those  originally  used,  so  that  the  patient  may  to  some  extent 
regain  his  muscle  sense.    This  plan  consists  in  making  him  take  certain  exercises 


830  DISEASES  OF  THE  NERVOUS  SYSTEM 

wliicli  r«iiiire  (•o-ordinatioii.  A  chalk  line  is  drawn  upon  the  floor  and  he  is  refjuired 
to  follow  it  as  closely  as  possible;  or,  a  series  of  cup-like  depressions  are  made  in  a 
plank,  which  is  placed  across  the  foot  of  the  patient's  bed.  These  depressions  are 
numbered  from  one  to  ten,  and  he  is  instructed  by  the  nurse  to  raise  his  leg  and 
then  rest  his  heel  in  the  cup  which  she  names.  In  this  way  the  patient  in  some 
in.stances  is  able  to  speedily  respond  to  the  order,  and  so  is  traine-d  to  carry  out 
well  co-ordinated  movements.  Still  another  method  consists  in  supplying  him 
with  a  small  double  flight  of  steps  provided  with  railings  so  that  he  cannot  fall. 
The  patient  is  then  required  to  mount  a  few  steps  on  one  side  and  then  descend  a 
few  on  the  other,  using  his  legs  to  lift  himself  up  on  each  step,  and  not  i)ulling  himself 
up  by  his  hands,  which  rest  upon  the  rails.  In  other  instances  still,  definite  spaces 
are  marked  out  on  the  floor,  and  he  is  directed  to  take  a  stride  which  will  bring 
his  heel  on  each  mark.  It  can  be  readily  seen  that  a  large  number  of  such  exercises 
can  easily  be  devised  if  a  little  ingenuity  is  used.  Care  should  be  taken  that 
the  exercises  are  not  continued  so  long  that  the  patient  becomes  in  the  slightest 
degree  exhausted.  For  this  reason  they  should  rarely  be  continued  more  than 
five  minutes  at  a  time,  although  they  may  be  resorted  to  several  times  a  day. 
Additional  methods  of  treatment  consist  in  the  empknTnent  of  massage,  which  is 
designed  to  maintain  the  nutrition  of  the  limbs  and  to  keep  in  health  the  blood- 
vessels and  lymphatic  system,  thereby  to  a  certain  extent  compensating  for  the 
lack  of  exercise  from  which  the  patient  inevitably  suffers. 

The  various  forms  of  baths  at  home,  or  at  health  resorts,  may  be  employed  rather 
for  the  mental  effect  which  they  will  exercise  upon  the  patient  than  with  any  hope 
that  they  would  be  in  any  way  curati\'e.  The  great  ad\-antage  in  resorting  to 
the  various  health  resorts  where  baths  can  be  obtained  is  that  the  patient  goes 
awav  for  the  purpose  of  getting  well  and  leaves  his  business  cares  behind  him. 
The  great  difficulty  with  cool  baths  is  that  the  patient  usually  has  not  sufficient 
power  of  reaction  to  stand  them,  and  tepid  and  hot  baths  often  seem  to  exercise 
an  enervating  effect.  Where  baths  can  be  used  with  the  object  of  aiding  in  the 
absorption  of  mercury  and  the  iodides,  and  where  they  do  not  produce  depression, 
they  arc  valuable. 

So  far  as  exercise  is  concerned,  this  should  be  governed  entirely  liy  the  strength 
of  the  patient.  Under  no  circmnstances  whatever  should  he  be  permitted  to 
become  exhausted.  Not  infrequently  severe  attacks  of  pains  in  the  limbs  are 
precipitated  by  exercise  w^hich  is  sufficiently  severe  or  prolonged  to  diminish  the 
nervous  \dtality  of  the  patient  or  to  tire  the  nerves  themseh-es. 

Electricity  may  be  used  in  the  form  of  the  galvanic  current,  the  positive  pole 
of  the  galvanic  battery  being  placed  at  the  nape  of  the  neck  and  the  negative  pole 
at  the  sacrum  and  at  the  soles  of  the  feet.  The  electrodes  should  be  large  so  that 
the  current  will  be  well  diffused.  As  a  matter  of  fact  the  condition  of  the  spinal 
cord  and  the  nerve  trunks  is  such  that  little  real  benefit  can  be  expected  from 
this  plan  of  treatment  except  for  its  sedative  influence. 


FRIEDREICH'S  ATAXIA. 

Definition. — Under  this  name  a  disease  of  the  nervous  system  is  rarely  met  with 
wliich  is  hereditary  and  which  depends  for  its  clinical  manifestations  upon  lesions 
in  the  posterior  and  lateral  columns  of  the  spinal  cord.  It  is,  therefore,  an  ataxic 
paraplegia  which  is  peculiar  in  that  it  develops  in  early  life.  Friedreich's  ataxia 
is  also  called  "hereditary  ataxic  paraplegia,"  "hereditary  ataxia,"  "Friedreich's 
disease,"  and  "family  ataxia." 

History. — The  malady  was  first  described  by  Friedreich  in  1861  and  again  in 
1876.     In  the  United  States  the  most  noteworthy  study  is  that  of  Everett  Smith 


FRIEDREICH'S  ATAXIA  8:51 

in  1885.     Schultze  showed  in  1877  that  the  disease  was  due  to  a  congenital  defect 
in  the  cord. 

Etiology. — The  exact  cause  is  unknown.  Occasionally  there  is  a  distinct  family 
history  of  the  disease,  but  often  no  more  than  one  child  in  a  family  is  affected. 
Sometimes  the  sjanptoms  develop  after  one  of  the  acute  infectious  diseases  of 
childhood,  and  it  is  then  supposed  to  be  due  to  development  of  the  evidences  of 
imperfect  growth  or  to  damage  to  poorly  vitalized  cells  which  have  never  become 
well  developed.  In  some  cases  the  parents  have  an  alcoholic  history;  in  others 
there  is  a  history  of  syphilis.  Neither  of  these  facts  are,  however,  of  real  etiological 
importance.  The  influence  of  age  is  uncertain.  Rarely  the  malady  manifests 
itself  in  infancy;  more  commonly  it  develops  about  the  sixth  or  eighth  year;  if 
not  at  this  period,  then  at  puberty,  and  if  not  at  puberty,  then  at  about  twenty-one 
years  of  age.  The  two  sexes  suffer  about  equally.  It  has  been  shown  that  defective 
development  of  the  cerebelliun  may  be  a  part  of  the  pathological  findings  in  this 
disease.  Marie,  however,  believes  that  spinal  cord  atrophy  in  these  areas,  when 
due  to  cerebellar  disease,  is  a  separate  malady,  and  the  symptoms  due  to  agencies 
of  the  cerebellum  are  sufficiently  distinctive  to  constitute  a  separate  type  of 
hereditary  ataxia. 


The  lesion  of  Friedreich's  hereditary  ataxia.     Maldevelopment  and  sclerosis  of  the  lateral  and 
posterior  columns.      (Schultze.) 

Pathology  and  Morbid  Anatomy. — ^As  already  stated,  the  lesions  of  Friedreich's 
ataxia  are  chiefly  found  in  the  posterior  and  lateral  tracts  of  the  spinal  cord,  and 
the  disease  may  therefore  be  considered  as  a  combination  of  two  maladies  so  far  as 
the  lesions  and  symptoms  are  concerned. 

When  the  spinal  cord  is  removed  from  such  a  case  at  autopsy  it  is  usually  seen 
to  be  smaller  than  normal,  and  the  pia  mater  is  commonly  thickened,  particularly 
over  its  posterior  surface. 

If  the  cord  is  examined  under  the  microscope  with  suitable  staining  (Fig.  138), 
it  is  found  that  the  posterior  dorsal  colimms,  particularly  those  of  Goll,  the  lateral 
pyramidal  tracts,  and  the  direct  cerebellar  tracts  all  show  degenerative  changes. 
These  changes  are  not  chiefly  limited  to  one  portion  of  the  cord,  as  they  are  in 
most  cases  of  locomotor  ataxia,  but  extend  up  into  the  cervical  region  as  well  as 
in  the  liunbar  region.  The  lesions  are  not  only  posterior  and  lateral,  but  anterior 
as  well,  for  the  direct  pyramidal  tract  on  either  side  of  the  anterior  median  fissure 
is  affected.  There  is  also  atrophy  of  the  cells  in  the  anterior  and  posterior  horns 
of  the  gray  matter.     The  anterior  and  posterior  nerve  roots  are  also  atrophied. 


832  DISEASES  OF  THE  NERVOUS  SYSTEM 

The  cells  in  the  column  of  Clarke  are  markedly  degenerated,  and  round-cell  infiltra- 
tion is  present  about  the  central  canal  of  the  cord.  In  tiiis  disease,  as  in  other 
maladies,  the  loss  of  nervous  tissue  is  followed  by  overgrowtli  of  tlic  neuroglia 
in  the  afl'ectcd  parts. 

Symptoms. — Friedreich's  ataxia  consists,  pathologically,  in  lesions  in  the  posterior 
and  lateral  columns  of  the  cord,  it  necessarily  follows  that  the  symptoms  are  closely 
allied  to  locomotor  ataxia  and  lateral  sclerosis.  The  onset  of  the  disease  is  char- 
acterized by  (/radval  loss  of  co-ordination,  affecting  the  legs  before  it  affects  the  arms, 
which  causes  unsteadiness  in  station,  so  that  the  feet,  when  the  i)atient  is  standing, 
are  placed  far  apart  to  maintain  the  balance  of  the  body.  In  some  instances  the 
first  symptom  is  that  the  child  falls  over  objects  which  hitherto  have  not  been 
obstacles  in  its  path.  When  the  child  walks  its  gait  is  tottering,  and  if  it  closes 
its  eyes  the  lack  of  co-ordination  and  consequent  instability  is  so  great  that  it 
may  fall.  The  muscles  of  the  legs  are  often  strongly  contracted  in  an  endeavor 
to  maintain  the  upright  posture,  and  this  condition  of  muscular  rigidity  is  increased 
by  the  disease  in  the  lateral  tracts.  The  child  if  stripped  and  left  standing  is 
seen  to  be  continually  writhing  in  an  endeavor  to  adjust  opposing  muscles  in  order 
to  maintain  its  equilibrium.  The  knee-jerks  are  lost,  but  cases  are  occasionally 
met  with  in  which  the  reflexes  are  exaggerated.  These  cases  closely  approximate 
the  group  called  hereditary  cerebellar  ataxia.     (See  below.) 

Loss  of  power  is  not  as  early  a  sjTiiptom  as  is  inco-ordination.  It  affects  the 
legs  far  more  severely  than  the  arms.  The  extensors  suffer  less  than  the  flexors, 
and  this  may  place  the  feet  in  a  posture  like  that  of  talipes  equinus  or  varus.  This 
deformity  may  also  be  caused  not  only  by  one  group  of  muscles  overcoming  others 
by  reason  of  their  loss  of  power,  but  by  the  fact  that  if  the  lesions  in  the  lateral 
columns  of  the  cord  predominate,  a  spastic  pareplegia  develops  which  may  result 
in  contractures  as  in  ordinary  ataxic  paraplegia.  Rlarked  hyperexteusion  of  the 
toes,  especially  of  the  great  toe  is  a  frequent  and  characteristic  svTnptom.  In 
those  instances  in  which  the  muscles  of  the  trunk  become  affected  curvature  of 
the  spine  may  develop. 

The  mind  is  not  aft'ected  by  the  disease,  but  nevertheless  the  patient  rarely 
develops  mentally  as  does  the  normal  child. 

When  the  disease  is  well  advanced,  the  movements  of  the  lower  and  upper 
limbs  become  not  only  irregular  from  inco-ordination,  but  jerking  in  character, 
and  this  jerking  movement  may  extend  to  the  head  and  be  accompanied  by  tremor. 
Speech  becomes  impaired,  the  words  are  blurred  because  of  imperfect  articulation, 
and  the  utterance  may  be  sudden  or  explosive.  The  disorder  of  speech  is  a  late 
symptom  of  the  malady,  and  may  not  appear  for  some  years  after  the  ataxic  mani- 
festations appear.  When  the  eyes  are  moved  laterally  or  upward  nystagmus  may 
be  present,  and  it  is  peculiar  in  that  it  is  absent  ^^•hen  the  e\'eballs  are  at  rest. 
The  extraocular  muscles  are  rarely  paralyzed,  and  the  optic  nerves  always  escape. 
In  these  respects,  therefore,  the  disease  differs  very  distinctly  from  locomotor 
ataxia,  in  which  malady  these  i)arts  are  commonly  involved.  Occasionally,  cases 
are  met  with  in  which  the  pupillary  reflex  is  lost.  In  these  cases,  however,  syphilis 
is  the  cause,  and  the  case  is  proljably  one  of  tabes  with  Argyll-Kobertson  pupils. 

The  disease  is  usually  characterized  by  an  absence  of  all  disturbances  of  sensation 
save  that  cramp-like  contractions  of  the  muscles  in  the  early  stages  may  cause  the 
patient  some  suffering.  In  rare  instances  severe  darting  pains  have  been  met  with, 
or  the  patient  has  experienced  nimibncss  in  the  limbs.  The  s\7nptoms  of  ataxia 
are  usually  made  worse  by  prolonged  rest. 

Diagnosis. — The  development  of  the  characteristic  symptoms  just  eniuuerated 
during  the  period  of  childhood  renders  the  diagnosis  easy,  for  the  maladies  which 
resemble  Friedreich's  ataxia  are  all  of  them  aft'ections  of  adult  life,  save  multiple 
neuritis,  which  may  cause,  of  course,  pseudotabes  and  a  disturbance  of  station  and 


CIIHONIC  ANTERIOR  POfJOMYELiriS  833 

gait.  From  Marie's  cerebellar  hereditary  ataxia  Friedreich's  ataxia  can  be  sepa- 
rated by  a  study  of  the  symptoms  of  that  affection  described  below. 

It  must  be  recalled,  however,  that  cases  of  Friedreich's  ataxia  develop  which 
present  sjTnptoms  which  do  not  follow  characteristic  lines.  Thus,  in  some  cases 
great  muscular  atrophy  has  occurred.  Nystagmus  may  not  appear.  Diplopia 
may  be  present. 

Prognosis. — The  prognosis  is,  of  course,  hopeless.  The  only  thing  favorable 
which  can  be  said  is  that  the  disease  often  develops  very  slowly  and  has  long  periods 
of  arrest.     The  child,  if  attacked  early  in  life,  rarely  reaches  adult  years. 

Treatment. — Treatment,  aside  from  that  devoted  to  the  maintenance  of  good 
nutrition,  is  of  little  avail,  for  obvious  reasons. 

Marie's  Cerebellar  Hereditary  Ataxia. — Under  this  name  a  form  of  hereditary 
ataxia  has  been  described  by  INIarie  in  which  he  has  shown  that  a  congenital  defect 
exists  in  the  cerebellum.  The  condition  is  characterized  by  ataxia,  difficulty 
in  speech,  and  nystagmus,  and  in  these  points  resembles  Friedreich's  ataxia. 
It  differs,  however,  in  the  presence  of  defective  pupillary  reaction  and  various 
ocular  palsies  with  optic  atrophy  and  exaggeration  of  the  knee-jerks.  Further, 
it  develops  in  the  third  decade  of  life,  whereas  Friedreich's  ataxia  nearly  always 
appears  before  the  fourteenth  year. 

L.  F.  Barker  has  recently  put  the  matter  thus:  The  direct  cerebellar  tracts  of 
the  cord  which  are  degenerated  in  Friedreich's  disease  end  in  the  middle  lobe  of  the 
cerebellum,  which  is  defective  in  Marie's  type.  The  ataxia  of  both  these  diseases 
therefore  results  from  lesions  of  different  parts  of  one  system.  In  Barker's  nomen- 
clature the  spinal  part  of  the  posterior  spinocerebellar  system  is  affected  in  Fried- 
reich's ataxia,  while  the  cerebellar  part  of  it  is  involved  in  Marie's  tj^pe.  An 
analysis  of  the  sjonptoms  in  all  the  reported  cases  of  ]\Iarie's  disease  has  led  H.  T. 
Patrick  to  say  that  increase  of  knee-jerk  is  its  sole  distinguishing  feature  from 
Friedreich's  ataxia.  Probably  the  most  advanced  view  is  that  the  two  conditions 
are  phases  of  one  disease. 

CHRONIC  ANTERIOR  POLIOMYELITIS. 

Definition. — It  is  evident  from  its  name  that  this  disease  closely  resembles  acute 
anterior  poliomyelitis.  A  very  important  dift'erence  lies  in  the  fact  that  in  the 
acute  form  the  damage  takes  place  suddenly,  and  then  ceases  to  progress,  some 
improvement  occurring  in  most  instances,  whereas  in  the  clironic  form  the  atrophic 
process  is  slow  in  onset  and  progressive  and  so  the  sjinptoms  get  worse  rather  than 
better.  When  the  sjinptoms  develop  during  a  period  of  from  two  weeks  to  a  month 
the  term  subacute  is  applied,  and  when  they  come  on  even  more  slowly,  so  that 
several  months  are  consimied  in  their  advance,  the  term  chronic  is  used.  The 
dominant  sjinptoms  are  muscular  wasting  with  paralysis.  Chronic  anterior 
poliomyelitis  is  sometimes  called  "clironic  atrophic  spinal  paralysis"  or  "progressive 
muscular  atrophy." 

Etiology. — 'This  is  unknown.  Exposure  to  cold  and  wet  has  been  thought  to  be 
a  cause  in  some  cases.  Among  other  possible  causal  factors  mentioned  are  spinal 
concussion  and  general  infections  including  syphilis. 

Pathology  and  Morbid  Anatomy. — The  lesions  of  chronic  anterior  poliomyelitis 
consist  in  atrophy  of  the  nervous  tissues  of  the  anterior  horns  of  the  gray  matter 
of  the  cord.  Not  only  the  cell  bodies  but  their  axones  and  dendrites  all  undergo 
degenerative  change.  There  is  no  acute  inflammatory  process  present  as  in  the 
acute  form  of  the  disease,  and  no  hemorrhages  into  the  tissues  about  the  vessels. 
The  dominant  change  is  a  simple  atrophy  or  wasting.  The  anterior  nerve  roots 
also  suffer  atrophic  changes,  and  the  so-called  association  fibres  of  the  cord  and 
the  cells  which  give  rise  to  them  also  atrophy.  As  these  association  fibres  pass  to 
53 


834  DISEASES  OF  rilK  SERVOIS  SYSTEM 

tlie  anterior  lateral  columns  of  the  cord  the  degenerative  process  extends  to  them 
as  well,  and  this,  combined  with  the  wasting  of  the  anterior  nerve  roots,  produces 
a  shrinkage  in  the  size  of  these  columns,  which  is,  however,  not  great  enough  to  be 
recognized  by  the  unaided  eye.  The  atrophic  process  extends  down  these  tracts 
and  involves  the  motor  nerve  fibres  all  the  way  to  the  nerve  plates  in  the  muscles, 
which  in  turn  undergo  atrophy,  the  muscular  fibres  losing  their  strife  and  showing 
fatty  globules  inside  the  sarcolemma.  It  is  the  rule,  in  a  case  of  poliomyelitis  of 
long  duration,  for  the  lateral  tracts  of  the  cord  also  to  become  afl'ected,  the  condition 
then  becoming  an  amyotrophic  lateral  sclerosis. 

Symptoms. — The  s^miptoms  of  this  malady  vary  somewhat  with  the  portion  of 
the  spinal  cord  which  is  chiefly  affected.  Most  commonly  the  earliest  manifesta- 
tions of  the  disease  appear  in  the  upper  extremities,  and  this  is  usually  called  the 
"Aran-Duchenne  type  of  the  disease."  It  generally  first  manifests  itself  in  the 
adductor  muscles  of  one  thumb.  From  these  it  extends  to  all  the  small  muscles 
of  the  hand,  which  rapidly  become  wasted.  Flexion  of  the  fingers  upon  the  hand 
is  impossible,  and  as  the  interossei  which  flex  the  first  phalanges  are  paralyzed,  the 
long  flexor  and  extensor  muscles  of  the  forearms  are  unopposed.  As  a  result  we  find 
that  the  long  flexors  flex  the  second  and  third  phalanges  and  the  long  extensors 
extend  the  first  phalanges,  giving  the  so-called  "claw-hand"  deformity.  This 
efl^ect  is  increased  by  the  prominence  of  the  extensor  tendons,  caused  in  part  by 
the  wasting  of  the  smaller  muscles  of  the  hand.  The  hand  or  the  shoulder  on  the 
opposite  side  soon  suffers.  In  a  considerable  nimiber  of  cases  the  wasting  appears 
first  in  the  muscles  of  one  or  both  shoulder  girdles.  Finally,  all  the  upper  arm  and 
shoulder  muscles  atrophy,  and  later  those  of  the  upper  thorax  as  well.  Still  later 
the  lower  extremities  become  involved.  Often  portions  of  the  latissimus  dorsi, 
the  trapezius,  the  triceps,  the  pectoralis  major,  or  other  muscles  escape.  When  the 
cervical  muscles  fail  the  head  cannot  be  held  erect,  and  when  the  costal  muscles 
are  atrophied  the  act  of  respiration  may  be  solely  diaphragmatic.  Finally,  sj-mp- 
toms  of  bulbar  paralysis  may  ensue. 

In  that  type  in  which  the  disease  first  aft'ects  the  Imnbosacral  portion  of  the  cord 
the  peroneal  muscles  in  one  leg  undergo  paraly.sis  and  wasting.  This  condition 
then  develops  in  the  muscles  of  the  other  leg.  A  little  later  the  anterior  tibial 
muscles  are  aft'ected,  first  on  one  side  and  then  on  the  other.  At  this  time  there  is 
"drop-foot"  and  the  patient  has  to  use  his  thigh  muscles  to  raise  the  leg  so  that 
the  toes  will  not  strike  obstructions  and  cause  stumbling.  As  the  pathological 
process  in  the  cord  advances  the  adductor  muscles  in  the  thighs  and  the  gluteal 
muscles  are  paralyzed. 

In  still  another  type,  sometimes  called  "Duchenne's  type  of  ascending  paralysis," 
the  paralysis  and  wasting  extend  upward  from  the  legs  and  speedily  affect  the 
muscles  of  the  trunk,  the  arms,  the  forearms,  and  the  hands  so  that  an  almost  total 
paralysis  ensues  and  death  comes  from  involvement  of  the  centres  in  the  medulla 
or  by  reason  of  some  intercurrent  disease  such  as  pneumonia.  Sensation  is  not 
disturbed,  but  in  a  few  cases  a  sense  of  discomfort  may  be  complained  of  in  the 
legs.  The  reaction  of  degeneration  develops  quite  early  in  the  aft'ected  parts  and 
finally  response  to  electrical  stimulation  is  completely  lost.  The  muscles  present 
fibrillary  contractions  both  sjiontaneously  and  if  irritated,  but  the  bladder  and 
rectum  are  not  jiaralyzed  and  sexual  power  is  preserved.  The  paralysis  is  due  to 
the  wasting.     The  reflexes  are  diminishetl  or  lost  in  the  affected  muscles. 

Diagnosis. — It  is  important  to  remember  that  chronic  muscular  atrophy  may 
ari.se  from  other  diseases  than  chronic  anterior  poliomyelitis,  such  as  amyotrophic 
lateral  sclerosis,  the  muscular  dystrophies,  peripheral  neuritis,  and  syringomyelia. 

From  amyotrophic  lateral  sclerosis  (which  see)  it  is  distinguished  by  the  absence 
of  spastic  s^Tiiptoms  and  lack  of  the  exaggerated  knee-jerk  and  of  Babinski's  reflex. 

From  muscular  dystrophy  by  the  absence  of  fibrillary  tremor  and  of  the  reaction 


BULBAR  PARALYSIS  835 

of  degeneration  in  the  latter  condition,  and  by  the  fact  that  the  spinal  form  is  a 
disease  of  adult  life.  PVom  syringomyelia  this  condition  is  separated  by  the  absence 
of  the  dissociated  anesthesia  and  of  trophic  lesions  in  the  skin. 

In  neuritis  the  distribution  of  the  paralysis  is  usually  symmetrical;  whereas, 
in  chronic  poliomyelitis  the  paralyzed  parts  are  irregularly  distributed.  Unless 
the  neuritis  be  purely  motor  in  character  there  are  sensory  disturbances  and  tender- 
ness on  pressure  over  the  nerve  trunks  and  in  the  bellies  of  the  muscles.  ^Moreover, 
in  neuritis  there  is  commonly  a  toxic  or  infection  cause  recognizable. 

The  Charcot-Marie-Tooth  type  of  muscular  atrophy  may  be  confused  with 
certain  forms  of  progressive  muscular  atrophy.  The  first  of  these,  however,  is  a 
disease  of  early  life,  and  the  paralysis  in  the  legs  does  not  extend  above  the  knees 
or  above  the  elbows,  as  a  rule.  Further,  sensation  is  usually  disturbed  or  impaired 
in  the  Charcot-Marie-Tooth  type  and  preserved  in  this  chronic  muscular  atrophy. 

Prognosis. — The  prognosis  is  grave.  The  future  of  the  case  can  be  determined 
somewhat  by  the  rapidity  of  the  development  of  the  symptoms,  for  in  the  rapidly 
advancing  cases  the  outlook  is  of  course  worse  than  in  others.  "When  the  symptoms 
follow  injury  to  the  spine  the  prognosis  is  better  than  in  the  idiopathic  cases. 

Treatment. — The  rapid  type  of  cases  should  be  treated  as  we  treat  acute  polio- 
myelitis. The  chronic  forms  should  be  cared  for  in  a  manner  practically  identical 
with  that  of  the  advanced  stages  of  acute  poliomyelitis.  The  treatment,  therefore, 
consists  in  hygienic  surroundings,  nutritious  food,  and  an  abundance  of  fresh  air 
and  sunshine.  Care  should  be  taken  that  the  paralyzed  muscles  are  not  exhausted 
by  too  much  rubbing  or  exercise.  Strychnine  may  be  given  in  moderate  doses 
three  times  a  day  for  several  weeks  at  a  time.  Fowler's  solution,  in  moderate 
dose,  is  also  useful  as  a  tonic.  Therapeutic  measures,  however,  cannot  promise 
much  in  this  disease. 

BULBAR  PARALYSIS. 

Bulbar  paralysis  is  a  term  applied  to  a  group  of  symptoms  referable  to  lesions 
of  cranial  nerve  nuclei  in  the  medulla  oblongata  or  "bulb,"  which  affect  the  tongue, 
lips,  and  larynx  in  peculiar  association,  so  that  the  condition  is  called  "glosso- 
labio-laryngeal  paralysis."  The  lesions  may  implicate  the  cranial  nerve  nuclei 
in  the  pons  and  crus,  and  the  gray  matter  of  the  spinal  cord,  but  atrophy  of  the 
tongue  and  lips  is  the  main  feature  of  the  disease  which  is  centred  in  the  medulla. 

Etiology. — The  cause  of  this  rare  disease  is  unknown.  It  occurs  most  frequently 
between  the  thirtieth  and  fiftieth  years. 

Pathology  and  Morbid  Anatomy. — The  lesions  of  this  malady  consist  in  degenera- 
tive changes  in  the  nuclei  of  the  motor  nerves  which  supply  the  tongue,  lips,  larynx, 
and  pharynx.  As  the  disease  advances,  additional  nuclei  of  the  cranial  nerves 
become  involved  so  that  the  pneiunogastric,  the  facial,  the  motor  fibres  of  the 
trifacial,  and  more  rarely  the  abducens  and  oculomotor  nerves  are  affected.  Occa- 
sionally, it  occurs  as  part  of  amyotrophic  lateral  sclerosis.  If  the  reader  has  a 
clear  conception  of  the  pathology  of  chronic  anterior  poliomyelitis  he  will  understand 
the  pathology  of  this  affection  as  well. 

Symptoms. — The  symptoms  of  chronic  bulbar  paralysis  usually  begin  with 
diffindty  in  moving  the  tongtie  in  speech  so  that  the  patient  is  unable  to  use  easily 
letters  like  v,  n,  r,f,  and  I.  The  speech  becomes  nasal,  swallowing  becomes  difficult, 
and  when  the  muscles  of  the  lips  become  affected  labial  sounds  become  imperfect, 
letters  like  b  and  p  being  difficult  to  pronounce.  When  the  laryngeal  muscles 
become  paralyzed  speech  is  lost  completely.  Cheiving  becomes  difficult,  owing  to 
the  paralysis  of  the  tongue  and  lips.  There  is  difficulty  in  swalloiving,  and  the  food 
not  infrequently  finds  its  way  into  the  larynx,  from  which  it  may  descend  and  cause 
septic  pneumonia.  Owing  to  the  paralysis  of  the  facial  nerves,  the  expression  of 
the  lower  portion  of  the  face  becomes  altered,  the  lips  sag,  and  saliva  may  flow  over 


830  DISEASES  OF  THE  NERVOUS  SYSTEM 

the  chin.  Fibrillary  mntrariions  of  the  afl'ected  muscles  also  occur,  and  the  tongue 
lies  relaxed  and  powerless  in  the  floor  of  the  mouth. 

Diagnosis. — True  bulbar  paralysis  must  be  separated  from  that  still  more  rare 
affection  known  as  myasthenia  gravis.  In  this  condition  the  general  muscular 
system  also  sufl'ers  from  feebleness,  but  degeneration  does  not  take  j)lace  in  the 
affected  muscles,  and  they  do  not  undergo  material  wasting.  Furthermore,  the 
condition  in  myasthenia  gravis  is  often  characterized  by  periods  of  remission  or 
partial  recovery.  Autopsy  in  those  cases  of  myastlienia  gravis  which  have  come  to 
a  fatal  termination  has  always  failed  to  reveal  the  lesions  which  have  been  described 
as  characteristic  of  true  bulbar  paralysis. 

Prognosis. — This  form  of  paralysis  is  invariably  fatal. 

Treatment. — The  treatment  of  bulbar  paralysis  consists  in  the  administration 
of  tonics,  and  in  an  endeavor  to  maintain  the  patient's  general  health  at  the  best 
possible  level.  Do  what  we  will,  the  disease  cannot  be  affected  by  any  ])lan  of 
treatment  yet  devised. 

LATERAL  SCLEROSIS. 

Definition. — Lateral  sclerosis,  also  called  "spastic  paraplegia,"  is  a  condition 
in  which  the  patient  suffers  from  stiffness  or  spasticity  of  the  muscles  of  the  lower 
extremities,  with  loss  of  power  which  ultimately  amounts  to  distinct  paralysis. 
The  condition  is  characterized  by  great  reflex  irritability.  There  are  no  sensory 
disturbances  nor  sphincteric  symptoms. 

History. — Tiirck  described  sclerosis  of  the  lateral  columns  of  the  cord  in  1856, 
and  Charcot  made  further  contributions  as  to  the  sjTnptoms  in  1805.  Seguin 
described  it  still  further  in  1873  as  "tetanoid  paraplegia,"  an  excellent  term,  but 
it  remained  for  Erb  in  1875  and  1877  to  make  a  full  exposition  of  the  disease. 

Etiology. — In  many  cases  the  cause  of  lateral  sclerosis  cannot  be  discovered. 
Syphilis  may  be  a  cause,  or,  to  speak  more  correctly,  the  malady  may  be  a  sequel 
of  syphilis.  In  some  instances  injuries  to  the  back  are  followed  by  these  symptoms. 
In  one  case  in  my  experience  a  horse  reared  and  fell  backward  on  his  rider,  who  at 
once  found  his  legs  paraplegic.  This  passed  away  in  a  few  moments,  but  after  a 
few  months  lateral  sclerosis  gradually  developed.  In  another  ca.se  under  my  care 
a  man  stood  in  very  cold  water  washing  sheep,  and  dated  the  beginning  of  his 
malady  to  that  exposure.  In  both  of  these  cases,  however,  it  is  quite  probable 
that  a  pachjineningitis  or  a  hemorrhage  into  the  cord  or  a  myelitis  was  the  cause 
of  the  symptoms  rather  than  a  true  primary  lateral  sclerosis.  In  other  cases 
prolonged  marches  have  seemed  to  produce  it.  It  is  a  disease  of  the  third  and  fourth 
decades  of  life.  In  some  instances  the  disease  seems  to  depend  upon  an  hereditary 
defect  in  the  lateral  columns  of  the  cord  (StriimpcH's  family  type  of  lateral  sclerosis). 

Pathology  and  Morbid  Anatomy. — The  lesions  of  lateral  sclerosis  are  clear  and 
definite.  As  the  name  of  the  disease  implies,  they  are  situated  in  the  lateral  or 
crossed  pyramidal  tracts  of  the  spinal  cord,  and  they  develop  chiefly  in  their  lower 
portions  in  the  early  stages  of  the  disease.  The  axones  progressively  atrophy 
from  below  upward,  and  this  is  associated  with  disappearance  of  the  myelin  and  an 
overgrowth  of  the  connective  tissue. 

When  the  disease  invades  the  cervical  region  the  anteromedian  colimins  of  the 
cord  may  be  afl'ected  as  well. 

Syro.ptoms. — In  studying  the  symi)toms  of  primary  lateral  sclerosis  it  must  not 
be  forgotten  that  they  may  be  simulated  by  secondary  lateral  sclerosis  following 
lesions  higher  up  in  the  cerebrospinal  system.  Thus,  it  is  a  well-known  fact  that  a 
large  number  of  lesions  in  the  brain  or  cord  may  result  in  degenerative  changes  in 
these  motor  pathways,  and  so  cause  spastic  paraplegia.  Those  in  the  brain  are 
hemorrhage,  abscess,  tumor,  and  softening,  which,  aiTecting  the  motor  cortex 
or  the  motor  pathways,  induce  a  descending  degeneration  in  the  pjTamidal  tracts. 


LATERAL  SCLEROSL'S  837 

In  these  cases  the  symptoms  are  usually  limited  to  one  side,  but  in  the  cerebral 
palsies  of  childhood  the  lesions  are  often  bilateral.  (See  Infantile  Cerebral  Palsy.) 
Any  lesion  in  the  spinal  cord  which  cuts  off  the  fibres  in  the  lateral  tracts  from 
their  trophic  cells  in  the  brain,  also  results  in  lateral  sclerosis.  Thus,  a  transverse 
myelitis,  disseminated  sclerosis,  hemorrhage  into  the  cord,  and  syringomyelia  may 
so  result.  Lateral  sclerosis  is  not  rarely  a  part  of  the  pathology  of  paresis.  Lesions 
outside  the  cord,  such  as  tumors,  disease  of  the  spinal  column,  or  thickening  of  the 
membranes  may  sometimes  cause  these  symptoms. 

The  symptoms  upon  which  we  base  the  diagnosis  of  lateral  sclerosis  are  the 
peculiar  spastic  contractions  of  the  muscles  of  the  legs,  so  that  they  are  in  a  state  of 
extension  as  soon  as  the  patient  attempts  to  move  them.  The  attitude  of  the  legs 
is  that  of  a  person  with  ankylosis  of  both  knees,  and  the  foot  is  apt  to  be  extended. 
When  the  patient  walks  he  has  difficulty  in  bending  the  knees  and  the  ankles,  and 
still  greater  difficulty  in  raising  the  toes  as  the  foot  is  brought  forward  for  another 
step.  For  this  reason  he  is  prone  to  trip  over  small  obstructions  and  to  have  bad 
falls,  because  his  muscles  are  so  stiff  that  he  cannot  catch  himself  as  he  loses  his 
balance.  The  stress  and  strain  of  walking  are  therefore  very  great,  and  the  muscles 
may  become  so  fatigued  that  they  ache,  but  this  is  the  only  sensory  symptom. 
Crossing  the  legs  when  sitting  becomes  impossible,  and  if  the  patient  is  recumbent 
the  knees  may  be  approximated  owing  to  the  greater  strength  of  the  adductor 
muscles.  This  adduction  of  the  knees  also  interferes  with  walking.  If  the  patient's 
muscles  are  grasped  they  are  found  to  be  hard  and  tense.  On  further  physical 
examination  it  will  be  found  that  the  reflexes  are  all  increased.  Ankle  clonus  is 
marked,  and  the  Babinski  reflex  is  soon  manifested.  The  reactions  of  degeneration 
do  not  appear  and  the  muscles  do  not  atrophy  until  the  disease  has  lasted  several 
years,  when  they  may  waste  from  disuse. 

Finally,  when  the  malady  has  continued  for  a  very  great  length  of  time  the 
position  of  the  lower  extremities  in  stiff  extension  may  be  changed  to  that  of  con- 
tracture so  that  they  are  sharply  flexed  at  the  knees  and  fixed  in  this  position. 

The  upper  extremities  nearly  always  escape,  but  in  the  rare  instances  in  which 
they  are  involved  the  extensor  muscles  suffer  first  and  suffer  most. 

Diagnosis. — As  already  pointed  out,  the  diagnosis  of  this  disease  should  not  be 
made  till  the  causes  capable  of  producing  secondary  lateral  sclerosis  are  excluded. 
Occasionally  hysteria  may  produce  sjTnptoms  very  like  it.  A  typical  picture  of 
such  a  case  will  be  found  in  my  book  on  Diagnosis  in  the  Office  and  at  the  Bedside. 
In  such  an  instance  the  sex  of  the  patient  and  the  other  signs  of  hysteria  should  be 
carefully  considered  before  a  diagnosis  of  lateral  sclerosis  is  made.  When  spastic 
paraplegia  is  combined  with  muscular  atrophy  the  condition  is  one  of  amyotrophic 
lateral  sclerosis  (which  see). 

Prognosis. — This  is  bad  as  to  recovery,  but  its  unfavorable  character  is  modified 
by  the  fact  that  the  progress  is  usually  very  slow.  Often  the  disease  lasts  twenty- 
five  years  or  more.  I  have  a  case  now  under  my  care  which  I  have  observed  for 
thirty  years. 

Treatment. — Unfortunately  the  results  which  may  be  obtained  from  the  treat- 
ment of  lateral  sclerosis  are  not  brilliant.  The  suggestion  that  nux  vomica  or 
strychnine  be  employed  does  not  seem  to  be  based  on  very  rational  views  of  the 
physiological  action  of  this  drug.  Excitation  of  the  motor  tracts  of  the  spinal 
cord  is  already  present,  and  strychnine  rather  tends  to  increase  this  condition 
and  to  exaggerate  the  spastic  condition  of  the  lower  extremities.  In  some  instances 
full  doses  of  the  extract  of  conium  are  advantageous.  In  others  large  doses  of 
chloral  or  one  of  the  bromides  may  be  employed.  The  gentle  forms  of  massage 
may  also  relieve  the  sensation  of  tension  and  aching  in  the  limbs.  Care  should 
be  taken  that  the  patient  does  not  walk  far  enough  to  exhaust  himself.  In  some 
instances  a  hot  pack  will  give  relief,  particularly  if  it  is  taken  at  bedtime,  although 


838  DISEASES  OF  THE  SERVOUS  SYSTEM 

of  course  it  exercises  no  curative  influence  upon  the  progress  of  tiie  disease.     Elec- 
tricity is  useless. 

Syphilitic  Spastic  Spinal  Paralysis. — Under  tlie  name  of  sypiiiiitic  si)iistic  spinal 
paralysis  Erl)  has  dcscrilied  a  form  of  lateral  sclerosis  developing  within  five  years 
of  the  i)riniary  sore,  but  differing  from  ordinary  lateral  sclerosis  by  the  presence  of 
some  lack  of  rectal  and  vesical  control  and  mild  disorders  of  sensation.  This 
so-called  syphilitic  spinal  spastic  paralysis  of  Erb  is  due  to  a  specific  endarteritis, 
which  produces  embolism  or  thrombosis  of  the  vessels  of  the  spinal  cord  and  a  true 
myelomalacia,  although  some  clinicians  have  considered  it  a  meningomyelitis. 

AMYOTROPHIC  LATERAL  SCLEROSIS. 

Definition. — Amyotrophic  lateral  sclerosis  is  a  progressive  form  of  chronic  spinal 
paralysis  characterized  by  advancing  musuclar  atrophy  associated  with  spastic 
paraplegia,  or,  in  other  words,  the  symptoms  of  lateral  sclerosis  are  present. 
Although  the  symptoms  are  largely  spinal,  modern  research  has  shown  that  the 
motor  pathway  is  aft'ected  throughout  in  advanced  cases,  from  the  beginning  of  its 
upper  segment  in  the  motor  cortex  to  the  endings  of  the  lower  segment  in  the 
peripheral  nerves.  The  cardinal  s.^Tnptoms  depend,  however,  upon  degeneration 
of  the  contiguous  parts  of  these  segments,  namely,  the  pyramidal  tracts  and  the 
anterior  horns  of  the  gray  matter;  and  the  disease  may  be  regarded  as  a  combination 
of  lateral  sclerosis  with  chronic  poliomyelitis.  Not  rarely  the  disease  invades  the 
medulla,  and  symptoms  of  progressive  bulbar  paralysis  are  added  to  the  clinical 
picture. 

Etiology. — Amyotrophic  lateral  sclerosis  is  usually  met  with  in  persons  between 
thirty  and  fifty  years  of  age.  In  some  instances  there  is  a  history  of  exposure  to 
cold  or  of  violent  exertion.  In  still  others,  it  is  found  that  the  patient  has  been  an 
artisan  employed  in  the  handling  of  such  metallic  poisons  as  mercury,  lead,  or 
arsenic,  or  that  he  has  been  addicted  to  the  excessive  use  of  alcohol.  In  some 
instances,  too,  the  disease  has  apparently  followed  severe  injuries,  but  in  no  instance 
has  it  been  proved  that  there  is  actual  relationship  between  any  of  these  causes 
and  the  development  of  the  disease.  In  all  probability,  these  factors  only  become 
active  in  those  cases  in  which  there  is  a  defective  development  in  the  central  nervous 
system,  which  renders  its  motor  elements  peculiarly  susceptible  to  damage  or 
disease. 

Pathology. — The  pathological  conditions  in  amyotrophic  lateral  sclerosis  may 
be  considered  in  three  parts.  The  first  and  most  important  is  the  advancing 
atrophy  which  involves  the  motor  neurones  in  the  anterior  horns  of  the  gray  matter 
of  the  spinal  cord.  Indeed,  the  condition  is  very  similar  to  that  which  occurs  in 
chronic  anterior  poliomyelitis  or  even  identical  with  it.  As  a  rule,  the  alterations 
take  place  chiefly  in  the  cervical  portions  of  the  cord,  but  in  some  instances,  par- 
ticularly if  the  disease  lasts  a  long  time,  the  anterior  portion  of  the  gray  matter 
in  the  lumbar  region  is  also  aft'ected.  Similar  atrophic  changes  take  place  in  the 
motor  nuclei  of  the  cranial  nerves  in  the  pons  and  medulla.  Next  in  importance 
to  these  alterations  in  the  trophic  portions  of  the  spinal  cord  is  the  atrophy  and 
degeneration  of  the  fibres  in  the  lateral  columns  and  the  anterior  median  columns. 
These  changes  extend  to  the  motor  cells  of  the  brain  and  are  not  limited  to  the 
lateral  columns,  the  cortex  being  involved  secondarily  by  "  retrograde"  degeneration 
from  the  cord  and  medulla  upward  througli  tlie  pons,  crura,  capsule,  and  corona 
radiata.  In  other  words,  the  degeneration  does  not  begin  in  the  motor  cortex, 
but  in  the  spinal  cord.  Following  the  wasting  of  the  nervous  elements  of  the  spinal 
cord,  there  is  an  overgrowth  of  connective  tissue  which  not  only  involves  the  lateral 
columns  and  the  anterior  median  columns,  but  also  the  association  fibres  wlnfh  are 
closely  connected  with  the  anterior  horns  of  the  gray  matter. 


AMYOTROPHIC  LATERAL  SCLEROSIS  839 

Symptoms. — The  symptoms  of  amyotrophic  lateral  sclerosis  are  quite  character- 
istic, and  depend  in  their  development  to  some  extent  upon  the  portion  of  the 
nervous  system  which  is  first  affected  by  the  disease.  In  tho.se  instances  in  which  the 
lesion  first  affects  the  cervical  portion  of  the  cord  and  the  anterior  horns  of  the  gray 
matter  the  arms  are  first  affected.  These  extremities  manifest  some  stiffness  in 
the  muscles,  and  their  reflex  excitability  is  increased.  Almost  simultaneously  with 
these  symptoms  there  is  toasting  of  the  muscles  of  one  or  both  hands,  with  associated 
loss  of  power.  From  the  hand  the  paralysis  extends  to  the  forearms,  or  it  passes 
directly  to  the  muscles  of  the  shoulder  and  affects  those  of  the  forearms  afterward. 
Fibrillary  contractions  develop  very  early,  occur  spontaneously,  and  may  be  pro- 
duced by  tapping  the  muscles  or  by  exposing  them  to  cold.  The  fingers  are  often 
in  semi-flexion,  and  if  the  physician  endeavors  to  straighten  them,  it  is  found  that 
the  muscles  are  rigid  and  resistant,  even  though  the  patient  has  lost  power  in 
them. 

When  the  disease  develops  chiefly  in  the  pyramidal  tracts  of  the  motor  columns 
of  the  cord,  the  evidences  of  spastic  paralysis  are  the  first  things  to  impress  them- 
selves upon  the  observer,  and  it  may  be  impossible  in  the  early  stages  of  the  disease 
to  separate  the  malady  from  ordinary  lateral  sclerosis,  since  the  legs  are  stiff  and 
move  with  difficulty,  the  knee-jerks  are  exaggerated,  and  ankle  clonus  and  the  Babin- 
ski  reflex  are  usually  present.  When  the  patient  walks  the  toe  is  dragged  along 
the  ground,  the  whole  leg  is  stiff,  and  one  foot  is  often  placed  awkwardly  in  front 
of  the  other,  through  the  contraction  of  the  adductor  muscles.  By  far  the  most 
common  clinical  picture  is  for  the  wasting  to  be  confined  to  the  upper  extremities, 
and  the  spasticity  to  be  manifest  chiefly  in  the  lower  extremities. 

Whether  the  disease  first  begins  in  the  arms  or  in  the  legs,  it  is  worthy  of  remem- 
brance that  it  is  often  very  much  more  marked  upon  one  side  than  upon  the  other. 

As  the  disease  advances  it  sometimes  happens  that  evidences  of  bulbar  paralysis 
develop,  the  speech  becoming  affected,  as  in  ordinary  bulbar  paralysis.  Sivallowing 
may  also  become  difficult.  Owing  to  paralysis  of  the  uvula  and  palate,  choking 
often  takes  place,  and  fluids  when  taken  into  the  mouth  escape  through  the  nose. 
Indeed,  all  the  symptoms  of  bulbar  paralysis  may  be  present,  and  inequality  of  the 
pupils  may  be  noted.  When  contractures  occur  the  hands  may  become  greatly 
deformed,  and  the  feet  may  be  distorted  into  any  of  the  forms  of  talipes. 

In  the  advanced  forms  of  the  disease  the  muscles  of  the  trunk  and  neck  become 
atrophied,  so  that  it  is  impossible  for  the  patient  to  sit  up,  and  the  head  falls  to 
either  side  or  forward.  The  muscles  develop  the  reactions  of  degeneration  and  lose 
their  electrical  excitability.  There  is  no  loss  of  intelligence,  but  sometimes  in 
advanced  cases  a  mild  dementia  appears.  When  the  bulbar  symptoms  are  marked, 
palpitation  of  the  heart  is  often  present. 

Diagnosis. — From  bulbar  paralysis  amyotrophic  lateral  sclerosis  is  separated 
by  the  fact  that  lateral  sclerosis  presents  marked  spinal  sj-mptoms  with  paralysis 
of  the  upper  extremities  and  spastic  paraplegia  of  the  lower  extremities.  If  in  a 
case  of  supposed  bulbar  paralysis  these  symptoms  develop  later  it  proves  that  the 
bulbar  palsy  has  been  due  to  the  oncoming  of  amyotrophic  lateral  sclerosis.  If  the 
sjinptoms  are  due  to  the  presence  of  a  meningitis  in  the  cervical  portion  of  the  cord, 
there  is  stiffness  and  loss  of  power  in  the  arms,  and  there  will  also  be  pain  of  a 
severe  character.  So,  too,  injury  or  pressure  upon  the  spinal  cord  in  the  dorsal 
and  lumbar  regions,  producing  a  spastic  paraplegia,  will  also  produce  sensory 
disturbances  and  involve  the  functions  of  the  bladder  and  rectum. 

From  syringomyelia  amyotrophic  lateral  sclerosis  is  separated  by  the  presence 
in  the  former  of  analgesia  and  the  rapid  trophic  changes  which  take  place  not 
only  in  the  muscles,  but  in  the  bones,  the  skin,  and  its  appendanges.  In  many 
instances  it  is  almost  impossible  to  differentiate  between  amyotrophic  lateral 
sclerosis  and  ordinary  lateral  sclerosis,  and  it  is  only  by  the  development  of  the 


840  DISEASES  OF  THE  NERVOUS  SYSTEM 

symptoms  which  arise  from  involvement  of  the  gray  matter  of  the  cervical  jjortion 
of  the  spinal  cord  and  the  medulla  that  the  separation  can  he  made. 

Prognosis. — The  prognosis  in  a  case  of  amyotrophic  lateral  sclerosis  is  absolutely 
unfavorable  so  far  as  recovery  is  concerned.  The  duration  of  life  depends  upon 
the  rapidity  with  which  the  vital  centres  in  the  medulla  become  involved.  In 
some  instances  death  comes  within  two  years  after  the  onset  of  the  malady,  whereas 
in  others  it  lasts  for  a  decade  or  even  longer.  The  prolonged  cases  are  usually 
those  in  which  the  involvement  of  the  lateral  columns  seems  to  be  the  first  stage 
of  the  disease.  As  a  rule,  death  does  not  occur  as  the  direct  result  of  the  disease, 
but  from  complications  which  are  produced  by  it;  as,  for  example,  the  inhalation 
of  partciles  of  food  into  the  respiratory  passages  because  of  the  bulbar  paralysis. 
Rarely  there  is  heart  failure  due  to  involvement  of  the  cardiac  centres. 

Treatment. — There  is  no  form' of  treatment  which  can  be  considered  curative. 
Gentle  massage  and  the  use  of  electricity,  with  the  hope  that  the  wasting  of  the 
muscles  may  be  diminished,  has  been  tried  by  some  clinicians,  but  it  is  manifest 
that  this  plan  of  treatment  must  be  used  with  great  caution,  since  if  the  trophic 
centres  are  destroyed,  the  muscles  must  necessarily  undergo  wasting  more  rapidly 
if  they  are  exercised  than  if  they  are  not  used.  If  bulbar  sjinptoms  are  present 
the  patient  should  be  fed  by  means  of  a  stomach-tube.  The  cmploj-ment  of 
nervous  stimulants,  such  as  strychnine,  is  inadvisable,  because  it  exaggerates  the 
spastic  condition  of  the  lower  extremities. 

MYELITIS. 

Definition. — Myelitis  is  a  term  which  at  one  time  was  loosely  applied  to  all 
inflammatory  processes  in  the  spinal  cord.  Its  application  is  becoming  limited  as 
our  conception  of  the  diseases  in  this  part  of  the  body  becomes  more  definite,  but 
it  is  still  used  to  describe  an  inflammatory  process  in  the  cord,  which  is  general 
or  widely  diffused  or  disseminated.  A  myelitis  may  be  acute,  subacute,  or  chronic. 
If  it  extends  across  a  given  segment  of  the  cord  it  is  called  a  "transverse  myelitis;" 
if  it  is  distributed  in  several  foci  through  the  cord,  it  is  called  "disseminated  mye- 
litis," and  if  it  extends  upward  or  downward,  it  is  called  an  "  ascending  or  descending 
myelitis." 

The  term  "acute  myelitis"  is  applied  to  those  cases  of  sudden  onset  taking  but 
a  fortnight  to  develop.  The  term  subacute  is  applied  to  those  which  consume  from 
two  to  six  weeks  in  onset,  and  the  term  chronic  to  those  which  develop  so  slowly 
that  a  longer  time  elapses  before  the  disease  is  marked. 

When  the  gray  matter  of  the  spinal  cord  is  affected,  it  is  called  "poliomyelitis," 
from  the  Greek  word  ~o/.!u:,  meaning  gray. 

When  the  brain  and  cord  are  involved  it  is  called  "encephalomyelitis,"  and 
when  the  gray  matter  about  the  central  canal  in  the  cord  is  affected  it  is  called 
a  "central  myelitis." 

Acute  and  Subacute  Myelitis. — Etiology. — The  chief  cause  of  this  condition 
is  without  doubt  an  intoxication,  due  to  the  action  of  toxins  devclojjed  during  the 
course  of  acute  infectious  diseases.  At  one  time  it  was  thought  that  exposure, 
sexual  excess,  and  severe  toil  were  causes,  but  we  now  know  that  at  the  most  they 
are  but  predisposing  factors  in  that  they  diminish  vital  resistance.  In  addition 
to  the  ordinary  infectious  fevers,  myelitis  may  be  caused  by  gonorrhea  and  malaria. 
Occasionally  severe  vesical  infection  produces  acute  myelitis.  JNIyelitis  has  also 
been  said  to  follow  concussion  of  the  spine  and  other  injuries,  but  they  probably 
act  solely  as  predisposing  agencies. 

Pathology  and  Morbid  Anatomy. — If  we  take  transverse  myelitis  as  a  type  of 
the  various  forms  of  this  disease,  we  will  find  on  opening  the  spinal  cord  that  the 
pia  mater  at  the  level  of  the  lesion  is  hypercmic  and  reddened.     The  cord  is  also 


MYELITIS  841 

reddened  and  somewhat  swollen,  and  its  bloodvessels  engorged.  On  section  of 
the  cord  the  lines  of  demarcation  between  the  white  and  gray  matter  arc  to  a  great 
degree  obliterated.  The  cord  is  softened  and  its  texture  may  be  actually  diffluent, 
this  very  soft  state  being,  however,  at  least  in  part  a  postmortem  change.  If  this 
part  of  the  cord  is  placed  under  the  microscope  it  is  seen  to  be  filled  with  granular 
cells,  the  bloodvessels  are  surrounded  by  extravasatcd  leukocytes,  and  bacteria 
may  be  found.  Small  extravasations  of  blood  into  the  tissue  of  the  cord  may  be 
present  from  rupture  of  the  vessels.  The  nerve  cells  are  found  to  have  undergone 
granular  degeneration,  and  their  axones  and  dendrites  have  also  been  destroyed. 
The  axis  cylinder  of  the  nerve  fibres  is  greatly  swollen  and  has  evidently  undergone 
segmentation.  Fatty  degeneration  of  the  myelin  is  found.  The  connective-tissue 
cells  are  swollen,  and  if  any  time  has  elapsed,  an  overgrowth  of  the  neuroglia  is 
present. 

For  a  clear  understanding  of  the  cause  of  the  symptoms  met  with  in  acute  myelitis, 
myelomalacia,  and  chronic  myelitis  it  must  be  remembered  that  the  presence  of  a 
lesion  in  the  spinal  cord  in  the  motor  tracts  produces  a  descending  degeneration 
in  that  tract,  because  the  nerve  fibre  is  cut  off  from  its  nerve  cell  or  neurone.  If 
the  lesion  be  in  the  sensory  tracts  the  degeneration  is  ascending.  The  ultunate 
symptoms,  therefore,  consist  not  only  in  those  which  arise  from  the  primary  focus 
or  lesion,  but  in  those  which  develop  as  the  result  of  those  secondary  changes. 
These  changes  are  demonstrable  within  a  few  days  after  the  injury,  and  rapidly 
progress  so  that  at  the  end  of  three  weeks  the  degeneration  of  the  affected  fibres 
is  at  its  height.  The  overgrowth  of  the  connective  tissue  is  not  marked  until  a 
later  period.  Thus,  we  find  that  the  chief  degenerative  change  below  the  lesion 
is  in  the  anterior  and  lateral  pyramidal  tracts,  and  above  the  lesion  in  the  dorsal 
columns  of  Goll  and  Burdach,  in  the  direct  cerebellar  tracts,  and  in  the  colmnns  of 
Gowers.  In  addition  to  these  chief  secondary  changes,  there  is  also,  for  a  short 
distance  below  the  primary  lesion,  descending  degeneration  in  the  anterior  and 
anterolateral  columns,  and  in  certain  small  "fields"  of  the  dorsal  columns  (oval 
field  of  Flechsig,  etc.),  which  contain  the  so-called  association  fibres. 

The  ascending  degeneration  which  takes  place  after  a  transverse  lesion  affects 
chiefly  Goll's  and  Gowers'  columns,  and  the  higher  the  primary  lesion  the  greater 
the  degree  of  the  degenerative  process.  The  cohunn  of  Burdach,  on  the  other 
hand,  while  markedly  degenerated  near  the  site  of  the  lesion,  is  less  and  less  affected 
higher  up  in  the  cord. 

Symptoms. — ^The  symptoms  of  myelitis  vary  somewhat  with  the  portion  of  the 
cord  which  is  afl^ected  and  with  the  extent  of  the  pathological  process. 

When  there  is  a  transverse  myelitis  of  the  dorsal  portion  of  the  spinal  cord  the 
symptoms  on  the  stage  of  onset  consist  in  wretchedness  and  moderate  fever.  There 
may  be  fain  in  the  hack  and  mimbness  and  tingling  in  the  lotver  extremities.  Twitch- 
ings  or  cramp-like  contractions  of  the  muscles  in  the  legs  may  occur,  and,  very  rarely 
in  adults,  a  convulsion  may  develop.  Sometimes,  however,  these  prodromata 
are  absent,  and  the  first  sjonptom  complained  of  is  loss  of  power  in  the  loiver  limbs, 
which  speedily  develops  into  a  coviplete  paraplegia.  Paraplegia  may  become 
complete  in  a  few  minutes  or  a  few  hours.  In  other  instances  of  the  subacute 
type  the  onset  is  so  slow  that  days  and  even  weeks  may  elapse  before  the  loss  of 
power  is  complete. 

The  paraplegia  arising  from  a  transverse  myelitis  in  the  dorsal  region  is  usually 
spastic,  and  the  deep  reflexes  are  increased.  The  legs  are  outstretched,  as  in  ordinary 
paraplegia,  unless  degenerative  or  irritative  lesions  arise  in  the  lateral  pyramidal 
tracts  below  the  site  of  the  transverse  lesion,  when  they  may  become  flexed  by  the 
spastic  state  of  the  muscles  of  the  thighs.  In  other  instances  these  muscles  suffer 
from  twitchings  and  temporary  contractions,  which  may  be  strong  enough  to  prevent 
the  examiner  from  eliciting  any  signs  of  exaggeration  of  the  deep  reflexes.     There 


842  DISEASES  OF  THE  NERVOUS  SYSTEM 

is  always  paralysw  of  the  bladder  and  rectum  in  transverse  myelitis,  and  retention 
or  incontinence  of  urine  and  feces  may  be  present.  Partly  because  of  j)ressiire  and 
unavoidable  uncleanliness,  but  chiefly  because  of  trophic  disorders  and  abnormal 
blood  supi)ly,  bed-sores  are  prone  to  develop  on  the  sacrum  and  buttocks.  The 
muscles  in  the  legs  do  not  rapidly  atrophy,  because  they  receive  tro])liic  impulses 
from  the  cells  in  the  anterior  cornua  of  a  lower  level  of  the  cord  than  that  of  the 
lesions.  The  skin  of  the  legs  and  of  the  body  below  the  level  of  tlie  lesion  is  anesthetic 
to  all  forms  of  irritation,  and  at  the  upper  margin  of  this  anesthetic  area  there  is  a 
girdle  sensation,  and,  it  may  be,  a  band  of  liyperestliesia. 

When  the  myelitis  affects  the  liimhar  cord  the  paraplegia  is  not  only  absolute 
as  to  voluntary  movement,  but  as  to  reflex  action  as  well,  all  reflexes  being  lost. 
A  similar  condition  also  occurs  in  some  cases  when  the  injury  is  at  a  higher  level, 
provided  that  the  cord  is  completely  severed  or  the  injury  so  severe  that  severance 
is  practically  complete. 

If  the  lesion  is  in  the  cervical  cord  the  arms  are  not  only  paralyzed,  but  undergo 
atrophy  and  are  flaccid,  the  legs  suffer  from  a  spaMic  paraplegia,  and  the  arms, 
legs,  and  body  are  anesthetic.  There  may  also  be  dilatation  or  contraction  of  the 
pupils.  If  the  lesion  is  high  up  in  the  cervical  area,  then  the  parcdysis  of  the  arms 
may  be  spastic  instead  of  flaccid,  and  they  do  not  undergo  atrophy.  In  such  a 
case  respiration  is  very  difficult,  because  of  the  loss  of  power  in  the  diapliragm  and 
in  the  other  respiratory  muscles. 

Prognosis. — While  it  is  a  fact  that  the  prognosis  in  transverse  myelitis  is  always 
grave,  it  is  also  a  fact  that  partial  recovery  sometimes  takes  place.  Thus, 
Oppenheim  states  that  that  form  following  gonorrhea  always  gets  better  under  good 
treatment,  and  that  that  form  due  to  the  acute  infectious  fevers  has  good  chances 
for  recovery.  On  the  other  hand  the  outlook  in  syphilitic  cases  is  not  good,  and 
in  septicemia,  tuberculosis,  or  puerperal  sepsis  it  is  bad.  Again,  the  prognosis 
varies  with  the  severity  of  the  sj'mptoms  and  the  lesion,  for  manifestly  it  must  be 
worse  in  complete  transverse  myelitis  than  in  that  form  in  which  the  destruction 
of  the  cord  is  not  so  complete.  The  cause  of  death  is  usually  bed-sores,  with 
exhaustion  and  septic  cystitis. 

Treatment. — An  understanding  of  the  lesions  of  this  disease  makes  it  evident 
that  treatment  of  a  curative  nature  is  useless.  Careful  feeding  with  easily  digested 
food,  the  maintenance  of  perfect  cleanliness  in  the  parts  pressed  upon  in  the  dorsal 
position,  and  the  cautious  use  of  the  catheter  should  be  resorted  to.  Ilyoscine 
may  be  given  to  stop  the  annoying  twitcliings  of  the  muscles. 

Chronic  Myelitis. — Definition  and  Etiology. — C'lironic  myelitis  is,  as  its  name 
implies,  a  chronic  form  of  inflammatory  process  in  the  cord  which  develops  as  a 
result  of  a  large  number  of  causes.  Not  only  may  the  causes  of  acute  myelitis 
set  up  a  process  which  may  become  slow  and  chronic  in  its  progression,  but  other 
factors  may  produce  it,  of  which  the  most  important  are  impairment  of  its  blood 
supply  resulting  from  degenerative  changes  in  the  bloodvessels  from  atheroma  or 
syphilitic  arteritis.  Chronic  myelitis  may  also  arise  as  a  result  of  pernicious  anemia. 
In  some  cases,  too,  the  primary  cause  lies  in  a  meningitis  of  the  membninc  surround- 
ing the  cord,  whether  this  meningitis  be  due  to  an  infection  or  to  injury  followed 
by  infection.  When  syphilis  is  the  cause,  it  not  rarely  happens  tliat  the  inflam- 
matory process  is  limited  to  one  or  more  parts  of  the  spinal  cord,  so  that  the  symp- 
toms of  spastic  paraplegia  due  to  disease  of  the  lateral  pyramidal  tracts  develops, 
or  in  other  instances  the  sjTuptoms  of  locomotor  ataxia  are  present,  because  the 
posterior  tracts  in  the  cord  are  aft'ected.  Rarely  but  one  side  of  the  cord  may  be 
affected,  producing  a  crossed  paralysis  of  motion  and  sensation  (Brown-Sequard 
syndrome) . 

Finally,  the  physician  must  recall  the  fact  that  most  of  the  forms  of  chronic 
disease  of  the  spinal  cord,  such  as  disseminated  sclerosis,  amyotropliic  lateral 


MYELITIS  843 

sclerosis,  and  the  various  forms  of  poliomyelitis,  may,  in  their  advanced  stages, 
resemble  what  has  been  called  chronic  myelitis.  Indeed,  it  is  so  rare  to  meet 
with  a  case  of  chronic  myelitis  which  cannot  be  placed  under  one  of  these  headings 
that  many  neurologists  are  inclined  to  deny  the  existence  of  chronic  myelitis  as  a 
separate  malady.     (See  below.) 

Pathology  and  Morbid  Anatomy. — ^The  changes  in  the  spinal  cord  which  are  found 
in  cases  of  so-called  chronic  myelitis  are  not  so  manifest  as  in  the  acute  form  when 
the  cord  is  studied  by  the  naked  eye.  In  one  class  of  cases  the  appearance  is 
quite  like  that  of  disseminated  sclerosis  in  that  areas  of  overgrowth  of  connective 
tissue  are  found  in  both  the  white  and  gray  matter  of  the  cord.  This  overgrowth 
of  the  neuroglia  is  situated  chiefly  around  the  bloodvessels,  the  walls  of  which  are 
also  thickened  and  their  lumen  narrowed.  When  as  a  result  of  the  degenerative 
process  an  axis  cylinder  has  become  distended  or  swollen,  a  small  cavity  is  formed, 
and  if  many  of  these  are  present  they  may  give  the  section  of  the  cord  a  cribriform 
appearance.    The  pia  mater  is  often  found  adherent  to  the  cord. 

In  the  other  type  of  case  a  microscopic  study  of  the  cord  reveals  changes  which 
are  evidently  the  result  of  the  several  diseases  of  the  cord  already  named,  and 
which  are  really  the  cause  of  the  symptoms  presented  by  the  patient  rather  than 
that  a  true  primary  chronic  myelitis  has  been  present.  Thus,  it  is  found  that  as  a 
result  of  a  lesion  in  the  pyramidal  tracts,  a  descending  degeneration  of  the  fibres 
in  that  tract  takes  place,  or  if  the  lesion  has  been  in  the  posterior  columns,  an 
ascending  degeneration  ensues. 

Symptoms. — When  the  condition  of  chronic  myelitis  follows  acute  myelitis, 
symptoms  of  that  state  persist  with  gradually  increasing  severity  until  death  by 
exhaustion  or  some  intercurrent  malady  ensues.  If,  however,  the  process  is  of  the 
slow  or  chronic  type  from  the  time  of  onset,  the  primary  feeling  of  'weariness  and 
weakness  on  exertion  passes  gradually  into  a  state  of  paralysis,  more  or  less  complete. 
Owing  to  the  degenerative  changes  in  the  lateral  tracts,  the  paralysis  is  usually 
spastic.  There  is  often  an  exaggeration  of  the  deep  reflexes,  with  aiilde  clonus  and 
Babinski's  sign.  In  other  instances  the  character  of  the  response  to  reflex  stunula- 
tion  is  entirely  dependent  upon  the  portion  of  the  cord  which  is  involved.  The 
muscles  may  gradually  waste  and  give  the  reactions  of  degeneration.  Not  rarely 
the  loss  of  power  extends  gradually  to  the  trunk  and  arms.  Sensory  disturbances 
are  common.  There  may  be  patches  of  anesthesia  and  paresthesia,  and  occasionally 
moderately  severe  pains  may  be  felt  in  the  nerves  in  the  extremities.  Vasomotor 
disorders  in  localized  areas  of  the  skin  may  be  present,  one  part  being  very  paUid 
and  another  hyperemic.  Bed-sores  finally  develop,  as  in  the  acute  form  of  the 
disease. 

Diagnosis. — Chronic  myelitis  as  a  separate  disease  is  so  rare  that  a  diagnosis 
of  its  presence  should  be  made  only  after  a  most  careful  study  of  a  case.  From 
disseminated  sclerosis  it  is  separated  by  the  absence  of  evidence  of  lesions  in  the 
brain  and  lower  cephalic  centres,  such  as  nystagmus,  intention  tremor,  optic 
atrophy,  and  scanning  speech.  From  lateral  sclerosis  it  is  separated  by  the  absence 
of  vesical  and  rectal  paralysis  in  that  disease.  Then,  too,  lateral  sclerosis  is  not 
characterized  by  loss  of  sensation.  Paralysis  due  to  poliomyelitis  is  separated 
also  by  the  absence  of  anesthesia,  and  the  fact  that  the  paralysis  of  the  muscles 
is  not,  as  a  rule,  so  general. 

Prognosis. — Recovery  does  not  occur.  Life  may  be  prolonged  for  years  if  the 
process  is  not  progressive  and  no  intercurrent  disease  attacks  the  enfeebled  sufferer. 

Treatment. — This  is,  of  course,  concerned  entirely  with  the  maintenance  of 
good  health,  with  the  hope  that  a  terminal  infection  may  not  occur.  If  there  is  a 
clear  history  of  syphilis,  salvarsan,  the  iodides  and  mercury  may  be  used,  but 
they  are  rarely  of  much  value  in  this  state. 


844  DISEASES  OF  THE  NERVOUS  SYSTEM 

SENILE  PARAPLEGIA. 

Under  this  unsatisfactory  clinical  title  may  he  described  a  condition  occasionally 
met  with  in  old  persons,  and  probably  depending  upon  impaired  blood  sujjply  to 
the  cord,  resulting  from  degenerative  changes  in  the  vessels  which  arc  not  severe 
enough  to  result  in  myelomalacia. 

Symptoms. — The  symptoms  consist  in  a  moderate  degree  of  loss  of  power  in  the 
loxoer  livihs  so  that  it  is  difficult  for  the  patient  to  move  about.  The  legs  may  be 
shufjled  along  the  floor  instead  of  lifted  clear  of  it.  There  is  sometimes  an  associated 
weakness  of  the  sphincters,  especially  of  the  bladder,  and  minor  sensory  changes 
have  sometimes  been  noted.  When  the  maladj'  develops  rapidly  and  is  severe  it 
may  be  impossible  for  a  time  to  separate  it  from  true  myelitis. 

Treatment. — The  treatment  consists  in  rest  in  bed,  massage,  and  hydrotherapy. 
Internally,  the  iodides  and  circulatory  stimulants,  such  as  strychnine  and  digitalis, 
should  be  used. 

MYELOMALACIA. 

This  term  is  applied  to  a  state  of  the  spinal  cord  in  which  it  undergoes  softening 
because  of  embolism  or  thrombosis  of  its  bloodvessels,  with  the  result  that  its 
blood  supply  is  impaired.  The  degenerative  changes  consist  in  those  which  we 
would  expect  to  find  when  necrosis  of  these  parts  occurs,  namely,  e.\tra\-asated 
red  and  white  blood  cells,  fat-globules,  and  broken  axones.  When  the  patient 
lives  for  a  considerable  length  of  time  after  this  accident  to  the  circulation  occurs, 
a  microscopic  examination  of  the  cord  will  reveal  an  overgrowth  of  connective 
tissue.  The  essential  difference  between  this  state  and  one  of  acute  myelitis  is 
that  in  this  condition  the  process  is  necrotic;  whereas,  in  the  latter  it  is  primarily 
inflammatory,  and  diapedesis  of  white  and  red  cells  takes  place  as  a  part  of  a  vital 
process. 

SYRINGOMYELIA. 

Definition. — Syringomyelia  is  a  condition  of  the  spinal  cord  characterized  by  the 
formation  of  a  cavity  or  cavities  in  its  substance;  by  loss  of  pain  sense  and  tempera- 
ture sense,  with  preservation  of  tactile  sense;  by  the  development  of  progressive 
muscular  atrophy  and  paralysis,  and  by  nutritional  changes  in  the  skin,  muscles, 
bones,  and  joints. 

History. — ^Although  a  very  rare  disease,  it  was  described  before  many  other 
very  common  maladies,  the  state  of  the  spinal  cord  having  been  first  noted  in 
1546  by  Etienne  and  given  its  name  by  Ollivier  in  1824.  We  are,  however,  able 
to  diagnosticate  the  affection  by  reason  of  researches  of  Schultze  and  other  later 
investigators. 

Etiology. — This  is  unknown.  In  some  cases  it  is  probably  dependent  upon  a 
congenital  defect.  In  other  instances  it  has  been  thought  to  be  due  to  disease  of 
the  spinal  arteries,  and  in  some  cases  Van  Gieson  has  shown  that  it  has  developed 
from  a  perforating  hemorrhage  into  the  cord  itself.  Westphal,  Oppenheim  and 
others,  believe  that  trauma  plays  an  important  role  in  the  development  of  syringo- 
myelia. 

Pathology  and  Morbid  Anatomy. — When  the  spinal  cord  in  a  case  of  syringomyelia 
is  examined  macroscopically,  the  membranes  are  found  to  be  normal,  but  the 
surface  of  the  cord  may  be  irregular  and  portions  of  it  protrude,  while  at  other 
places  retraction  of  its  surface  seems  to  be  present.  A  closer  examination  of  the 
areas  of  bulging  may  reveal  fluctuation,  and  from  such  areas,  if  they  be  piuictured, 
a  clear  serous  fluid  may  run  quite  freely.  This  cystic  state  may  extend  ^•e^y 
considerable  distances  up  and  down  the  cord,  and  may  extend  so  far  transversely 
as  almost  to  cut  the  cord  in  two.     The  cavity  is  usually  largest  in  the  cer\ical  and 


SYRINGOMYELIA  845 

upper  dorsal  regions  of  the  cord,  but  it  may  be  confined  to  the  lower  part  of  the 
cord.  On  the  other  hand,  as  just  stated,  it  may  extend  from  tlic  end  of  the  cord 
even  to  the  pons.  The  cavity  may  have  large  dimensions  as  to  length  and  be  so 
wide  as  to  convert  the  cord  into  a  thin-walled  tube. 

It  is  because  of  these  extraordinary  changes  that  the  Greek  words  syrinx,  a 
tube,  and  myelon,  marrow  of  the  spine,  are  applied  to  it.  So  complete  may  be  the 
excavating  process  that  when  the  cord  is  severed  from  the  medulla  the  fluid  may 
escape  and  the  cord  flatten  out  like  a  ribbon.  In  some  cases  there  are  several 
cavities  superimposed.  On  cross-section  the  cavity  is  usually  found  to  be  just 
back  of  the  central  canal  in  the  gray  commissure  and  in  the  posterior  cornua,  or 
it  may  be  present  where  the  central  canal  should  be.  Occasionally  it  affects  the 
anterior  horns  or  the  lateral  or  posterior  white  columns. 

The  wall  of  the  cavity  consists  in  a  well-developed  mass  of  neuroglia  (gliomatosis) , 
which  in  its  growth  encroaches  upon  surrounding  tissues  and  may  cause  definite 
symptoms  before  its  centre  becomes  broken  down.  Some  neurologists,  on  that 
account,  prefer  to  call  this  disease,  at  least  in  its  earliest  stages,  spinal  ghomatosis, 
or  ghosis. 

The  loss  of  pain  sense  and  temperature  sense  which  is  so  characteristic  has  been 
ascribed  to  pressure  by  the  neuroglia  mass  upon  the  fibres  conducting  these  sensa- 
tions as  they  cross  in  the  central  gray  matter  on  their  way  to  the  lateral  region  of 
the  cord.     This  is  at  least  a  good  working  hypothesis. 

Around  the  margin  of  the  connective-tissue  boundary  just  described  there  is 
usually  an  abnormal  development  of  bloodvessels  which  are  numerous,  distorted, 
and  larger  than  normal. 

Dilatation  of  the  central  canal  by  serous  fluid  is  called  hydromyelia,  and  is 
ordinarily  associated  with  hydrocephalus. 

Symptoms. — The  symptoms  of  syringomyelia  consist  in  loss  of  pain  sense  and 
of  temperature  sense,  so  that  the  patient  may  be  cut  or  burnt  without  feeling  pain, 
although  his  sense  of  touch  in  the  affected  part  is  still  preserved.  In  some  cases 
the  temperature  sense  may  be  preserved,  or  the  sense  of  heat  is  lost  and  that  of 
cold  preserved,  or  vice  versa.  The  areas  in  which  the  loss  of  pain  sense  exists  are 
not  symmetrical,  but  are  irregularly  distributed  over  the  body.  The  fact  that 
the  lesion  usually  affects  the  cerA-ical  portion  of  the  cord  explains  why  it  is  that  the 
areas  of  analgesia  are  usually  found  in  the  upper  extremities.  Associated  with 
this  impairment  of  pain  sense  there  develop,  as  the  disease  advances,  nutritional 
changes  in  the  bones,  muscles,  and  skin,  and  a  progressive  paralysis  due  to  the 
muscle  changes. 

The  outward  evidences  of  trophic  disturbance  are  usually  first  noticed  in  connec- 
tion with  some  injury  which  fails  to  heal  and,  becoming  infected,  forces  a  recognition 
of  its  presence  upon  the  patient,  not  by  pain,  but  by  his  observation  with  his  eyes 
that  healing  does  not  take  place.  In  some  instances,  however,  nutritional  changes 
occur  without  any  history  of  injury.  Felons  may  develop.  When  they  are  accom- 
panied by  severe  necrosis  the  condition  is  usually  called  "Morvan's  disease." 
In  still  other  cases  the  finger-nails  become  deformed,  or  superficial  gangrene  of  the 
skin  develops.  The  shoulder-,  elboiv-,  and  wrist-joints  become  swollen,  filled  with 
fluid,  and  absorption  of  the  articulating  surfaces  takes  place,  the  condition  in  the 
upper  extremities  in  this  disease  being  practically  identical  with  that  seen  in  the 
joints  of  the  lower  extremities  in  certain  cases  of  locomotor  ataxia. 

The  shafts  of  the  long  bones  often  suffer  fracture,  but  these  fractures  are  painless 
and  only  enforce  attention  because  of  the  incapacity  produced.  Painless  disloca- 
tions may  be  caused  by  insignificant  traumata.  Curvature  of  the  spine  may  also 
occur,  due  to  muscular  atrophy,  and  perhaps  to  changes  in  the  vertebrae.  Secondary 
contractures  may  take  place  and  produce  great  deformity  of  the  hands,  which,  added 
to  the  progressive  muscular  atrophy  and  the  paralysis,  impairs  the  use  of  the  upper 


846  DISEASES  OF  THE  NERVOUS  SYSTEM 

extremities  very  much.  In  addition  to  tiiese  symptoms  several  special  symptoms, 
depenilent  upon  the  site  of  the  lesion,  must  be  considered.  Thus,  if  the  lower 
part  of  the  spinal  cord  is  affected  there  may  be  vesical  or  rectal  paralysis;  whereas, 
if  the  upper  cervical  cord  is  affected  there  may  be  nnilateral  retraction  of  the  eyeball, 
narrowing  of  the  palpebral  opeyiing,  and  a  slow  pupillary  reaction  because  of  involve- 
ment of  the  spinal  centre  of  the  cervical  sympathetic.  When  anesthesia  is  found 
on  the  face  it  is  ascribed  to  implication  of  the  spinal  root  of  the  fifth  ner\-c  in  the 
cervical  region. 

Diagnosis. — As  already  stated,  the  loss  of  pain  sense  with  preservation  of  tactile 
sense,  tlie  trophic  changes,  and  the  muscular  atrophy  all  form  a  picture  which 
reveals  syringomyelia.  Before  all  these  symptoms  develop  the  presence  of  a 
slowly  increasing  muscular  atrophy  may  mislead  the  physician  into  the  diagnosis 
of  chronic  poliomyelitis  or  progressive  muscular  atrophy.  Indeed,  in  its  commonest 
type,  syringomyelia  presents  the  picture  of  progressive  muscular  atrophy  when 
it  is  advanced,  including  the  "claw-hand."  Less  frequently  the  white  columns 
of  the  cord  are  pressed  upon  by  the  central  mass  and  symptoms  of  locomotor 
ataxia  or  of  lateral  sclerosis  are  found.  The  true  condition  is  recognized  by  the 
dissociated  anesthesia  already  described.  Tumor  in  the  cord  usually  produces 
so  much  pressure  that  the  symptoms  of  paraplegia  are  more  marked  than  in  syringo- 
myelia, and  a  tumor  is  usually  associated  with  severe  pain.  The  dactjditis  of 
syringomj'elia  bears  a  resemblance  to  leprosy,  which,  however,  does  not  reveal  the 
more  general  signs  of  disease  in  the  cord. 

Prognosis. — The  chance  of  recovery  is  of  course  nil,  but  as  the  disease  progresses 
very  slowly  indeed,  life  may  be  prolonged  for  years. 

Treatment. — There  is  no  treatment  for  syringomyelia.  The  affected  extremities 
should  be  carefully  protected  from  injury. 

HEMORRHAGE  INTO  THE  SPINAL  CORD. 

Definition  and  Etiology. — Spontaneous  hemorrhage  into  the  spinal  cord  is  a  very 
rare  accident,  so  rare  that  some  writers  have  denied  its  existence  except  when  it 
has  arisen  from  a  direct  traumatism.  ^Minute  hemorrhages,  of  course,  occur  in 
severe  forms  of  acute  myelitis.  The  most  common  period  of  life  for  this  accident 
to  occur  is  between  the  twentieth  and  fortieth  years,  but  it  may  occur  in  infants. 
Hemorrhage  due  to  injury  may,  of  course,  develop  at  any  time.  Gowers  cites  a 
case  of  hemorrhage  occurring  apparently  as  the  result  of  repeated  sexual  intercourse. 
Occasionally  hemorrhage  into  the  cord  ensues  in  cases  of  asphyxia,  as  in  coal-gas 
poisoning,  and  cases  have  been  reported  in  which  hemophilia  produced  this  lesion. 
The  clot  is  usually  found  in  these  cases  chiefiy  in  the  gray  matter  of  the  cord. 
Sometimes  it  is  single;  in  other  instances  there  are  multiple  clots.  If  the  escape 
of  blood  has  been  copious  the  blood  may  perforate  the  white  matter  and  find  its 
way  to  the  pia. 

When  the  clot  is  of  any  size  and  the  cord  is  examined  shortly  after  the  accident, 
changes  resembling  those  due  to  hemorrhage  into  the  brain  are  present.  The  cord 
is  softened  and  infiltrated  with  small  round  cells  and  with  red  and  white  corpuscles 
which  are  seen  to  be  undergoing  granular  change.  The  tissues  are  also  stained  by 
blood-coloring  matter.  If  the  patient  lives  for  some  weeks  and  then  at  death 
the  cord  is  studied,  there  is  found  fatty  degeneration  of  the  neighboring  tissues  or  a 
cicatrix  of  coiuiective  tissue  which  occupies  the  site  of  the  hemorrhage.  Secondary 
descending  and  ascending  degenerations  may  ensue  as  in  myelitis. 

Symptoms. — The  symptoms  of  hemorrhage  into  the  spinal  cord  \'ary,  of  course, 
with  the  level  at  which  the  lesion  takes  place.  The  general  symptoms  are  para- 
plegia with  loss  of  sensation  in  the  paralyzed  limbs,  and  loss  of  control  of  the  bladder 
and  rectum.    These  symptoms  are  those  of  acute  myelitis  as  well.     In  addition 


'HEMORRHAGE  INTO   THE  SPINAL  MEMBRANES  847 

quite  severe  pain  may  be  felt  in  the  spine  or  be  referred  to  the  front  of  the  thorax 
or  to  the  epigastric  region,  and  even  to  the  legs. 

When  the  hemorrhage  is  in  the  cervical  cord  there  is  paralysis  of  the  arms  as 
well  as  the  legs.  The  reflexes  are  usually  lost  at  first  because  of  shock,  but  soon 
reappear  and  are  usually  exaggerated  unless  the  cervical  or  the  lumbar  enlargemen 
of  the,  cord  is  affected,  when  they  are  permanently  absent  in  the  arms  or  in  the 
legs.  Spastic  contractions  may  develop  later  from  descending  changes  in  the  crossed 
pyramidal  tracts,  as  in  myelitis.  The  muscles  may  undergo  degenerative  changes 
very  rapidly  because  of  damage  to  the  cells  in  the  anterior  horns  of  the  gray  matter 
at  the  level  of  the  lesion. 

Not  rarely,  if  the  hemorrhage  has  been  at  all  large,  a  stage  of  secondary  irritation 
and  inflammation  develops  as  a  result  of  the  extravasation  of  blood,  and  this  may 
not  only  greatly  increase  the  gravity  of  the  symptoms,  but  destroy  life.  On  the 
other  hand,  it  not  infrequently  happens  that  the  hemorrhage  in  the  gray  matter 
may  not  only  destroy  this  part  of  the  cord,  but  by  pressure  abrogate  the  function 
of  the  white  matter. 

After  the  acute  process  is  over,  the  paraplegia  is  greatly  decreased  as  the  pressure 
is  decreased,  but  complete  recovery  does  not  ensue  because  the  cord  is  permanently 
damaged,  and  so  atrophy  of  the  muscles,  governed  by  that  part  of  the  gray  matter 
which  has  been  damaged,  ultimately  develops  as  in  acute  poliomyelitis.  Some 
degree  of  spasticity  persists  through  loss  of  fibres  in  the  pyramidal  tracts,  and 
various  sensory  defects  if  the  dorsal  columns  have  not  completely  recovered. 

Diagnosis.' — The  diagnosis  of  hemorrhage  in  the  cord  is  not  to  be  made  until  the 
symptoms  are  so  well  defined  that  there  can  be  little  doubt  as  to  their  cause.  The 
onset  of  the  symptoms  must  be  sudden,  that  is,  almost  instantaneous.  If  several 
hours  are  passed  in  their  development  it  is  probably  a  case  of  acute  myelitis.  Pain 
is  also  an  important  symptom,  for,  if  it  is  present,  it  points  to  hemorrhage. 

Prognosis. — This  depends  upon  the  severity  of  the  symptoms  and  upon  the  site 
of  the  lesion.  If  it  is  in  the  cervical  or  lumbar  enlargements,  the  prognosis  is 
more  grave  than  if  it  is  in  the  dorsal  cord.  If  bed-sores  speedily  develop  the 
outlook  is  correspondingly  bad  not  only  because  their  presence  shows  grave  lesions 
in  the  cord,  but  also  because  their  existence  is  a  menace  to  the  patient's  life. 

Treatment. — Absolute  rest  in  bed  is  essential.  An  ice-bag  should  be  kept  over 
the  spine,  and  small  doses  of  aconite  and  the  bromides  used  to  allay  circulatory 
excitement.  The  use  of  ergot  in  such  cases,  as  commended  by  Gowers,  does  not 
seem  to  be  based  upon  a  correct  conception  of  the  physiological  action  of  this  drug. 
Some  time  after  the  hemorrhage  the  iodides  may  be  used  to  aid  in  clearing  up  the 
inflammatory  exudate. 

HEMORRHAGE  INTO  THE  SPINAL  MEMBRANES. 

Definition  and  Etiology. — A  hemorrhage  about  the  spinal  cord  may  be  outside 
the  dura  mater  (extrameningeal  or  extradural),  or  inside  the  dura  mater  (intra- 
meningeal) .  If  it  is  between  the  dura  mater  and  the  arachnoid  it  is  called  subdural, 
and  if  it  is  between  the  arachnoid  and  pia  mater  it  is  called  subarachnoid. 

Rupture  of  a  vessel  in  the  spinal  meninges  occurs  usually  in  adult  life,  and  more 
frequently  in  males  than  females.  Its  most  common  cause  is  injury  to  the  spine. 
It  has  been  known  to  follow  violent  convulsions  and  as  a  sequel  to  those  infections 
which  result  in  purpura.  In  newborn  infants  the  blood  found  between  the  spinal 
membranes  has  its  origin  in  the  meninges  of  the  brain,  and  follows  the  cord  down- 
ward. Sometimes,  in  cases  of  very  severe  inflammation  of  the  spinal  meninges, 
small  extravasations  of  blood  take  place. 

In  extradural  hemorrhage  the  blood  comes  from  the  veins  which  lie  between  the 
dura  and  the  bony  canal.     The  quantity  of  blood  which  is  poured  out  varies  greatly. 


848  DISEASES  OF  THE  NERVOUS  SYSTEM 

In  some  instances  it  reaches  the  full  length  of  the  cord.  In  otlier  instances  but  a 
small  area  is  covered  by  a  clot.  The  most  common  seat  for  tiie  hemorrhage  is  the 
cervical  portion  of  the  cord.     The  cord  may  or  may  not  be  compressed. 

Subdural  hemorrhage,  that  is,  the  escape  of  blood  between  the  dura  and  the 
arachnoid,  also  varies  greatly  in  quantity.  In  subarachnoid  hemorrhage  the  blood 
comes  from  the  vessels  of  the  pia  mater,  and  the  clot  may  surround  the  cord  for  a 
few  inches  or  extend  throughout  the  whole  subarachnoid  space.  In  very  rare 
instances  it  may  actually  force  its  way  into  the  cerebral  ventricles. 

In  all  cases  of  hemorrhage  into  the  spinal  membranes,  save  the  extradural  type, 
the  cerebrospinal  fluid  is  blood-stained.  This  may  be  a  valuable  diagnostic  point, 
since  lumbar  puncture  may  reveal  the  presence  of  blood  in  this  fluid. 

Symptoms. — No  symptoms  may  be  present  unless  the  hemorrhage  is  extensive 
enough  to  cause  compression,  or  unless  a  secondary  meningeal  inflammation 
develops.  When  the  effusion  of  blood  is  considerable  there  is  sudden  severe  pain 
in  the  bade,  usually  about  the  level  of  the  hemorrhage,  which  extends  into  the  loins, 
and  it  may  be  to  the  anterior  surface  of  the  body.  There  may  also  be  some  muscu- 
lar spasm  in  the  parts  involved  by  those  nerves,  the  roots  of  which  are  pressed  upon 
after  leaving  the  spinal  cord.  These  spasms  may  be  severe  enough  to  produce  a 
convulsion,  localized  or  general.  Immediately  after  these  symptoms  evidences  of 
loss  of  poicer  develop  and  the  sjoaptoms  resemble  the  early  stages  of  acute  myelitis, 
or  of  hemorrhage  into  the  cord  itself,  save  that  it  is  rare  for  the  paralysis  of  either 
sensation  or  motion  to  be  as  complete  as  it  is  in  those  conditions. 

If  the  hemorrhage  is  in  the  cervical  region,  the  pain  is  felt  in  the  neclc  and  arms. 
There  is  difficulty  of  sicallowing  and  of  breathing,  and,  it  may  be,  dilatation  of  the 
pupils.  When  it  is  in  the  dorsal  region  the  pain  is  in  the  chest  and  abdomen,  and 
when  in  the  lumbar  region  it  is  chiefly  felt  in  the  legs.  Conscioiisness  is  presermd 
unless  it  be  lost  through  shock.  Some  hours  or  days  after  the  hemorrhage  a 
secondary  reaction  with  febrile  movement  may  develop.  In  fatal  cases  death 
usually  comes  on  within  a  few  hours. 

From  a  medicolegal  standpoint  it  is  interesting  to  note  that  at  least  one  case  of 
meningeal  hemorrhage  in  the  spine  very  closely  resembled  strychnine  poisoning. 
If  the  symptoms  are  severe,  death  is  very  likely  to  occur  within  a  few  hours.  If 
the  patient  sur\'ives  the  first  few  days,  partial  recovery  from  the  paralysis  may  occur. 
'  Prognosis. — The  prognosis  as  to  life  is  worse  when  the  hemorrhage  is  high  up 
in  the  meninges  than  when  it  is  low  down. 

Treatment. — The  treatment  of  this  condition  consists  in  absolute  rest,  the  employ- 
ment of  small  doses  of  the  bromides  and  aconite  as  nervous  and  circulatory  sedatives, 
and  counter-irritation  over  the  back  in  the  shape  of  dry  cups  or  leeches.  The 
patient  should  be  made  to  lie  on  his  side  or  on  liis  face  rather  than  on  his  back, 
in  order  to  prevent  the  accumulation  of  extravasated  blood  at  the  posterior  portion 
of  the  cord.  Where  the  quantity  of  blood  which  is  poured  out  is  very  large,  and 
the  symptoms  so  severe  that  death  is  threatened,  it  may  be  ad^•isable  to  call  upon 
a  skilful  surgeon  to  relieve  pressure  by  operation. 

COMPRESSION  OF  THE  SPINAL  CORD. 

Definition  and  Etiology. — Compression  of  the  spinal  cord  occurs  as  the  result 
of  disease  of  the  vertebr;?,  of  growths  in  the  vertebrae  or  the  meninges;  of  growths 
occurring  within  the  spinal  canal,  inside  or  outside  of  the  dnra  mater;  of  aneurysm 
of  the  aorta,  which,  by  pressure  on  the  vertebrae,  cause  their  absorption;  as  the 
result  of  syphilitic  inflammatory  processes  in  the  spinal  canal,  or  by  the  develop- 
ment of  a  i)achymeningitis,  which  may  involve  the  cervical  or  lumbar  portions  of 
the  cord,  and  which  is  characterized  by  a  thickening  of  the  parts  invoh'ed.  The 
result  of  pressure  exercised  by  any  of  these  causes  interferes  with  the  nutrition  of 


COMPRESSION  OF  THE  SPINAL  CORD  849 

the  spinal  cord  and  with  the  transmission  of  impulses  along  its  tracts,  and  the 
symptoms  which  arise  vary  in  their  character  and  severity  with  the  degree  of 
pressure  and  the  alterations  caused  by  it. 

Disease  of  the  vertebra;  is  most  commonly  the  result  of  tuberculous  infection, 
particularly  in  children.  As  a  result  of  this  process,  the  bones  become  softened, 
give  way  under  the  pressure  which  is  exerted  upon  them,  and  as  they  do  so  pressure 
upon  the  cord  results.  In  other  instances  a  suppurative  process  results  in  the 
development  of  so  much  pus  that  pressure  is  produced  by  it,  and  not  uncommonly 
a  carious  process  in  the  vertebrte  is  associated  with  an  inflammation  of  the  dura 
mater,  with  consequent  thickening  of  this  meml)rane,  so  that  pressure  is  produced. 
Again,  the  caseous  masses  which  are  formed,  or  the  overgrowth  of  connective 
tissue  which  takes  place,  may  cause  pressure.  In  some  instances  the  dura  mater 
suffers  from  tuberculous  infection,  and  tubercles  are  found  upon  its  inner  surface, 
and  both  the  arachnoid  and  pia  mater  may  be  involved.  As  a  result  the  nutrition 
of  the  spinal  cord  at  this  point  is  impaired  through  interference  with  the  circulation 
in  its  bloodvessels  and  probably  also  because  of  the  obstruction  to  the  circulation 
of  lymph  as  well.  The  cord,  in  the  majority  of  instances,  is  involved.  If,  however, 
the  pressure  is  severe,  there  is  apt  to  be  an  overgrowth  of  connective  tissue  whereby 
a  sclerotic  process  is  developed.  The  axis  cylinders  become  swollen,  and  fatty 
globules  can  be  found  in  the  myelin  sheaths.  If  the  pressure  is  severe  and  is 
long  continued,  the  cord  may  be  markedly  atrophied  and  the  overgrowth  of  con- 
nective tissue  be  very  great.  In  some  instances  there  may  be  nothing  left  of  the 
cord  but  a  band  of  connective  tissue.  '  If  the  damage  done  to  the  cord  is  of  a  more 
severe  type,  ascending  and  descending  degenerative  changes  occur. 

The  symptoms  produced  by  these  lesions  consist  in  pain  in  the  spine  and  in  the 
distribution  of  the  nerves  supplying  the  trunk  and  limbs.  Not  infrequently  pain 
will  be  felt  in  the  abdominal  wall  or  in  the  neighborhood  of  the  sternum  because 
of  the  irritation  of  the  nerve  trunks  as  they  make  their  exit  from  the  spinal  cord, 
according  to  the  well-known  law  that  pain  is  frequently  referred  to  the  peripheral 
ends  of  the  nerve  affected.  Any  jarring  of  the  body  by  a  misstep  or  a  sudden 
movement  or  even  a  gentle  blow  upon  the  spinal  column  may  cause  the  patient 
suffering.  The  muscles  of  the  back  are  usually  fixed,  in  order  to  protect  the  spinal 
column  as  much  as  possible.  This  fixation  is  partly  voluntary  and  partly  involun- 
tary. In  some  instances  a  girdle  sensation  is  felt  in  the  nerves  which  make  their 
exit  from  the  area  which  is  diseased. 

When  the  lesions  are  high  in  the  cord  there  may  be  painful  sensations  in  the  arms, 
and  if  the  lateral  tracts  are  compressed  there  is  an  exaggeration  of  the  reflexes,  with 
a  tendency  to  spasticity  of  the  muscles.  In  other  instances  the  patient  may  present 
all  the  symptoms  of  transverse  myelitis  and  develop  bed-sores.  The  rapidity 
with  which  these  symptoms  develop  in  different  cases  varies  very  much,  depending 
entirelj'  upon  the  activity  of  the  pathological  process  in  the  spinal  column.  In 
some  instances  years  are  consumed  in  the  development  of  the  advanced  stage  of 
the  malady.  In  others  paralysis  of  the  lower  extremities  may  be  produced  in  a 
few  months. 

The  diagnosis  of  these  cases  is  not  difficult  if  the  pliysician  will  carefully  examine 
the  spine. 

The  prognosis  is,  of  course,  not  very  favorable,  but  it  is  a  noteworthy  fact  that 
in  those  stages  in  which  the  process  in  the  spinal  column  becomes  arrested  a  very 
marked  degree  of  recovery  may  take  place.  On  the  other  hand,  it  sometimes 
happens  that  spinal  disease  in  infancy  results  in  later  life  in  the  development  of 
lateral  sclerosis  or  other  diseases  of  the  spinal  cord.  Much  depends  in  the  way  of 
prognosis  upon  what  the  surgeon  is  able  to  do  for  the  spinal  disease.  The  nervous 
symptoms  are  to  be  considered  purely  secondary,  and  every  effort  made  to  modify 
the  pathological  process  in  the  spine. 
54 


850  DISEASES  OF  THE  NERVOUS  .SYSTEM 

Tlie  treatment  of  compression  of  the  spinal  cord  due  to  disease  of  the  vertebrie 
is  entirely  in  the  hands  of  the  orthopedic  surgeon,  who,  by  means  of  proper  appara- 
tus, can  often  do  much  good.  The  medicinal  plan  of  treatment  consists  in  the 
use  of  cod-li\er  oil,  iron,  and  arsenic,  the  following  of  a  perfectly  healthy  mode  of 
life,  and  the  use  of  good  food.  Pain  is  to  be  relieved,  if  necessary,  by  opiates, 
and  the  nervous  twitchings  by  sedatives,  like  bromide  and  chloral.  In  some  cases 
hydrotherapeutic  measures  are  advantageous. 

Malignant  growths  of  the  vcrtebnie,  such  as  carcinoma  and  sarcoma,  are  rare. 
They  are  usually  rapid  in  their  growth  and  produce  symptoms  of  spinal  compression 
as  soon  as  thej-  invade  the  spinal  canal.  These  malignant  growths  soon  penetrate 
the  dura,  the  arachnoid,  and  the  pia,  and  speedily  infiltrate  the  spinal  cord  itself, 
although  the  dura  mater  is  usually  capable  of  protecting  the  spinal  cord  from 
direct  infection  when  the  disease  is  tuberculous. 

When  a  tumor  of  the  spinal  cord  develops  it  is  in  the  great  majority  of  instances 
due  to  sarcoma.  Tumor  of  the  spinal  cord  is,  however,  exceedingly  rare.  Schle- 
singer  found  only  147  spinal  tumors  in  35,000  autopsies,  and  Starr  states  that  the 
ratio  of  tumors  of  the  spinal  cord  to  tumors  of  the  brain  is  1  to  13. 

Here,  again,  the  symptoms  consist,  as  a  rule,  in  intense  neuralgic  pain  of  a 
shooting  or  stabbing  character  caused  by  pressure  upon  the  nerves  as  they  leave 
the  spinal  canal.  These  pains  are  more  severe  than  those  produced  by  any  other 
form  of  spinal  disease,  and  they  are  felt  in  different  portions  of  the  body,  according 
to  the  portion  of  the  spinal  cord  which  is  involved.  If  the  lower  cervical  portion 
of  the  cord  is  afl'ected,  the  pain  may  be  felt  in  one  or  both  hands  and  forearms. 
If  the  growth  is  in  the  upper  cervical  region,  they  are  felt  in  the  shoidder  or  neck; 
if  it  occurs  as  low  as  the  sixth  dorsal  segment  the  pain  is  felt  in  the  chest,  near  the 
nipjjle;  in  the  tenth  dorsal  segment  it  is  felt  in  the  abdomen  and  groin.  When  a 
tumor  compresses  the  cord  in  its  entire  thickness  degenerations  ensue,  descending 
in  the  lateral  columns,  ascending  in  the  dorsal  and  other  sensory  columns,  just  as 
they  arise  in  cases  of  marked  caries  of  the  vertebrje.  I'nder  these  conditions  the 
symptoms  are  those  of  a  transverse  myelitis.  The  le\e\  at  which  the  tumor  is 
growing  can  largely  be  determined  by  localizing  the  symptoms,  and  the  fact  that 
tumor  is  present  may  be  pointed  to  by  the  presence  of  growths  elsewhere  in  the 
body.  If  the  tumor  is  of  the  malignant  type  its  growth  is  usually  exceedingly 
rapid. 

Spinal  symptoms  due  to  new  growth  differ  from  those  due  to  caries  of  the  spine 
by  the  fact  that  the  stiffness  of  the  muscles  of  the  back  and  tendons  on  jarring 
the  spine  is  not  so  marked  in  growths  as  it  is  in  tuberculous  disease.  In  the  latter 
case,  also,  there  may  be  found  a  primary  tuberculous  focus. 

When  compression  is  due  to  tumor  the  treatment  is  operative.  In  many  instances 
it  is  possible  to  give  the  patient  some  relief  by  tliis  means.  Starr  has  collected 
58  cases  of  tumor  of  the  spinal  cord  in  which  an  operation  was  attempted.  In  all 
his  cases  the  tumor  was  found,  and  in  16  of  them  the  patients  recovered.  If  the 
growth  is  malignant  the  possibility  of  doing  much  good  by  operation  is,  of  course, 
remote.  Pain  may,  however,  be  temporarily  relieved  by  the  removal  of  the 
pressure. 

The  compression  of  the  spinal  cord  produced  by  gummatous  growth  or  by 
syphilitic  exudations  about  the  spinal  cord  present  symptoms  which  also  depend 
upon  the  area  which  is  involved,  particularly  upon  the  level  of  the  lesion.  The 
condition  may  arise  either  in  acquired  or  in  hereditary  syphilis,  and  the  diagnosis 
is  made  by  the  history  of  the  patient  and  the  presence  of  pressure  symptoms.  The 
treatment  is  antisyphilitic. 

When  an  anenri/sm  of  the  aorta  grows  in  such  a  manner  that  it  erodes  the  ver- 
tebrae, it  may  produce  symptoms  of  compression  of  the  spinal  cord.  Thus,  para- 
plegia may  be  developed,  or  se\"ere  pain  may  he  felt  in  those  parts  of  the  body  which 


SPINAL  MENINGITIS  851 

are  supplied  by  the  nerve  trunks  which  have  their  origin  in  that  portion  of  tlie 
spinal  cord  which  is  affected.  If  the  physical  signs  of  the  presence  of  aneurysm 
are  demonstrable  the  diagnosis  is  not  diflicult,  but  if  the  growth  is  in  a  backwarfl 
direction  it  may  present  no  symptoms  which  indicate  its  presence.  An  examiiiation 
of  the  patient's  back  may  not  only  reveal  signs  of  vertebral  disease,  but  a  bruit  or 
a  transmitted  pulsation  and  a  history  of  syphilis  and  of  trauma,  if  added  to  a  dis- 
covery that  the  bloodvessels  are  sclerotic,  will  aid  in  discovering  this  cause  of  the 
symptoms. 

A  sixth  cause  of  compression  of  the  spinal  cord  is  hypertrophic  cervical  pachy- 
meningitis, the  pachymeningitis  cervicalis  hypertrophica  of  Charcot.  This  disease 
consists  in  thickening  of  the  dura  mater  to  such  a  degree  that  the  spinal  cord  and 
the  spinal  nerves  as  they  pass  through  the  dura  are  pressed  upon.  As  a  result 
the  spinal  cord  suffers  from  meningomyelitis,  and  the  dura  mater  becomes  adherent 
to  the  pia  mater.  Sometimes  hemorrhagic  extravasations  occur  under  the  dura, 
and  there  is  usually  an  overgrowth  of  connective  tissue  about  the  bloodvessels, 
both  in  and  about  the  cord. 

The  symptoms  of  this  form  of  meningomyelitis  are  identical  with  those  already 
described  as  occurring  in  cases  in  which  the  cord  is  compressed  by  other  causes  in 
the  cervical  region,  but  they  have  certain  peculiarities  which  may  aid  in  the  diagnosis 
of  the  condition.  There  is  pain  in  the  back  of  the  head  and  neck,  with  a  certain  degree 
of  stiffness  and  difficulty  in  movement.  The  pain  radiates  down  into  the  hands  and 
arms,  and  is  often  exceedingly  severe  and  neuralgic  in  type.  Patches  of  anesthesia 
or  paresthesia  may  be  present  and  localized  muscular  spasms  may  occur,  followed 
by  loss  of  power  and  the  development  of  reactions  of  degeneration,  when  the  disease 
has  lasted  long  enough  to  interfere  with  the  transmission  of  trophic  impulses  from 
the  cord  to  the  muscles  affected.  Finally,  if  the  pressure  becomes  great  enough 
to  seriously  impair  the  nutrition  of  the  spinal  cord,  there  will  develop  symptoms 
of  spastic  paraplegia  due  to  descending  degenerative  changes  in  the  lateral  tracts. 
If  the  muscles  supplied  by  the  ulnar  and  median  nerves  are  chiefly  affected,  the 
disease  is  present  in  the  lower  part  of  the  enlargement;  but  if  those  muscles  supplied 
by  the  musculospiral  nerve  lose  power,  the  upper  part  of  the  ce^^•ical  enlargement 
is  involved.  Loss  of  power  in  the  triceps,  anconeus,  supinator  longus,  extensor 
carpi  radialis  longior,  and  the  brachialis  anticus,  therefore  indicate  disease  of  the 
upper  segment;  whereas,  a  loss  of  power  in  the  flexor  carpi  ulnaris  and  flexor  pro- 
fundus digitorum  (ulnar  nerve)  and  all  the  muscles  of  the  front  part  of  the  forearm 
and  thumb  (median  nerve)  indicates  disease  in  the  lower  segment.  In  some  cases 
myosis  from  paralysis  of  the  cervical  sympathetic  may  be  present. 

Treatment  of  cervical  pachymeningitis  promises  more  than  would  be  supposed 
from  the  character  of  the  lesions,  probably  because  the  condition  is  so  often  due  to 
syphilis.  Active  counter-irritation  of  the  back  of  the  neck  by  the  electrocautery 
and  the  administration  of  salvarsan,  combined  with  the  free  use  of  the  protiodide 
of  mercury,  alternating  with  large  doses  of  iodide  of  potassium,  should  always  be 
resorted  to.  Pain  is  to  be  relieved  by  the  use  of  acetanilid  or  phenacetin,  and  if 
these  drugs  fail  to  give  relief  they  must  be  combined  with  morphine. 

SPINAL  MENINGITIS. 

Definition  and  Etiology. — ^A  condition  of  inflammation  of  the  membranes  covering 
the  spinal  cord  is  practically  always  secondary  to  some  lesion  at  another  part  of 
the  body.  In  some  instances  the  specific  micro-organisms  of  croupous  pneumonia, 
of  enteric  fever,  of  acute  articular  rheumatism,  or  septicemia  finds  its  way  to  these 
parts  and  causes  the  pathological  process.  In  other  instances  tuberculosis  is  the 
cause,  whether  it  be  primarily  present  in  distant  parts  of  the  body  or  in  the  vertebral 
column.     In  some  instances  an  injury  affords  a  means  of  entrance  to  the  body 


852  DISEASES  OF  Till':  XERVOiS  SYSTEM 

for  micTo-orjianisms,  which  attack  the  spinal  meninjjes,  particularly  if  the  vital 
resistance  has  been  lowered  by  an  accident.  Spinal  meningitis  may  also  arise  from 
ccrclira!  niciiiiinitis  liy  direct  extension  of  an  infection. 

Pathology  and  Morbid  Anatomy. — Following  tiie  stage  of  acute  hyjieremia  present 
in  all  acute  inflammatory  processes,  there  is  an  excess  of  serous  fluid  poured  out 
between  the  dura  mater  and  the  pia,  wiiich  fluid  may,  at  autop.sy,  be  found  to  be 
purulent.  Patches  of  fibrinous  exudate  are  foimd  on  the  surface  of  the  pia  mater, 
the  bloodvessels  of  which  are  engorged  with  blood  and  often  sufl'er  from  small 
hemorrhagic  extravasations.  The  spinal  cord,  the  pia  and  the  dura  mater  are 
often  adherent.  After  the  inflammatory  process  has  been  present  for  some  time, 
the  pia  mater  becomes  much  thickened  by  the  development  of  connective  tissue. 
The  secondary  changes  which  ensue  consist  in  an  inflammatory  process  which 
affects  the  superficial  parts  of  the  spinal  cord  and  causes  degenerative  changes 
in  the  spinal  nerve  roots,  the  axis  cylinders  of  which  become  swollen.  Fatty 
globules  appear  in  the  myelin  sheath.  The  changes  in  the  spinal  cord  are  most 
marked  in  the  posterior  and  lateral  cohmms,  and  in  subacute  or  chronic  cases  these 
are  aft'ected  by  an  o\'ergrowth  of  connective  tissue,  which  ultimately  produces 
sclerotic  patches. 

Symptoms. — The  onset  of  acute  spinal  meningitis  develops,  as  do  most  acute 
inflammations  of  serous  membranes,  with  pain,  chill,  and  (/cueral  wretchedness. 
The  pain  is  felt  in  the  hacli  and  linihs,  and  is  greatly  increased  by  movements. 
There  is  also  a  state  of  hyperesthesia  of  all  the  spinal  nerves,  so  that  touching  the 
patient  may  cause  great  sutt'ering.  It  is  soon  noticed  that  the  patient  is  stiff  and 
more  or  less  fixed  by  muscular  rigidity,  which  is,  in  part,  due  to  the  pain  produced 
by  movement  and  to  the  irritation  of  the  nerves  as  they  pass  from  the  spinal  cord. 
The  stift'ness  of  the  muscles  of  the  back  and  of  the  neck  is  the  most  marked.  At 
this  time  "  Kernig's  sign"  is  developed,  which  consists  in  an  inability  of  the  physician 
to  straighten  the  patient's  leg  at  the  knee  after  the  thigh  has  been  flexed  to  a  right 
angle  with  the  trunk.  This  state  is  due  to  spasm  of  the  flexor  muscles  induced  by 
the  irritation  at  the  point  of  exit  of  the  nerve  trunks.  There  is  often  soon  developed 
an  increase  in  the  reflexes,  chiefly  in  the  legs,  and  this  in  turn  is  succeeded  by 
paralysis  and  final  loss  of  refte.xes  if  the  process  is  severe  and  prolonged.  Along 
with  these  symptoms  there  speedily  develops  a  paralysis  of  the  bladder  and  rectnm, 
so  that  there  is  retention  or  incontinence  of  urine  and  incontinence  of  feces.  There 
may  also  be  paralytic  incontinence.  Because  of  the  lesions  produced  in  the  nerve 
roots  and  in  the  spinal  nerves  as  they  pierce  the  meninges,  trophic  changes  in  the 
skin  may  develop,  as  shown  by  localized  areas  of  pallor  and  congestion  and  the 
speedy  development  of  bed-sores. 

If  the  disease  is  severe  and  the  inflammatory  process  spreads  until  the  upper 
portions  of  the  cord  are  involved,  death  may  ensue  by  reason  of  the  inflammation 
reaching  the  level  of  the  medulla  and  causing  fatal  disturbance  of  the  function  of 
respiration  or  of  the  heart.  In  such  cases  Cheyne-Stokes  breathing  and  irregularity 
of  the  ])ulse  may  be  the  symptoms  of  impending  dissolution.  Not  rarely  the 
development  of  paralysis  of  the  cranial  nerves  with  convulsions  and  coma  jjrecede 
death.  Death  may  come  within  a  few  days  of  onset  or  after  several  weeks.  In 
the  severe  cases  which  recover  the  patient  often  permanently  suH'ers  from  localized 
palsies,  anesthesias,  and  atrojjhic  lesions  in  the  skin  and  muscles. 

Diagnosis. — Aside  from  the  character  of  the  .symptoms  just  dcscrilied,  which 
points  strongly  to  spinal  meningitis,  we  may  resort  to  lumbar  puncture  for  the  pur- 
pose of  making  the  diagnosis  more  certain.  A  strong,  hollow  needle  attached  to  a 
syringe,  so  that  it  may  be  easily  handled,  or  a  small  trocar  and  cannula  are  passed 
into  the  spinal  canal  between  the  third  and  fourth  lumbar  vertebne,  on  a  line 
drawn  between  the  crests  of  the  ilia.  The  direction  of  the  needle  should  he  slightly 
to  one  side  and  upward.     (For  further  details  as  to  this  method  see  ^leningococcic 


SPINAL  MENINGITIS  !^53 

Meningitis.)  As  soon  as  it  enters  the  spinal  canal  the  cerebrospinal  fluid  will  escape, 
drop  by  drop,  or  with  a  squirt,  if  the  pressure  is  great.  This  fluid  should  he  examined 
for  bacteria  to  determine  the  nature  of  the  infection.  If  tlie  fluid  contains  disin- 
tegrated blood,  the  cause  of  the  affection  is  a  pachymeningitis  or  an  injury.  If 
fresh  blood  is  present,  the  blood  is  probably  due  to  the  puncture.  If  the  fluid  is 
clear  there  is  probably  no  true  meningitis  present.  In  cases  of  tuberculosis  of  the 
meninges  it  is  usually  quite  cloudy.  If  it  contains  pus  a  purulent  meningitis  is 
present.  If  inflammation  of  the  meninges  is  present  no  sugar  will  be  found  in  the 
fluid.  A  study  of  the  leukocytes  in  the  cerebrospinal  fluid  may  throw  light  upon 
the  case.  They  are  much  increased  in  number  in  acute  inflammatory  processes. 
In  chronic  conditions  the  mononuclear  cells  are  particularly  increased. 

Prognosis. — Tuberculous  meningitis  is,  of  course,  a  state  gi\ing  a  hopeless  prog- 
nosis. Septic  cases  are  also  grave.  Those  types  due  to  pneumonia  and  typhoid 
fever  sometimes  recover.     (See  Pneumonia  and  Typhoid  Fever.) 

Treatment. — The  treatment  of  spinal  meningitis  consists  in  absolute  rest,  the 
patient  being  placed  upon  a  soft  bed.  In  some  instances  if  there  is  any  sign  of 
bed-sores  it  is  essential  that  an  air-bed  or  water-bed  should  be  used.  The  applica- 
tion of  blisters  or  the  actual  cautery  has  been  recommended,  but  in  view  of  the 
possibility  of  bed-sores  developing,  it  is  questionable  whether  their  use  is  safe. 
The  same  objection  holds  in  regard  to  such  forms  of  counter-irritation  as  cupping 
and  leeching.  Twitchings  or  cramps  of  the  muscles  are  to  be  relieved  by  the 
administration  of  sedatives  to  the  spinal  cord,  such  as  bromide  and  chloral,  and 
if  the  pain  is  very  severe  morphine  must  be  used.  At  one  time  it  was  believed  that 
full  doses  of  calomel  combined  with  opium  were  exceedingly  valuable  in  the  treat- 
ment of  acute  inflammation  of  all  serous  membranes,  particularly  those  co^■e^ing 
the  brain  and  spinal  cord.  At  the  present  time  this  method  of  treatment  has  almost 
entirely  ceased,  but  in  certain  instances  it  would  seem  advisable  to  have  recourse 
to  it.  The  object  is  to  give  enough  mercurial  to  exercise  its  so-called  antiphlogistic 
influence,  and  to  use  the  opium  not  only  for  the  relief  of  pain,  but  for  the  purpose 
of  preventing  the  calomel  from  purging  the  patient.  The  mercurial  may  be  pushed 
until  slight  tenderness  of  the  gums  is  manifested. 

Chronic  Spinal  Meningitis.  —  Etiology.  —  Chronic  spinal  meningitis  is  said  to 
occasionally  have  its  origin  in  an  acute  inflammation  of  the  meninges  of  the 
spinal  cord.  In  all  probability,  however,  such  an  origin  is  exceedingly  rare, 
and  in  the  majority  of  instances  it  is  the  result  of  syphilitic  infection,  whereby 
there  is  a  thickening  of  the  dura  and  the  formation  of  an  abnormal  quantity  of 
serum  and  connective  tissue  under  it.  As  the  result  of  the  chronic  inflammatory 
process  in  the  membrane,  a  somewhat  similar  one  is  set  up  in  the  spinal  cord  near 
its  surface,  producing  a  meningomyelitis,  which  is  in  its  nature  closely  allied  to 
the  acute  form  of  meningitis  just  considered.  There  is  always  present  a  thickening 
of  the  bloodvessels,  a  small-cell  infiltration  about  their  walls,  and,  if  the  process  is 
severe,  an  obliterating  endarteritis.  Sometimes  gummatous  masses  are  formed. 
In  most  of  these  cases  there  is  also  present  cerebral  meningitis  as  well. 

Symptoms. — The  symptoms  of  chronic  spinal  meningitis  consist  in  stiffness 
of  the  back  and  extremities,  with  pai7is  and  cramps.  There  are  also  disturbances 
in  sensibility,  some  portions  of  the  skin  being  hyperesthetic,  others  anesthetic. 
Motor  -power  is  also  ivipaired,  and  if  the  inflammation  is  in  the  lower  portion  of  the 
spinal  cord  there  may  be  interference  with  the  function  of  the  bladder  or  rectum. 

Diagnosis. — Chronic  spinal  meningitis  is  to  be  recognized  by  the  presence  of  the 
symptoms  just  described  and  by  the  use  of  lumbar  puncture,  which,  if  meningitis 
is  present,  will  show  an  increased  quantity  of  cerebrospinal  fluid,  which  is  usually 
under  pressure,  and  which  will,  therefore,  escape  from  the  needle  with  a  spurt. 
Care  must  be  taken  that  ordinary  lumbago  with  spasm  of  the  muscles  of  the  back 
and  fixation  and  pain  is  not  confused  with  this  condition.     Myehtis  is  to  be  sepa- 


854  DISEASES  OF  THE  XERVOUS  SYSTEM 

rated  by  the  absence  of  severe  pain  and  of  cramps  in  tlic  extremities,  and  by  the 
presence  of  paraplegia. 

Treatment. — The  treatment  of  chronic  meningitis  consists,  as  must  be  evident 
from  its  cause,  namely,  late  .syphilis,  in  the  free  use  of  protiodide  of  mercury  and 
the  iodide  of  potassium,  given  until  a  full  jjliysiological  effect  is  produced.  In 
other  words,  it  is  not  a  question  of  grains  administered,  but  effects  obtained.  These 
cases  are  usually  much  benefited  by  going  to  the  various  hot  springs,  because,  in 
addition  to  the  use  of  mercurials  by  the  mouth,  they  permit  the  simultaneous 
use  of  hot  baths  and  mercurial  inunctions.  While  salvarsan  has  not  proved  to 
be  of  so  much  value  in  syphilis  of  the  nervous  system  as  in  specific  lesions  elsewhere, 
still  its  use  is  often  followed  by  marked  improvement,  and  the  remedy  should  be 
used  in  conjunction  with  our  longer  known  drugs.  Whether  the  use  of  salvarsan- 
ized  serum  is  a  safe  procedure  in  these  cases  is  unknown.  It  is  certainly  a  doubt- 
ful method  in  view  of  the  inflammation  alread\'  present.  Everything  should  be 
done  to  keep  the  general  condition  of  the  patient  at  the  highest  possible  level 
approaching  that  of  health. 


ACUTE  ASCENDING  PARALYSIS  (LANDRY'S  PARALYSIS). 

Defmition. — This  is  an  acute  ascending  flaccid  paralysis  beginning  in  the  lower 
extremities  and  rapidly  passing  upward  until  it  involves  the  muscles  of  the  trunk 
and  upper  extremities,  finally  causing  death  by  failure  of  respiration.  The  con- 
dition is  a  very  rare  one.  It  must  be  clearly  separated  from  those  forms  of  acute 
ascending  paralysis  due  to  an  acute  ascending  myelitis,  or  to  a  hemorrhage  into 
the  spinal  membranes,  and  from  ascending  peripheral  neuritis.  It  is  a  symptom- 
complex  which  results  from  a  lesion  of  the  lower  segment  of  the  motor  pathway, 
either  in  the  cord  and  bulb  or  in  the  peripheral  nerves.  It  is  sometimes  called 
acute  progressive  paralysis,  or  Landry's  paralysis,  having  been  first  described  by 
Landry  in  1859.  Rare  cases  have  been  recorded  in  which  the  disease  has  begun 
in  the  arms  and  passed  to  the  legs. 

Etiology. — The  exact  etiological  causes  of  this  malady  are  not  understood.  The 
disease  occurs  more  frequently  in  males  than  in  females,  and  its  most  common  period 
of  occurrence  is  between  twenty  and  forty  years  of  age.  In  all  probability  every 
case  is  due  to  an  infection  of  the  peripheral  nerves  and  spinal  cord,  for  it  sometimes 
follows  an  acute  illness  due  to  a  micro-organism,  as,  for  example,  influenza,  small- 
pox, erysipelas,  typhoid  fever,  and  pelvic  peritonitis.  The  excessive  use  of  alcohol 
has  seemed  in  some  cases  to  be  a  powerful  predisposing  cause,  and  cases  have  been 
recorded  in  which,  in  the  presence  of  a  history  of  syphilis,  the  malady  has  been 
arrested  by  the  use  of  specific  remedies. 

Pathology  and  Morbid  Anatomy. — The  lesions  found  at  autopsy  in  a  case  of  Lan- 
dry's paralysis  are  by  no  means  constant  in  all  cases.  In  some  instances  the  chief 
lesions  have  been  found  in  the  spinal  cord,  in  others  in  the  peripheral  nerves  and 
nerve  roots.  In  the  spinal  cord  the  lesions  described  in  some  cases  have  been 
practically  identical  with  tho.se  of  acute  disseminated  myelitis,  and  in  others  they 
have  been  identical  with  those  met  with  in  severe  peripheral  neuritis.  In  every 
case,  however,  it  is  evident  that  the  perijjheral  motor  neurones  are  the  portions 
of  the  nervous  system  most  affected. 

Symptoms. — In  some  cases  of  acute  ascending  paralysis  the  onset  of  the  paralytic 
symptoms  is  preceded  for  a  few  hours  by  a  sense  of  general  icretchedness,  with  iincjling 
or  pain  in  the  limbs  or  back.  This  is  followed  by  a  rapidly  increasing  weakness 
in  the  lower  limbs,  which  may  amount  to  a  complete  loss  of  power  in  from  a  few 
hours  to  scA-eral  days.  The  muscles  of  the  lower  part  of  the  trunk  are  next  in\-oh-ed, 
and  finally  the  muscles  of  the  arms  and  of  the  upper  thorax  fall  victims  to  the 


CAISSON  DISEASE  855 

rapidly  spreading  malady.  The  respiration  becomes  difficult,  the  speech  indistinct, 
and  dysphagia  may  be  present.  Sensation  in  the  paralyzed  parts  may  be  impaired, 
but  it  is  not  lost.  The  reflexes  are  decreased,  and  perhaps  lost,  but  they  may  be 
restored  later  on  and  ultimately  become  excessive.  Muscular  atrophy  does  not 
develop  even  when  the  patient  survives  for  weeks,  and  the  sphincters  usually, 
but  not  always,  retain  their  power.  Bed-sores  do  not  develop.  The  mind  nearly 
always  remains  clear,  and  the  temperature  is  usually  not  elevated,  ^'ery  rare 
cases  have  been  reported  in  which  the  paralysis  has  been  of  the  acute  descending 
type,  the  armS  being  the  parts  first  affected.  In  such  cases  fatal  bulbar  paralysis 
may  occur  before  the  lower  parts  of  the  body  are  affected. 

Diagnosis. — Acute  ascending  paralysis  is  to  be  separated  from  acute  poliomyelitis 
by  the  absence  of  rapid  atrophy.  From  the  paralysis  due  to  an  acute  hemorrhage 
into  the  spinal  meninges  it  is  separated  by  the  absence  of  pain  and  of  spasm.  From 
an  acute  ascending  myelitis  it  is  separated  by  the  fact  that  there  is  no  loss  of  sensa- 
tion, that  the  sphincters  are  unaffected,  and  that  the  paralysis  progresses  more 
rapidly. 

Prognosis. — The  prognosis  depends  upon  the  state  of  the  respiratory  centre  and 
the  lungs,  and  upon  the  condition  of  the  centres  governing  cardiac  action.  If 
these  parts  are  involved,  death,  of  course,  speedily  ends  the  case.  Death  may 
come  in  a  few  hours  or  days,  or  not  for  several  weeks.  Cerebral  and  bulbar  symp- 
toms are  always  grave.  A  fatal  ending  usually  occurs,  but  cases  sometimes  improve 
and  recovery  may  occur. 

Treatment. — The  treatment  of  a  patient  suffering  from  Landry's  paralysis  should 
be  almost  identical  with  that  advised  in  cases  of  acute  myelitis.  A  warm  bath 
may  be  given  to  draw  the  blood  to  the  surface,  and  moderate  counter-irritation 
should  be  applied  over  the  vertebra;.  It  is  absolutely  essential  that  perfect  rest 
be  obtained,  and  that  the  patient  shall  lie  upon  the  side  rather  than  upon  his  back 
since  the  dorsal  position  maj'  increase  the  tendency  to  congestion  of  the  cord. 
As  the  disease  is  probably  dependent  upon  infection  and  toxemia,  the  skin  should 
be  kept  active  by  mild  diaphoretics,  and  the  kidneys  should  be  stimulated  to  activity 
by  the  use  of  the  vegetable  salts  of  potash  or  other  mild  diuretics.  Some  writers 
recommend  the  administration  of  salicylate  of  sodium,  although  they  do  not  seem 
to  be  able  to  explain  how  it  can  do  good.  Gowers  speaks  highly  of  the  use  of 
ergotin,  and  mentions  the  case  of  a  man  of  fifty-seven  who  developed  symptoms  of 
Landry's  paralysis  after  exposure  to  cold  and  wet.  To  this  patient  ergotin  was 
given  every  hour  till  20  grains  had  been  taken,  when  the  symptoms  became  markedly 
improved  and  the  patient  speedily  recovered,  so  that  by  the  end  of  a  week  he  was 
well.  One  cannot  help  feeling  that  in  all  probability  the  ergotin  had  little  to  do 
with  this  remarkable  recovery,  as  it  is  hard  to  see  how  this  drug  could  be  useful  in 
combating  an  infection  which  was  so  severe  in  its  nervous  effects.  When  there  is 
a  history  of  syphilis  the  protiodide  of  mercury  should  be  administered  freely. 


CAISSON  DISEASE. 

Caisson  disease  is  a  condition  met  with  in  persons  who  have  been  exposed  to 
high  atmospheric  pressures  for  a  number  of  hours,  and  is  particularly  prone  to 
develop  if  severe  toil  has  been  maintained  during  the  exposure.  The  disease  is 
usually  met  with  in  artisans,  or  laborers,  who  are  engaged  in  the  building  of  piers 
or  foundations  many  feet  under  water,  where  it  is  necessary  to  have  a  pressure  of 
several  atmosphers  in  order  to  keep  the  caisson  dry.  In  some  instances  the 
pressure  is  as  great  as  ninety  pounds  to  the  square  inch.  The  atmosphere 
in  the  caisson  often  has  a  high  proportion  of  humidity,  and  the  temperature 
may  also  be  quite  high.     The  symptoms  develop  when  the  workman  leaves  the 


856  DISEASES  OF  THE  NERVOUS  SYSTEM 

caisson  and  is  exposed  to  normal  atmospheric  pressure.  In  mild  cases  nothing 
more  than  a  feeling  of  dizziness  and  vertigo  de\elop,  associated,  it  may  be, 
with  neuralgic  pains  in  the  head.  In  severe  cases  the  neuralgic  pains  become 
excruciating,  so  that  the  patient  feels  as  if  his  mu.scles  were  being  stripped  from 
his  bones,  and  this  pain  is  followed  by  a  loss  of  both  motion  and  sensation  in 
the  lower  limbs,  although  the  i)atient  still  complains  of  the  i)ain.  Often  nausea 
and  vomiting  are  present,  accompanied  by  violent  epigastric  paroxysmal  pain. 
Occasionally,  there  is  loss  of  power  in  the  sphincters.  In  some  instances  pain 
is  absent,  but  paralysis  is  present,  paralysis  being  the  more  constant  symptom. 
In  still  more  severe  cases  coma  develops,  in  which  case  death  invariably  results. 
The  prognosis  is  generally  favorable  unless  the  symptoms  of  paralysis  and  pain  are 
imusually  severe.  The  mildest  cases  rarely  last  over  twelve  hours,  sometimes  only 
three  or  four;  but  in  severe  cases,  recovery  may  not  take  ])lace  for  days  or  weeks. 

The  pathology  of  this  curious  condition  is  not  well  understood.  (A  discussion 
of  many  of  the  views  concerning  it  will  be  found  in  the  author's  Fiske  Fund  Prize 
Essay  for  1886.')  It  would  seem  probable  that  the  symptoms  are  largely  dependent 
upon  disorder  of  the  circulation  in  the  central  nervous  .system.  Air  emboli  have 
been  found  in  the  small  arteries  of  the  posterolateral  tracts  of  the  spinal  cord. 
These  vessels  may  rupture  and  allow  blood  and  gas  to  pass  into  the  tissues.  Autopsy 
reveals  congestion  of  the  central  nervous  system  and  at  the  base  of  the  lungs. 
Vacuolated  areas  in  the  cord  indicate  the  presence  of  gas.  In  those  who  recover, 
secondary  softening  may  follow  severe  lesions.  A  microscopic  examination  of  the 
brain  also  reveals  dilatation  of  the  lymph  spaces,  irregularly  distributed  areas  of 
edema,  but  no  changes  in  the  ganglion  cells.  Small  hemorrhagic  extravasations  are 
also  found  in  addition  in  the  pons  and  merlulla  oblongata.  Hemorrhages  in  the 
dorsal  portion  of  the  spinal  cord  are  also  present  and  in  this  area  the  ganglion  cells 
are  degenerated.  Those  who  have  had  a  large  experience  with  the  disease  in  this 
country  are  Jaminet,  Bauer,  and  Woodward,  who  made  many  observations  during 
the  building  of  the  St.  Louis  Bridge,  and  A.  H.  Smith,  of  Xew  York,  who  studied 
it  during  the  building  of  the  Brooklyn  Bridge. 

Treatment. — The  treatment  is  both  prophylactic  and  palliative.  The  prophy- 
laxis consists  in  having  sujjerimposed  air  chambers,  each  one  having  a  different 
pressure  so  that  the  workmen  may  pass  by  degrees  from  the  high-pressure  caisson 
to  the  pressure  of  atmospheric  air.  It  is  also  advisable  to  have  the  workmen 
brought  to  the  surface  with  as  little  muscular  efl'ort  as  possible.  In  the  building 
of  the  St.  Louis  Bridge,  thirteen  of  the  men  who  were  employed  in  the  building 
of  the  east  pier,  which  was  sunk  127  feet  below  high-water  mark,  died;  but  in 
building  the  east  abutment,  which  was  sunk  five  feet  rleeper,  only  one  man  died. 
In  the  latter  case  the  workmen  were  lifted  to  the  surface  by  an  elevator  instead  of 
having  to  climb  a  ladder. 

^Yhen  the  symptoms  come  on,  morphine  should  be  given  hypodermically  in 
adequate  dose.  A.  H.  Smith  considered  that  ergot  is  of  value.  Hot  compresses 
should  be  wrung  out  and  applied  to  the  feet  and  spine.  Jaminet  recommends  a 
draught  of  a  strong  alcoholic  stimulant,  with  ginger. 

The  whole  object  of  the  physician  should  be  to  re-establish  and  equalize  the  cir- 
culation. If  the  pulse  is  full  and  the  heart  laboring,  venesection  should  be  freely 
employed.  Sometimes  relief  can  be  obtained  by  returning  the  patient  to  the 
caisson.  In  some  instances  a  small  caisson  for  the  resuscitation  of  workmen  has 
been  built  im  the  surface,  with  advantageous  results. 

'  New  and  Altered  Forms  of  Disease  due  to  the  Advance  of  Ci\ilization  in  the  Last  Half  Century. 


NEURITIS  857 


DISEASES  IN  WHICH  THE  CHIEF  MANIFESTATIONS  ARE  IN  THE 

NERVES. 

NEURITIS. 

Definition. — Neuritis  i.s  an  inflammation  of  a  nerve.  When  tiie  inflammatory 
process  chiefly  involves  the  perineurium  it  is  called  "perineuritis;"  if  the  tissue 
surrounding  the  nerve  bundles  and  between  the  nerve  fibres  are  aft'ected,  it  is  an 
"interstitial  neuritis,"  and  if  the  nerve  fibres  themselves  are  primarily  affected 
it  is  said  to  be  a  "parenchymatous  neuritis."  The  latter  condition  is  usually  a 
subacute  or  chronic  process  and  is  characterized  by  degenerative  changes  in  the 
nerve  fibres.  The  distinction,  however,  between  these  different  forms  is  theoretical 
rather  than  clinical,  because  it  is  not  possible  to  draw  a  definite  line  between  them 
in  most  cases. 

Etiology. — The  causes  of  neuritis  are  very  numerous.  Any  injury  to  a  ner\-e 
trunk,  as  by  a  blow,  stretching,  or  a  wound,  may  give  rise  to  the  inflammatory 
process,  as  may  also  tumors,  which  by  pressure  cause  irritation.  Sometimes  the 
use  of  a  tool  or  a  crutch  may,  bj^  constant  pressure  on  a  nerve,  produce  neuritis. 
Various  infectious  diseases  and  the  abuse  of  alcohol  may  produce  it,  as  may  also 
many  of  the  metallic  poisons.  In  those  cases,  however,  in  which  the  malady  arises 
as  the  result  of  a  poison,  the  neuritis  is  usually  a  multiple  neuritis  and  does  not 
affect  one  nerve  alone.  (See  Multiple  Neuritis.)  Gout  and  lithemic  states  also 
cause  it. 

Pathology  and  Morbid  Anatomy. — The  nerve,  which  is  acutely  inflamed,  is  found 
on  examination  to  be  red  and  swollen  and  lacking  its  usual  lustre;  the  bloodvessels 
supplying  it  are  hyperemic  or  congested.  If  the  process  has  been  present  for  some 
time  the  nerve  may  be  marked  by  swellings  due  to  overgrowth  of  connective  tissue 
and  its  endoneurium  may  be  infiltrated  by  small  cells.  At  this  time  one  of  three 
processes  develops.  Either  the  results  of  the  acute  inflammatory  process  undergo 
resolution  or  the  inflammation  becomes  so  severe  that  the  nerve  is  destroyed,  or 
if  the  process  is  more  moderate,  but  continued,  there  is  an  overgrowth  of  connective 
tissue  and  gradual  atrophy  and  loss  of  function.  Microscopically,  the  inflamed 
nerve  presents  additional  changes  which  serve  to  separate  the  parenchymatous 
form  of  the  disease  from  that  in  which  the  perineurium  and  interstitial  tissues  are 
chiefly  affected.  In  the  parenchymatous  type  the  myelin  is  opaque  and  swollen 
and  soon  undergoes  segmentation  with  granular  material  between  the  segments. 
The  axis  cylinder  may  be  continuous  or  broken  into  segments  corresponding  to  the 
breaks  in  the  myelin.  Finally,  the  myelin  and  cylinder  entirely  disappear  and 
only  the  nerve  sheath  containing  a  little  granular  matter  is  left.  This  last  state 
may  also  arise  as  a  result  of  the  interstitial  form  of  neuritis,  but  in  this  form  the 
nerve  is,  in  the  early  stage  of  the  inflammation,  more  swollen  and  congested  and 
the  sheath  filled  with  serum  or  purulent  exudate. 

Symptoms. — The  symptoms  of  neuritis  vary  over  a  wide  range  in  severity.  When 
the  inflammatory  process  is  very  mild  so  that  the  normal  function  is  but  slightly 
perverted,  as  from  moderate  pressure,  a  tingling  sensation  is  felt  or,  in  its  place, 
a  sense  of  numbness  is  experienced.  This  is  called  jMresthesia  and  can  scarcely 
be  said  to  be  due  to  any  real  change  in  the  nutrition  of  the  nerve. 

When  the  change  in  the  nerve  is  more  severe  the  symptoms  are  more  definite. 
Tingling  or  pricJcing  sensations  may  be  present  not  only  at  the  site  of  the  lesion,  ' 
but  at  the  peripheral  part  of  the  nerve.  If  the  damage  is  the  result  of  pressure 
there  is  rarely  any  pain,  and  motor  paralysis,  more  or  less  complete,  is  present 
instead.  If,  on  the  other  hand,  the  lesion  is  associated  with  any  wound,  and  an 
infection  of  the  nerve  has  taken  place,  then  'pain  is  usually  present  and  is  often 


858  DISEASES  OF  THE  NERVOUS  SYSTEM 

severe.  Pressure  upon  the  inflamed  nerve  trunk  by  the  fin<;er-ti|)s  also  increases 
tiie  pain  not  only  at  the  point  of  pressure,  but  at  the  end  of  the  nerve  as  well. 
After  the  process  in  the  nerve  is  so  advanced  that  its  function  is  {;reatly  impaired, 
trophic  changes  occur  in  the  muscles  and  skin,  the  former  ira.s-fiiui  and  tlie  .s7,-//i 
becoming  glossy.  The  muscles  cease  to  respond  fo  faradic  elecfricifi/  and  later  fail  to 
respond  to  galvanic  electricity,  the  reactions  of  degeneration  being  first  (ievcl()i)ed. 
Injuries  to  parts  supplied  by  the  nerve  afl'ectcd  may  result  in  slougliing,  but  sores 
rarely  develop  unless  an  injury  is  sufferefl. 

When  recovery  begins  the  electrical  contractility  to  galvanic  stimulation  first 
returns  in  part  and  later  the  power  of  vohnitary  movement. 

Diagnosis. — The  diagnosis  of  neuritis  invohing  a  single  nerve,  or  several  nerves 
in  nearly  related  parts,  is  not  difficult,  for  the  paiii  is  limited  to  the  area  of  the  nerve, 
as  is  also  the  anesthesia  or  hyjieresthcsia  and  loss  of  power.  The  condition  is 
also  pointed  to  by  the  history  of  injury  or  of  some  diathetic  state  which  produces 
the  affection.     Pressure  on  the  nerve  trunk  will  elicit  pain. 

Prognosis. — The  outlook  for  recovery  in- most  cases  of  neuritis  is  quite  good 
because  of  the  extraordinary  power  of  regeneration  possessed  by  nerves.  Even  if 
the  damage  to  the  nerve  has  been  so  severe  that  its  function  is  abolished  by  the 
division  of  all  its  conducting  fibres,  the  function  can  be  restored  by  the  surgeon, 
who,  by  excising  the  destroyed  portion  and  joining  the  distal  and  proximal  ends 
together,  may  re-establish  the  pathway  for  both  sensory  and  motor  impulses. 
So  rapid  is  the  regeneration  that  if  a  nerve  is  severed  by  accident,  and  immediately 
sewed  together,  power  may  return  in  two  weeks.  When  the  damage  has  been 
done  by  pressure  or  inflammation  the  recovery  rarely  ensues  in  less  than  six  weeks, 
and  even  eight  months  or  a  year  may  be  consumed  in  the  regenerative  process. 
When  recovery  fails  to  occur  and  it  is  believed  that  only  a  small  part  of  the  nerve 
is  diseased  surgical  procedures  are  necessary,  but  if  there  is  reason  to  believe  that 
permanent  damage  to  a  large  part  of  a  nerve  has  taken  place,  then  the  prognosis  is 
hopeless.  Sometimes  the  mere  exposure  of  the  nerve  and  the  breaking  up  of 
adhesions  or  exudates  that  cause  pressure  is  sufficient  to  produce  recovery. 

Treatment. — The  treatment  of  neuritis  may  be  divided  into  two  parts,  that 
devoted  to  the  relief  of  pain  and  that  to  the  abatement  of  the  inflammation  and  to 
the  regeneration  of  normal  function.  For  the  relief  of  pain  the  part  affected  may  be 
wrapped  in  lint,  which  is  heavily  smeared  with  equal  parts  of  an  ointment  of  ichthyol 
and  lanolin,  outside  of  which  is  placed  some  oil-silk  to  retain  moisture.  In  some 
instances  a  hot  poultice  of  flaxseed  or  hot  compresses  may  be  used  in  the  earlier 
stages  to  diminish  the  activity  of  the  inflammatory  process.  If  the  pain  is  so 
severe  that  sleep  is  interfered  with,  the  ^•arious  coal-tar  products  may  be  employed, 
of  w^hich  the  most  valuable  are  phenacctin  in  the  dose  of  5  grains  four  or  five  times 
a  day,  if  need  be.  Acetanilid  may  be  given  in  similar  dose,  and  antipyrin  in  slightly 
larger  dose.  On  other  cases  better  results  accrue  if  to  these  products  of  the  coal-tar 
group  are  added  small  doses  of  codeine  or  morphine.  If  the  pain  does  not  yield 
to  these  remedies,  hypodermic  injections  of  morphine  may  be  necessary  for  a  short 
time,  but  their  continued  use  is  dangerous,  as  the  patient  only  too  readily  develops 
the  morjihine  habit.  If  the  neuritis  aft'ects  the  arm  or  some  portion  of  the  body 
which  docs  not  by  its  disability  force  the  patient  to  lie  in  bed,  it  is  essential  that 
the  part  involved  shall  be  placed  at  rest.  Thus,  if  the  arm  is  afl'ected  it  should  be 
carried  in  a  sling,  and  it  may  be  necessary  to  protect  it  by  a  splint. 

For  the  restoration  of  function  no  therajjcutic  measure  should  be  instituted 
beyond  those  already  named  until  the  acute  stage  of  the  inflammatory  process 
has  ceased.  When  it  is  evident  that  the  acute  process  is  no  longer  present,  strych- 
nine or  nux  vomica  may  be  given  internally  in  full  doses.  These  may  also  be 
combined  with  phosphorus  and  small  quantities  of  quinine.  The  area  of  the  skin 
which  is  supplied  by  the  afl'ected  nerve  should  also  be  stimulated  by  the  application 


NEURITIS  859 

of  faradic  electricity,  care  being  taken  that  the  current  employed  is  not  so  strong 
as  to  damage  the  part.  It  is  a  good  rule  never  to  use  a  current  so  strong  as  to 
produce  suffering.  This  method  of  treatment  not  only  tends  to  rapidly  restore 
sensation  in  the  paralyzed  part,  hut  also  to  bring  back  faradic  contractility  in  the 
muscle,  and  so  ultimately  restore  motor  power.  If,  however,  the  parts  fail  to 
respond,  then  galvanic  electricity  must  be  used,  and  the  current  -interrupted  so  as 
to  produce  a  stimulant  effect.  In  some  instances  the  mu.scle  seems  to  respond 
better  to  the  negative  than  to  the  positive  pole,  much  depending  of  course  upon 
the  stage  of  degeneration  which  is  present.  Care  should  be  taken  that  the  applica- 
tions of  electricity  are  not  prolonged  for  more  than  a  few  minutes  at  a  time,  and 
that  they  are  not  made  oftener  than  once  a  day.  Additional  measures  for  improving 
the  nutrition  of  the  part  are  massage  and  manipulation.  None  of  these  measures 
should,  however,  be  employed  if  there  is  tenderness  in  the  nerve  trunk  or  if  they 
produce  exhaustion  in  the  parts  affected.  Indeed,  it  is  possible  in  some  instances  to 
produce  injuries  of  the  nerve  by  too  active  manipulation.  It  must  be  remembered 
that  the  electricity,  the  massage,  and  the  Swedish  movements  only  do  good  by 
increasing  the  circulation  and  modifying  the  nutritional  processes  in  the  parts 
affected.  If  anesthesia  of  an  extremity  exposes  it  to  injury,  by  reason  of  the 
patient  being  unconscious  of  the  presence  of  heat  or  cold,  or  of  objects  which  are 
capable  of  doing  damage,  the  part  should  be  carefully  protected  by  a  splint  or  soft 
dressing. 

Special  Forms  of  Neuritis. 

Cervicobrachial  Neuritis. — Cervicobrachial  neuritis  follows  injuries  to  the  neck 
and  shoulder,  and  is  usually  produced  by  falls  or  severe  blows.  Symptoms  may 
also  arise  as  the  result  of  disease  of  the  \'ertebrff  or  from  an  aneurysm.  In  other 
cases  the  acute  infectious  diseases  or  gouty  or  rheumatic  conditions,  associated  with 
exposure  to  cold,  seem  to  be  responsible  for  the  condition.  The  symptoms  depend 
to  a  large  extent  upon  the  portion  of  the  cervicobrachial  plexus  which  is  affected. 
If  the /our  upper  cervical  nerves  are  involved,  severe  pain  in  the  neighborhood  of  the 
occiput  is  felt,  and  the  head  is  held  in  a  fixed  position  because  movement  increases 
the  suffering.  When  the  fifth  or  sixth  cervical  nerves  are  involved,  the  pain  is  in 
the  neck  and  the  upper  portion  of  the  shoulder  and  axilla,  and  it  may  be  felt  down 
the  back  of  the  arm.  Whereas,  when  the  lower  cervical  nerves  are  affected,  includ- 
ing the  branches  of  the  first  dorsal,  the  pain  is  clavicular  and  axillary  in  the  area 
of  its  distribution  and  extends  down  the  front  of  the  arm  and  forearm  into  the 
fingers.  There  is  also  loss  of  power  in  all  the  muscles  which  are  supplied  by  the 
nerves  making  up  the  cervicobrachial  plexus  when  their  fibres  are  invoh-ed.  Because 
of  the  fact  that  the  cervical  sympathetic  nerve  receives  fibres  from  this  part  of 
the  spinal  cord  it  sometimes  happens  that  ocular  symptoms  accompany  manifesta- 
tions of  the  neuritis  in  the  lower  portions  of  the  cervicobrachial  plexus,  with  the 
result  that  there  may  be  retraction  of  the  eyeball  and  narrowing  of  the  palpebral 
fissure,  with  a  mild  degree  of  myosis  and  some  pallor  of  the  side  of  the  face  affected. 
The  skin  on  this  side  is  dry  and  does  not  become  flushed  on  exercise.  Cases  of 
neuritis  of  the  cervicobrachial  plexus  show  marked  evidences  of  pain  when  pressure 
is  made  over  the  plexus  or  when  the  arm  is  moved  away  from  the  body. 

The  same  numbness  and  tingling  as  has  been  described  under  neuritis  in  general, 
followed  by  loss  of  sensation  and  of  motor  power,  occurs  in  cervicobrachial  neuritis. 
Trophic  changes  in  the  skin  and  muscles  take  place,  and  the  reactions  of  degenera- 
tion develop. 

In  some  instances  of  cervicobrachial  neuritis  of  very  sudden  onset  actual  hemor- 
rhage may  occur  into  the  sheath  of  the  nerves,  the  so-called  "apoplectic  neuritis." 

Before  making  a  positive  diagnosis  of  cervicobrachial  neuritis  exclude  cervical 
rib. 


SCO  DISEASES  OE  THE  XERVOCS  SYSTEM 

Prognosis. — Tlit'  jjrof^iiosis  in  cases  of  cervicobradiial  neuritis,  like  that  of  neuritis 
in  i,'('n(Tal,  is  j,'oo(l  ])r<)vi(le(l  the  injury  has  not  been  so  severe  as  to  sc\(t  tlie  nerve 
fibres,  and  ])ro\i(ie(l  tiie  condition  has  not  histed  too  long. 

Treatment. — Tiie  treatment  consists  in  absolute  rest,  the  employment  of  liot 
compresses  if  the  conflition  is  seen  early  in  its  course,  and  later  on  the  constant 
use  of  counter-irritation.  It  is  often  advisable  to  carry  the  affected  arm  in  a  sling 
or  to  render  it  immoblie  by  placing  it  upon  a  right-angle  splint.  Rubbing  the 
parts  with  some  stimulating  liniment  like  that  of  chloroform  or  anmionia  is  of 
value.  Electricity,  massage,  and  Swedish  movements  are  to  be  resorted  to  after 
all  evidence  of  acute  inflammation  is  passed.  The  rest  of  the  treatment  is  identical 
with  tliat  given  for  neuritis. 

Obstetrical  or  Birth  Palsy. — A  paralysis  of  brachial  nerves  is  a  frequent  occur- 
rence in  (liJiicult  and  protracted  labors,  especially  in  cases  of  breech  presentation. 
Pressure  with  the  finger  or  tenaculum  introduced  into  the  axilla  in  order  to  facilitate 
delivery  will  injure  the  nerves  and  produce  paralysis.  In  birth  pal.sy  the  following 
muscles  are  affected;  deltoid,  biceps,  supinator  longus,  and  infraspinatus.  This 
leads  to  inward  rotation  of  the  arm,  extension  of  the  forearm,  and  pronation  of  the 
hand.  The  paralysis  is  soon  followed  by  atrophy  of  the  muscles.  The  prognosis 
of  birth  palsy  is,  generally  speaking,  favorable,  except  when  reaction  of  degeneration 
exists.  As  to  treatment,  massage  and  electricity  are  the  only  means,  and  should 
commence  as  early  as  possible. 

Sciatica. — Sciatica,  or  pain  in  the  course  and  distribution  of  the  sciatic  nerve 
is  usually  unilateral  and  occurs  as  sciatic  neuralgia  and  as  the  result  of  a  true 
sciatic  neuritis.  The  onset  of  the  pain  is  generally  sudden  and  it  may  vary  in 
severity  from  a  dull  ache  to  agony.  In  some  instances  the  pain  is  felt  only  near 
the  sciatic  notch;  in  others  it  extends  all  the  way  to  the  foot.  In  still  ( ther  cases 
pain  is  felt  in  the  thigh  and  a  .sense  of  fullness  or  numbness  in  the  leg.  Sciatic 
neuritis  is  to  be  separated  from  neuralgia  by  the  fact  that  in  the  latter  state  flexing 
the  thigh  on  the  trunk  and  extending  the  leg  does  not  increase  the  pain  and  by 
the  fact  that  the  neuralgic  pain  is  not  so  prone  to  be  constant.  Care  must  be 
taken  before  reaching  a  diagnosis  of  sciatica  that  sacro-iliac  strain  is  excluded  and 
that  flat-foot  is  not  responsible  for  the  pain.  In  .some  instances  sciatic  pain  is 
due  to  a  growth  in  the  spine  or  in  the  pelvis.  Sometimes  a  sarcoma  of  the  femur 
gives  rise  to  a  diagnosis  of  sciatica. 

Treatment. — The  treatment  of  sciatic  neuralgia  consists  in  the  use  of  coal-tar 
analgesics  such  as  phenacetin,  combined  with  salicylates,  and  avoidance  of  cold 
and  damp.  When  neuritis  is  present  these  facts  are  also  essential  and  in  addition 
wet  or  dry  cups  may  be  used  over  the  nerve,  or  the  leg  protected  by  cloth  or  news- 
paper and  ironed  with  a  hot  laundry  iron.  ]\Ior])hinc  or  codeine  may  be  needed 
if  the  pain  is  excessive.  In  obstinate  cases  the  ner\e  should  be  exposed  and  any 
adhesions  broken  up. 

Multiple  Neuritis.  —  Definition  and  Etiology.  —  Multiple  neuritis,  .sometimes 
called  "polyneuritis"  or  " i)eri[)heral  neuritis,"  is  a  condition  in  which  a  large 
number  of  the  peripheral  nerves  of  the  body  suft'er  from  subacute  or  chronic  inflam- 
mation as  a  result  of  the  action  of  some  toxic  agent.  These  toxic  agents  may  be 
derived  from  external  or  internal  sources.  The  external  agents  are  alcohol,  lead, 
arsenic,  copper,  mercury,  anilin,  carbon  monoxide,  and  carbon  bisulphide.  The 
internal  agents  are  the  j)oisons  develojied  in  the  \'arious  acute  infectious  fevers, 
as  typhoid  lever,  smallpox,  scarlet  fever,  influenza,  erysii)elas,  pneumonia,  diph- 
theria, dysentery,  and  other  infectious  maladies.  Occasionally',  too,  a  multiple 
neuritis  develops  as  a  comiilication  of  septic  infection,  either  that  following  a 
wound  or  occurring  during  the  puerperal  period.  Cases  have  also  been  recorded 
in  which  the  toxic  substance  apparently  has  arisen  from  decomposition  changes 
in  the  intestines.     In  some  instances  syphilis,  tuberculosis,  diabetes  mellitus,  and 


NEURITIS  ■SOI 

malarial  fever  have  seemed  to  be  provoking  agents,  but  in  all  probability  these 
affections  act  indirectly  by  rendering  the  nerve  trunks  susceptible  to  the  action 
of  the  poison.  A  special  form  of  multiple  neuritis  is  that  which  is  kufmn  as  beriberi 
or  "kakke."  (See  Beriberi.)  In  several  instances  small  epidemics  of  multiple 
neuritis  have  been  described.  Multiple  neuritis  occurs  most  frequently  between 
the  twentieth  and  the  fiftieth  year  of  age,  and  is  very  rare  in  children,  unless  it  is 
due  to  diphtheria.  Whatever  may  be  the  cause  of  an  attack  of  multiple  neuritis, 
the  pathological  changes  which  are  found  in  the  affected  nerves  do  not  differ  greatl\- 
from  those  already  described  as  occurring  in  ordinary  neuritis  of  a  more  limited 
extent. 

Symptoms. — The  symptoms  of  multiple  neuritis,  be  the  cause  what  it  may,  are 
fairly  constant,  although  slight  variations  in  the  character  of  the  symi)toms  occur 
according  to  the  peculiar  influence  exercised  by  the  poison.  As  alcoholic  neuritis 
is  the  type  most  frequently  met  with,  a  description  of  this  disease  may  be  used 
for  all  forms  of  multiple  neuritis.  At  the  beginning  of  the  malady  there  ma>-  be 
some  slight  elevation  of  temperature,  but  in  many  cases  this  does  not  occur.  The 
patient  first  complains  of  tingling  or  numbness  in  the  feet  and  fingers.  In  other 
cases  dull  pain  may  be  experienced.  Rarely  this  pain  may  be  severe.  These 
disturbances  of  sensation  are  usually  increased  by  moving  the  affected  limb  and 
by  deep  or  superficial  pressure  over  thcnerve  trunks,  and  especially  by  deep  pressure 
upon  the  muscle  bellies  of  the  forearms  and  of  the  calves. 

Following  these  symptoms  weakness  develops,  and  it  may  become  so  severe 
that  the  patient  is  unable  to  move  his  hands  or  feet,  and  foot-drop  or  wrist-drop 
may  develop.  After  the  paralysis  has  lasted  for  some  little  time,  some  wasting  of 
the'  muscles  of  the  affected  parts  takes  place.  The  reflexes  are  diminished  or 
altogether  arrested. 

A  peculiarlity  of  the  paralysis  of  peripheral  neuritis  is  that  very  often  it  does  not 
involve  all  the  nerves  of  a  limb.  Thus,  it  not  infrequently  happens  that  the  pero- 
neal nerves  suff'er  chiefly.  In  other  instances  the  tibialis  posticus  is  chiefly  affected ; 
and  it  is  only  when  the  condition  is  unusually  severe  that  a  complete  paraplegia 
is  present.  In  the  arms  the  musculospiral  nerve  is  most  commonly  affected.  It  is 
a  noteworthy  fact  that  the  paralysis  is  usually  symmetrical.  In  some  instances  the 
symptoms  are  more  sensory  than  motor,  but  this  is  rarely  the  case.  Sensory 
symptoms  are,  however,  very  constant  in  alcoholic  neuritis,  and  in  most  of  the 
other  forms.  They  may,  however,  be  absent  or  be  very  slight,  as  in  neuritis  due 
to  lead,  and  in  such  forms  of  infectious  disease  as  diphtheria  and  influenza.  These 
forms  of  neuritis  are  often  spoken  of  as  "motor  neuritis"  to  indicate  that  the 
sensory  functions  escape. 

In  addition  to  the  numbness  and  tingling  already  mentioned,  patches  of  anes- 
thesia and  hyperesthesia  are  often  found  existing  near  one  another  or  even  coincid- 
ing. So,  too,  there  may  be  a  hypersensitiveness  to  pain  and  a  loss  of  the  sense 
of  touch,  or  vice  versa. 

Not  infrequently  the  affection  develops  a  train  of  symptoms  which  are  so  exactly 
like  those  met  with  in  locomotor  ataxia  that  even  the  most  skilful  neurologist 
may  have  difficulty  in  differentiating  the  two  diseases.  In  other  words,  a  so-called 
"  pseudotabes"  due  to  multiple  neuritis  is  present.  This  resemblance  depends  upon 
the  fact  that  the  fibres  for  "muscle  sense"  which  are  affected  in  their  spinal  course 
(posterior  columns)  in  tabes  are  implicated  in  cases  of  multiple  neuritis  in  the 
joints  and  muscle  fascia?.  The  presence  of  the  Argyll-Robertson  pupil  in  true 
ataxia,  however,  usually  determines  that  the  case  is  not  one  of  peripheral  neuritis. 
As  an  illustration  of  how  closely  multiple  neuritis  may  resemble  locomotor  ataxia, 
cases  have  been  reported  in  which  perforating  ulcer  of  the  foot  occurred  due  to 
neuritis. 

Aside  from  the  trophic  changes  already  spoken  of  as  occurring  in  the  muscles, 


8()2  DISEASES  OF  THE  XERVOUS  SYSTEM 

local  disorders  of  blood  supply  and  secretion  are  often  present.  There  may  be 
areas  of  skin  which  suffer  from  excessive  sweating.  In  other  cases  localized  patches 
of  edema  are  found,  and  rarely  the  joints  become  swollen,  so  that  the  case  resembles 
Charcot's  joints  in  ataxia.  Actual  breaking  down  of  the  skin  as  the  result  of 
trophic  changes,  however,  rarely  occurs.  The  bladder  and  rectum  arc  usually 
iniaffected,  and  this  aids  materially  in  separating  the  paraplegia  of  severe  neuritis 
from  that  due  to  myelitis.  Rarely,  however,  this  valuable  aid  to  differentiation 
fails  us,  and  retention  or  incontinence  of  urine  or  feces  is  present. 

Associated  with  these  evidences  of  impairment  in  function  in  the  peripheral 
nerves  it  is  not  infrecjuent  for  disturbances  to  occur  in  connection  with  intellection. 
Confusion  of  thought  and  impairment  of  memory  are  frecjuently  present,  occasion- 
ally in  a  peculiar  form  characterized  by  fabrication  or  "pseudoreminiscence," 
the  patient  relating  imaginary  recent  experiences.  This  mental  condition,  com- 
bined with  multiple  neuritis,  is  sometimes  called  "  Korssakoti"s  disease." 

The  cranial  nerves  also  share  in  the  malady.  Indeed,  in  some  instances  they 
sufl'er  most.  Nystagmus,  or  squint,  may  be  present,  but  the  optic  nerve  is  not 
often  affected,  although  occasionally  it  may  suffer  very  slight  atrophy.  The 
paralysis  of  the  cranial  nerves  may  be  symmetrical.  Thus,  Oppenlieim  has  reported 
cases  of  double  facial  palsy  due  to  this  cause. 

Tachycardia  and  interference  with  the  function  of  the  diaphragm  may  be  mani- 
fested from  tlie  infection  involving  the  pneumogastric  and  phrenic  nerves.  Manna- 
berg  asserts  that  the  multiple  neuritis  may  be  confined  entirely  to  the  cranial  nerves. 

When  the  multiple  neuritis  is  due  to  lead,  it  is  a  noteworthy  fact  that  tiie  inflam- 
matory process  is  not,  as  a  rule,  very  widely  distributed,  and  that  the  sensory 
nerve  fibres  usually  escape.  In  association  with  the  symptoms  of  neuritis,  already 
described,  there  may  be  a  history  of  lead  colic,  which  will  aid  in  determining  the 
cause  of  the  paralysis.  The  presence  of  a  blue  line  on  the  gums  is  also  pathogno- 
monic. Anemia  is  often  marked.  Aside  from  the  fact  that  sensation  is  usually 
not  involved,  the  multiple  neuritis  caused  by  lead  is  noteworthy,  in  that  it  chiefly, 
and  it  may  be  exclusively,  aft'ects  the  extensor  muscles  of  the  hand  and  fingers. 
Indeed,  the  paralysis  may  be  so  localized  in  mild  cases  that  only  the  extensor 
communis  digitorum  may  be  involved,  so  that  the  ring  and  little  finger  cannot  be 
extended.  When  the  paralysis  is  very  marked,  double  drop-wrist  is  present. 
Another  peculiarity  of  lead  palsy  is  that  the  supinators,  especially  the  supinator 
longus,  and  the  triceps,  escape.  The  deltoid,  however,  may  be  partially  paralyzed, 
and  the  abductor  pollicis  longus  and  the  interossei  may  be  palsied.  Occasionally, 
however,  the  supinators  are  affected,  as  is  also  the  biceps.  ^Muscular  atrophy 
is  nearly  always  marked  in  lead  paralysis,  and  the  reaction  of  degeneration  usually 
speedily  develops.  Muscular  tremor  may  also  be  present.  The  noteworthy 
fact  that  sensation  is  not  disturbed  in  most  cases  may  be  well  reiterated.  Drop-foot 
is  rarely  seen  in  cases  of  lead  paralysis.  Paralysis  of  the  cranial  nerves  due  to  lead 
is  exceedingly  uncommon.     (See  Lead  Poisoning.) 

When  the  paralysis  is  due  to  arsenic,  it  is  not  infrecpiently  associated  with  gastro- 
intestinal disturbances,  and,  unlike  that  due  to  lead,  it  is  usually  associated  with 
marked  disturbances  of  sensation  in  the  afl'ected  parts.  Wasting  of  the  muscles 
supplied  by  the  affected  nerves  usually  develops  cjuite  early.  Not  only  are  the 
extensors  affected,  as  they  are  in  lead  poisoning,  but  the  flexors  are  also  involved. 
Another  point  of  difference  between  arsenical  paralysis  and  that  due  to  lead  lies 
in  the  fact  that  the  lower  extremities  are  cpiite  as  frequently  affected  as  the  upper 
extremities,  so  that  quadriplegia,  that  is,  a  paralysis  of  all  four  extremities,  is 
present.  Iteactions  of  degeneration  speedily  develop.  The  pulse  is  apt  to  be 
rapid.  Disturbances  of  the  psychic  functions  are  said  to  occur,  which  is  rare  in 
lead  poisoning,  unless  encephalopathia  saturnina  is  present.  Symptoms  of  ataxia 
are  usually  marked.     The  reflexes  are  lost,  and  these  two  factors  may  make  the 


NEURITIS  803 

case  more  closely  resemble  true  locomotor  ataxia  than  any  other  form  of  multiple 
neuritis.  Nutritional  changes  in  the  skin  are  quite  frequent  in  arsenical  neuritis. 
In  some  instances  herpetic  eruptions  develop.  In  others  the  skin  becomes  glossy, 
and  there  may  be  falling  out  of  the  hair.  It  is  exceedingly  rare  for  the  cranial 
nerves  to  be  involved. 

Of  all  the  forms  of  multiple  neuritis  due  to  toxic  substances  having  their  origin 
in  the  body,  that  due  to  the  poison  of  diphtheria  is  most  frequently  met  with.  As 
diphtheria  is  essentially  a  disease  of  childhood,  it  is  evident  that  diphtheritic  multi- 
ple neuritis  must  be  more  commonly  met  with  in  young  persons.  Tiie  peculiarity 
of  this  form  of  neuritis  is  that  it  most  frequently  affects  the  muscles  of  the  soft 
palate,  changing  the  character  of  the  speech  and  rendering  swallowing  difficult. 
This  paralysis  is  both  motor  and  sensory,  and  is  often  accompanied  by  wasting. 
Sometimes  the  external  ocular  muscles  are  paralyzed.  In  other  instances  the 
internal  ocular  muscles  sufl'er  chiefly,  and  accommodation  may  be  paralyzed  as 
the  result  of  oculomotor  involvement.  The  pupillary  reflex  is,  however,  usually 
preserved.  In  other  instances  the  paralysis  produced  by  diphtheria  is  almost 
universal.  I  have  seen  more  than  one  instance  in  which  the  child  was  not  only 
paralyzed  in  all  its  extremities,  but  was  unable  to  exercise  any  control  o^^er  the 
movements  of  its  head,  and  could  only  swallow  when  put  in  such  a  position  that 
the  liquids  could  readily  pass  down  the  gullet.  Such  cases  are  usually  characterized 
not  only  by  loss  of  motor  power,  but  by  loss  of  sensation  as  w^ell.  The  bladder 
and  rectum  usually  escape  the  general  paralysis,  but  they  may  be  involved.  It  is 
a  noteworthy  fact  that  diphtheritic  paralysis  is  not  a  concomitant  symptom,  but  a 
sequel  to  an  attack  of  diphtheria,  and  the  full  severity  of  the  symptoms  may  not 
be  present  for  several  weeks  after  the  diphtheria  has  ceased.  In  some  instances 
the  diaphragm  is  paralyzed,  and  if  the  nerve  supply  of  the  heart  becomes  affected 
sudden  death  may  occur.     (See  Diphtheria.) 

Diagnosis. — The  presence  of  numbness  and  tingling  followed  by  more  or  less 
impairment  of  motion  and  sensation  in  certain  nerve  trunks,  with  complete  or 
partial  escape  of  other  nerve  trunks,  of  course,  points  to  multiple  neuritis  as  the 
cause  of  the  malady,  particularly  if  the  history  of  the  patient  reveals  the  fact 
that  he  or  she  has  been  exposed  to  one  of  the  provoking  causes  already  named. 
In  some  instances  more  than  one  of  these  causes  has  been  effective,  and,  therefore, 
the  precise  factor  in  determining  the  neuritis  cannot  be  relied  upon.  Thus,  I 
have  known  more  than  one  instance  in  which  the  administration  of  very  large 
quantities  of  alcohol  as  a  stimulant  during  typhoid  fever  has  produced  a  multiple 
neuritis,  which  was  attributed  to  a  typhoid  toxin,  wdien  in  reality  the  alcohol  was 
the  active  agent.  In  those  cases  in  which  the  paralysis  comes  on  ^'ery  rapidly 
and  is  severe,  the  differentiation  must  be  made  between  this  condition  and  Landry's 
paralysis  (which  see),  and  this  is  the  more  important  because  Eichliorst  has  described 
a  neuritis  acutissima  progressiva.  A  so-called  apoplectiform  type  has  been  described 
by  other  observers.  The  presence  of  the  Argyll-Robertson  pupil,  optic  nerve 
atrophy,  and  the  laboratory  examination  of  the  blood  and  cerebrospinal  fluid 
on  the  one  hand,  and  the  history  of  exposure  to  a  poison  on  the  other  hand,  aid 
us  in  differentiating  between  true  locomotor  ataxia  and  multiple  neuritis. 

Prognosis. — The  prognosis  is  favorable  in  nearly  every  case,  unless  the  patient 
has  been  exposed  to  the  evil  influences  of  lead  or  arsenic  or  alcohol  for  so  long  a 
time  that  the  nerves  cannot  undergo  regenerative  change.  In  cases  of  profound 
alcoholic  intoxication  sudden  death  may  take  place  when  the  pneumogastric 
nerve  becomes  involved.  In  nearly  all  instances  recovery  is  exceedingly  slow. 
The  first  symptom  of  improvement  is  a  diminution  in  the  pain  and  a  decrease  in 
tenderness  of  the  nerves  on  palpation.  In  other  instances  the  power  of  motion 
returns  before  the  sensory  functions  are  restored  to  their  normal  condition,  and 
inability  to  get  about  may  be  caused  by  the  intense  hj-persensitiveness  of  the  feet. 


S(i4  DISEASES  OF  THE  XERVOCS  sySTE}f 

Even  if  the  patient  does  not  recover  for  eif^htecn  inontiis  or  two  years,  the  condition 
is  by  no  means  hopeless.  Care  should  he  taken,  however,  that  complete  recovery 
should  not  be  promised  in  cases  which  have  been  exjmsed  to  the  poisons  for  very 
long  periods  of  time.  Not  infrequently  great  disappointment  is  caused  by  periods 
in  which  no  improvement  takes  place,  or,  indeed,  in  wliicli  a  relapse  seems  to  be 
threatened. 

The  prognosis  in  multiple  neuritis  due  to  lead  is  good  so  far  as  the  preservation 
of  life  is  concerned.  It  is  bad  in  direct  proportion  to  tiie  duration  of  the  condition 
and  of  the  exposure  to  the  poison.  The  same  facts  hold  true  in  regard  to  the 
peripheral  neuritis  due  to  arsenic. 

Occasionally  secondary  contractures  occur  as  the  result  of  the  contraction  of 
non-paralyzed  muscles,  whereby  deformities  are  produced. 

After  diphtheria,  even  in  tho-se  cases  in  which  the  paralysis  is  most  severe,  the 
progress  is  not  necessarily  very  grave.  The  immediate  danger  is  that  some  nervous 
mechanism  connected  with  a  vital  function  may  be  involved.  If  this  does  not 
occur,  partial  or  complete  recovery  of  motion  or  sensation  nearly  alwax's  takes 
place,  although  twelve  months  may  pass  before  recovery  occurs.  Usually,  however, 
two  or  three  months  is  sufficient. 

Treatment. — The  treatment  of  multiple  neuritis  gives  better  results  tiian  that 
devoted  to  the  relief  of  any  other  form  of  paralysis.  If  the  cause  of  the  malady 
is  one  of  the  metallic  poisons  already  named,  the  patient  must  be  removed  from 
further  exposure  to  the  poison.  Thus,  workers  in  lead  and  arsenic  must  cease 
following  such  occupations.  For  the  purpose  of  aiding  in  the  elimination  of  any 
of  the  poisons  which  may  remain  in  the  body,  moderate  doses,  20  to  30  grains,  of 
iodide  of  potassium  may  be  given  twice  or  thrice  a  day.  If  the  patient  uses  alcohol 
to  excess,  this  agent  must,  of  course,  be  withdrawn.  While  the  ner\es  are  hyper- 
sensitive to  pressure  and  while  pain  is  present,  strychnine  and  faradic  electricity 
should  not  be  applied  to  them,  since  they  tend  to  increase  irritation;  but  when  there 
is  anesthesia  and  loss  of  power,  full  doses  of  strychnine  and  phosphorus  are  often 
useful,  and  the  rapidly  interrupted  faradic  current  may  be  used  to  stimulate  the 
affected  nerve  fibres.  Muscles  which  are  sufl'ering  from  loss  of  power  may  be 
exercised  by  the  use  of  the  slowly  interrupted  faradic  current.  ^Massage  may  also 
be  employed,  but  it  is  of  vital  importance  that  no  form  of  exercise  shall  be  used  to 
the  point  of  exhaustion  of  the  affected  parts.  In  other  words,  only  healthy  exercise 
designed  to  improve  the  nutrition  of  the  parts  affected  should  be  resorted  to. 

If  it  is  thought  that  the  neuritis  is  due  to  toxic  materials  arising  inside  the  body, 
these  should  be  removed,  if  possible.  The  administration  of  laxatives  or  purges 
is  usually  needful.  If  anemia  is  present,  particularly  if  it  is  associated  with  septic 
conditions  such  as  are  met  with  in  sepsis  and  puerperal  fever,  iron  and  arsenic  are 
useful.  If  the  patient  is  rheumatic  or  of  gouty  tendency,  hot  baths,  or  a  visit  to  any 
of  the  well-known  hot  springs  may  be  resorted  to,  anfl  the  \"arious  salicylates  or 
iodides  should  be  administered  in  sufficiently  full  doses  to  produce  mild  physiological 
effects.  For  the  purpose  of  aiding  in  the  elimination  of  toxic  materials,  pure  water 
should  be  drunk  freely  to  flush  the  kidneys,  and  Turkisli  iiaths  may  be  taken  to 
produce  sweating.  Pain  is  to  lie  relieved  by  the  use  of  such  remedies  as  jihenacetin 
or  acetanilld,  and  by  hot  applications  to  those  areas  wiiich  suffer  most.  Sometimes 
the  aijplication  of  splints  to  proNide  perfect  rest  for  the  painful  part  is  useful. 

In  those  forms  of  multiple  neuritis  which  depend  upon  infection,  such  as  diph- 
theria, smallpox,  or  typhoid  fever,  the  heart  should  be  carefully  examined,  and  if 
any  evidences  of  tachycardia,  bradycardia,  or  arhythmia  are  present,  the  patient 
should  be  warned  against  sitting  up  in  bed,  and  should  be  protected  from  all  causes 
which  may  throw  an  increased  strain  upon  the  circulation.  This  is  particularly 
important  in  diphtheritic  multiple  neuritis.  Contractures  should  be  prevented  by 
massage  and  Swedish  movements  and  remedied,  if  they  occur,  by  tenotomy. 


DISEASES  OF  THE  CRANIAL  NERVES  865 

DISEASES  OF  THE  CRANIAL  NERVES. 

The  Olfactory  Nerve. — Disease  of  the  olfactory  nerve,  of  course,  interferes 
with  the  special  sense  of  smell,  and  if  this  sense  is  entirely  lost  the  condition  is 
called  anosmia.  Partial  or  complete  loss  of  this  sense  results  from  lesions  of  the 
peripheral  ending  of  the  nerve  in  the  nasal  mucous  membrane  and  from  pathological 
states  of  the  tissues  beneath  it,  such  as  morljid  growths  or  disease  of  the  ethmoid 
bones.  Similar  loss  of  function  results  from  meningitis,  from  injury  of  the  bones 
forming  the  base  of  the  skull,  or  morbid  growths  affecting  these  bones.  Tumors 
of  the  brain  may  destroy  the  olfactory  nerves  or  the  olfactory  bulbs.  When  com- 
plete loss  of  the  sense  of  smell  occurs  and  no  local  lesion  in  the  nasal  bones  or  mucous 
membranes  is  present,  it  is  usually  an  evidence  of  a  tumor  or  abscess  in  the  anterior 
cranial  fossa. 

The  Optic  Nerve. — The  optic  tract  of  either  side  arises  by  two  roots  from  struct- 
ures in  the  midbrain  called  the  primary  optic  centres.  These  structures  are  the 
external  geniculate  body,  the  posterior  part  (pulvinar)  of  the  optic  thalamus,  and 
the  anterior  quadrigeminal  body. 

It  is  important  to  remember  that  the  fibres  from  the  optic  tract  undergo  partial 
decussation  in  the  chiasm.  The  outer  fibres  do  not  decussate  and  they  connect 
the  outer  half  of  the  retina  with  the  primary  optic  centres  of  the  same  side.  The 
inner  fibres,  on  the  other  hand,  all  cross  to  the  opposite  side,  and  they  connect 
the  inner  half  of  the  retina  with  the  nuclei  on  the  opposite  side.  It  is  evident, 
therefore,  that  the  right  optic  tract  contains  fibres  which  carry  impulses  from  the 
right  halves  of  both  retinte  to  the  right  side  of  the  brain,  and  that  the  left  optic 
tract  contains  fibres  which  convey  impulses  from  the  left  halves  of  both  retinae 
to  the  left  side  of  the  brain.  It  is  essential  to  remember  these  facts  in  order  to 
understand  the  condition  known  as  hemianopsia,  which  will  be  described  shortly. 

Optic  neuritis,  sometimes  called  papillitis,  is  an  inflammatory  condition  which 
is  manifest  in  the  intra-ocular  end  of  the  nerve,  and  it  may  be  due  to  several  causes. 
In  the  great  majority  of  cases  it  is  due  to  brain  tumor.  Choked  disk  is  an  edematous 
state.  The  degree  of  neuritis  has  no  direct  relationship  to  the  size  of  the  tumor, 
nor  to  the  area  of  the  brain  which  it  aft'ects,  although  a  tumor  of  the  corpora  quad- 
rigemina  seems  to  cause  the  condition  more  commonly  than  do  growths  elsewhere. 
Tumor  of  the  parieto-occipital  region  and  of  the  cerebellum  also  produces  papillitis 
in  a  large  proportion  of  cases  in  which  these  growths  occur,  while  a  tumor  of  the 
frontal  lobes  of  the  cerebrum  causes  it  less  frequently.  The  condition  is  not 
materially  affected  as  to  frequency  or  severity  by  the  character  of  the  groMi;h. 
Meningitis  in  any  of  its  forms  may  cause  papillitis,  but  tuberculous  meningitis 
does  so  more  commonly  than  any  other  form.  Rarer  causes  are  cerebral  softening, 
inflammation,  and  atrophy,  or  any  cause,  such  as  aneurysm  or  hydrocephalus, 
which  produces  an  increase  in  intracranial  pressure.  Very  rarely,  general  paresis, 
or  myelitis  may  cause  papillitis,  as  may  the  various  acute  infectious  diseases,  or 
the  excessive  use  of  alcohol,  or  lead  poisoning. 

Symptoms. — There  are  often  no  symptoms  whatever  which  point  to  optic  neuritis, 
at  least  in  so  far  as  the  patient  complains  of  impairment  of  vision.  The  diagnosis 
rests  solely  upon  the  use  of  the  ophthalmoscope  and  upon  a  study  of  the  fields  of 
vision.  The  ophthalmoscope  reveals  an  indefinite  outline  of  the  head  of  the  nerve, 
with  redness,  followed  by  swelling  of  the  papilla,  which  becomes  grayish  in  hue. 
Finally,  the  disk  protrudes,  its  outlines  become  lost  and  whitish  'patches  may  be  seen 
upon  its  surface.  The  retinal  arteries  are  contracted  and  the  veins  co?igesfed  and 
tortuous.  At  the  point  of  exit  and  entrance  of  the  vessels  this  part  may  seem  devoid 
of  vessels,  because  they  are  hidden  in  the  infiltrated  mass.  Small,  narrow,  flame- 
like hemorrhages  may  be  seen  along  the  vessel  walls.  The  field  of  vision  is  concen- 
irirally  contracted,  and  the  jjerccptinn  of  red  and,  green  is  lost  before  the  other  color 


866  DISEASES  OF  THE  XERVOrs  SYSTEM 

senses  are  destroyed.  Hemiannpsia  is  present  if  the  lesion  is  so  situated  as  to  cause 
tliis  symptom. 

Another  form  of  optic  neuritis,  called  retrobulbar  neuritis,  exists  in  which  the 
inflammatory  process  develops  in  the  optic  nerve  in  the  orbit.  In  the  acute  form 
the  symptoms  consist  in  dimness  of  vision  which  always  occurs  in  the  centre  of  the 
field,  and  which  may  end  in  complete  blindness  in  from  one  to  eight  days.  With 
the  ophthalmoscope,  when  the  disease  is  well  developed,  the  edges  of  the  disk  are 
seen  to  be  indistinct,  its  surface  hyperemic,  and  its  main  bloodvessels  slirunken. 
The  cause  of  the  acute  form  is  usually  some  one  of  the  acute  infections,  such  as 
influenza,  scarlet  fever,  or  one  of  the  diathetic  diseases,  such  as  rheumatism,  gout, 
and  sometimes  syphilis. 

The  treatment  of  retrobulbar  neuritis  consists  in  the  production  of  profuse 
sweating  liy  pilocarpine,  the  use  of  large  doses  of  the  salicylates  if  gout  or  rheumatism 
is  present,  or  the  employment  of  mercury  and  the  iodides  if  syphilis  is  suspected. 
Counter-irritation  on  the  temple  is  also  advisable. 

The  chronic  form  of  retrobulbar  neuritis  is  usually  a  toxic  condition  produced,  in 
the  majority  of  instances,  by  tobacco,  alcohol,  arsenic,  lead,  or  poisons  made  by 
infectious  diseases.  Its  symptoms  consist  in  diminution  of  vision  and  in  color 
scotomata.  The  prognosis  when  the  cause  is  tobacco  and  alcohol  is  good,  if  the 
patient  will  give  up  these  drugs,  and  if  he  does  so  in  the  early  stages  of  the  disease ; 
otherwise  the  prognosis  is  bad. 

The  treatment  consists  in  the  elimination  of  the  causes  as  far  as  possible,  in  the 
use  of  massive  doses  of  strychnine,  and  the  employment  of  the  iodides  and  free 
sweating. 

Treatment. — This  depends  upon  the  cause.  If  it  is  due  to  brain  tumor  or  abscess, 
operative  treatment  is  required,  unless  a  gummatous  growth  is  present,  when 
mercury  and  the  iodides  are  needful.  Trephining  of  the  skull  to  relieve  pressure 
may  be  resorted  to  as  a  palliative  measure  in  cases  where  a  growth  cannot  be 
removed, 

Optic  Atrophy. — ^Atrophy  of  the  optic  nerve,  as  its  name  implies,  is  a  condition 
in  which  a  degenerative  process  affects  its  fibres.  It  is  divided  into  five  forms: 
the  primary,  secondary,  consecutive,  retinitic,  and  choroiditic  atrophy.  The  last 
two  forms  are  really  of  the  consecutive  class. 

Etiology. — Primary  atrophy  of  the  optic  nerve  has  been  thought  to  be  due  to 
impaired  nutrition,  sexual  excesses,  and  to  such  diseases  as  chronic  malarial  infection, 
diabetes,  syphilis,  and  to  the  overaction  of  certain  drugs.  The  most  important 
causes  of  primary  optic  atrophy  are  diseases  of  the  spinal  cord,  notably  locomotor 
ataxia.  It  is  also  seen  in  cases  of  general  paresis  and  disseminated  sclerosis.  In 
many  instances  the  optic  atrophy  may  be  one  of  the  early  symptoms  of  ataxia. 
It  has  also  been  met  with  in  cases  of  lateral  sclerosis,  chronic  myelitis,  and  bulbar 
palsy. 

Secondary  atrophy  arises  from  causes  which  produce  pressure  upon  the  optic 
tract  and  tlie  optic  fibres,  as,  for  example,  the  growth  of  a  tumor  or  an  aneurysm, 
or  meningitis.  So,  too,  injuries  to  the  head  sometimes  produce  atrophy.  Con- 
secutive atrophy  follows  the  various  forms  of  optic  neuritis. 

Pathology. — The  axones  lose  their  medullary  sheaths  and  are  converted  into 
fine  fibrils,  between  which  are  interspersed  numerous  fatty  granules.  When  the 
condition  is  far  advanced,  the  nerve  elements  entirely  disappear  and  there  is  a 
marked  increase  in  connective-tissue  formation. 

Symptoms. — The  subjective  sjTnptom  complained  of  by  the  patient  is  diminution 
in  the  acuiti/  of  vision.  The  other  symptoms  are  developed  by  the  use  of  the  ophthal- 
moscope. When  this  instrument  is  used  it  is  found  that  the  optic  disk  is  gray  or 
greenish-gray,  or  actually  wliite  in  color,  although  there  may  be  patches  of  red 
throughout  it.     The  centre  of  the  disk  is  depressed  in  direct  proportion  to  the  degree 


DISEASES  OF  THE  CRANIAL  NERVES  SG7 

of  atrophy  which  has  taken  place.  The  margin  of  the  disk  is  distinct,  and  in  some 
cases  when  the  condition  of  the  optic  nerve  is  due  to  disease  of  the  spinal  cord, 
there  is  broadening  of  the  normal  scleral  ring.  The  bloodvessels  are  narrowed,  but 
in  some  cases  only  the  arteries  seem  to  be  afi'ected,  the  veins  escaping.  An  examina- 
tion of  the  central  vision  shows  that  it  is  markedly  impaired,  or  absolute  blindness 
may  be  present.  The  field  of  vision  is  greatly  narrowed  and  there  may  be  a  central 
scotoma  or  hemianopsia.  The  color  fields  are  markedly  diminished,  the  green 
being  most  affected;  after  it  the  red,  and  then  the  blue  and  yellow.  Sometimes 
the  field  for  red  is  first  affected.  The  pupil  usually  manifests  some  degree  of 
paralytic  dilatation,  and  when  the  nerve  is  completely  atrophied  the  pupil  is  dilated 
and  the  iris  motionless.  In  secondary  atrophy  the  disk  is  apt  to  be  whiter  than 
in  the  primary  forms,  when  it  is  usually  gray.  In  that  form  of  optic  nerve  atrophy 
called  retinitic  and  choroiditic  atrophy,  the  disk  is  often  slightly  yellowish  in  hue, 
but  its  borders  are  not  distinct. 

Diagnosis. — The  mere  discovery  that  the  optic  disk  is  grayer  than  normal  and 
that  its  margins  are  sharply  defined,  does  not  justify  the  diagnosis  of  optic  atrophy. 
If,  however,  any  of  the  diseases  so  far  named  are  also  present,  such  a  diagnosis  is 
usually  correct. 

Prognosis. — The  prognosis  as  to  complete  recovery  is  bad.  On  the  other  hand,  it 
must  be  remembered  that  the  atrophic  process  is  often  a  slow  one  which  may  last 
for  years.  Indeed,  the  prognosis  in  secondary  cases  depends  largely  upon  the 
rapidity  with  which  the  underlying  disease  is  advancing. 

Treatment. — The  treatment  consists  in  the  administration  of  full  doses  of  mercury 
and  the  iodides  if  there  is  any  suspicion  that  a  recent  or  ancient  syphilitic  infection 
has  been  present.  Strychnine  in  large  doses  combined  with  nitroglycerin  is  also 
useful. 

Of  ihe  functional  disorders  of  the  optic  nerve  the  most  important  are  blindness 
due  to  uremia,  that  due  to  diabetes,  malaria,  profound  anemia,  and  the  abuse  of 
drugs.  When  uremia  is  the  cause  the  presence  of  the  symptoms  of  that  condition, 
in  association  with  dimness  of  vision  or  blindness,  make  the  diagnosis  clear.  The 
so-called  albuminuric  retinitis  may  be  present,  but  the  ophthalmoscope  may, 
however,  reveal  no  morbid  changes.     If  the  patient  survives,  vision  usually  retiu-ns. 

When  the  dimness  of  vision  is  due  to  diabetes,  the  prognosis  is  unfavorable 
because  the  disease  is  incurable.  That  form  which  is  due  to  malarial  infection 
has  associated  with  it  other  symptoms  of  this  disease.  Recovery  usually  takes 
place  if  proper  treatment  is  administered.  So,  too,  in  cases  of  dimness  of  vision, 
due  to  hemorrhage  and  profound  anemia,  the  prognosis  is  good,  unless  the  anemia 
is  one  of  the  so-called  essential  anemias  which  always  go  from  bad  to  worse.  The 
treatment  in  such  a  case  consists,  of  course,  in  the  use  of  drugs  designed  to  combat 
anemia. 

Hemianopsia. — Hemianopsia,  or  blindness  of  one-half  of  the  visual  field,  occurs 
in  three  forms:  that  known  as  bitemporal  hemianopsia,  binasal  hemianopsia, 
and  homonymous  hemianopsia,  each  variety  being  named  not  from  that  part  of 
the  retina  which  is  blind,  but  from  the  visual  field  which  is  affected.  In  the  first 
there  is  loss  of  vision  in  both  temporal  fields,  in  the  second  in  the  nasal  half  of  each 
field,  and  in  the  third  form  the  same  side  of  each  eye  is  lacking  in  function — that 
is,  for  example,  the  outer  half  of  the  left  eye  and  the  inner  half  of  the  right  eye. 
When  the  left  half  of  each  retina  is  inactive,  the  condition  is  called  right  homony- 
mous bilateral  hemianopsia,  and  when  the  right  half  is  functionless  it  is  designated 
left  homonymous  bilateral  hemianopsia.  Homonymous  hemianopsia  is  the  most 
common.  Binasal  hemianopsia  is  very  rare.  Bitemporal  hemianopsia  is  produced 
by  a  lesion,  such  as  a  tumor  or  an  aneurysm,  which  presses  upon  the  middle  of  the 
chiasm.  Homonymous  lateral  hemianopsia  is  produced  by  a  lesion  of  one  optic 
path  at  any  point  back  of  the  chiasm,  either  in  the  neighborhood  of  the  calcarine 


SGS 


DISEASE.^  OF  THE  NERVOUS  SYSTEM 


fissure  (occipital  lobe),  in  the  optic  radiations,  including  the  point  where  they  pass 
just  back  of  the  internal  capsule,  in  the  primary  optic  centres,  or  in  the  optic  tract. 
(See  Fig.  139.)     It  is  important  to  remember  that  the  lesion  in  cases  of  hemianopsia 


Fig.  139 

,  Left  Eye  Vi^^Fiela  , 

-portion^ 


''I'lUt. 


'"■r.ohc 


Eigi'' 


The  visual  tract.  The  result  of  a  lesion  anywhere  between  the  chiasm  and  the  cuneus  is  to  produce 
homonymous  hemianopsia.  //,  lesion  at  chiasm  causing  bilateral  temporal  hemianopsia.  A'',  lesion  at 
chiasm  causing  unilateral  nasal  hemianopsia.  T,  lesion  at  chiasm  causing  unilateral  temporal  hemi- 
anopsia. SN,  substantia  nigra  of  crus.  L,  lemniscus  in  crus.  RN,  red  nucclus.  ///,  third  nerves. 
V,  Q,  li,  S,  U,  lesions  in  the  occipital  lobe  and  in  front  of  it,  producing  left  homonymous  lateral 
hemianopsia. 

is  on  the  opposite  side  to  tliat  of  the  dark  field.'  (See  Fig.  140.)  de  Schweinitz 
has  condensed  the  following  rules  as  to  the  significance  of  various  forms  of  hemian- 
opsia from  a  series  prepared  by  Dr.  Seguin: 


J '  For  a  complete  study  of  the  significance  of  this  difficult  subject  see  the  author's  Practical  Diagnosis, 
fifth  edition. 


DISEASl^S  OF  THE  CRANIAL  NERVES 


S69 


(a)  The  lesion  in  hemianopsia  is  on  the  opposite  side  of  the  dark  fields. 

(b)  If  the  preserved  fields  are  accompanied  by  concentric  contraction,  the 
smaller  half-field  will  be  in  the  eye  opposite  to  the  lesion;  contraction  of  the  pre- 
served half-field  is  most  common  with  lesions  of  the  cortex,  but  also  may  occur  in 
lesions  of  the  tractus. 

(c)  If  the  hemianopsia  is  relative,  the  lesion  is  probably  in  the  cortex;  but  cortical 
lesions  are  not  excluded  by  absolute  hemianopsia. 

(d)  A  lesion  confined  to  the  cuneus,  or  to  it  and  the  gray  matter  immediately 
surrounding  it,  on  the  mesial  surface  of  the  occipital  lobe,  produces  homonymous 
lateral  hemianopsia  without  motor  or  sensory  symptoms,  at  least  without  these 
as  a  direct  consequence  of  the  lesion,  although  they  may  appear  as  indirect  or,  as 
they  are  sometimes  called,  distant  symptoms.  Slight  motor  symptoms  such  as 
deviation  of  one  eye  inward  may,  however,  be  added  to  the  visual  symptoms  of  a 
lesion  in  the  occipital  lobe  (Mills). 

Fig.  140 
LEFT  VISUAL  FIELD.    RIGHTVISUAL  FIELD  , 

fixation  Poi/t/.  Fixation  Point . 


Diagram  illustrating  why  it  is  that  the  lesion  is  on  the  opposite  side  to  the  dark  field.     (Oliver.) 

(e)  A  lesion  producing  typical  hemiplegia,  aphasia,  if  the  right  side  is  paralyzed, 
little  or  no  anesthesia,  and  lateral  hemianopsia,  is  probably  due  to  disease  in  the 
area  supplied  by  the  middle  cerebral  artery. 

(/)  A  lesion  causing  hemiplegia,  hemianesthesia,  and  lateral  hemianopsia  is 
probably  situated  in  the  posterior  portion  of  the  internal  capsule. 

{g)  A  lesion  causing  hemianesthesia,  ataxic  movements  of  one-half  of  the  body, 
no  distinct  hemiplegia,  and  lateral  hemianopsia,  could  be  situated  in  the  posterior 
lateral  part  of  the  optic  thalamus. 

(/i)  A  lesion  causing  the  symptoms  of  disease  of  the  base  of  the  brain,  associated 
at  the  same  time  with  changes  in  the  pupil,  changes  in  the  nerve  head,  and  lateral 
hemianopsia,  could  be  situated  in  one  optic  tract  or  in  the  primary  optic  centres 
on  one  side. 

{%)  Incomplete  hemianopsia,  assuming  usually  a  quadrant-shaped  defect,  may 
be  present  on  account  of  a  lesion  confined  to  the  lower  half  of  the  cuneus.     It  may 


870 


DISEASI'JS  OF  rilE  NERVOUS  SYSTEM 


also  occur  with  less  definite  limitations  in  lesions  of  the  subcortical  substance  of 
the  occipital  lobe,  and  then  may  be  associated  with  other  symptoms,  as  hemiplegia 
and  hemianesthesia.  Finally,  it  may  occur  from  a  lesion  of  the  tract,  but  then 
will  be  accompanied  by  other  symptoms  indicating  basal  disease,  or  from  a  lesion 
of  the  external  geniculate  body. 

(j)  A  hemianopsia  in  which  there  is  preservation  of  the  light  sense,  l)ut  loss  of 
either  the  color  sense  or  the  form  sense,  indicates  that  the  lesion  is  in  the  visual 
centre  of  the  cortex. 

The  Third  or  Oculomotor  Nerve. — The  third  nerve  has  its  origin  from  groups 
of  cells  in  the  floor  of  the  aqueduct  of  Sylvius.     It  then  passes  through  the  tegmen- 
tum of  the  crus  cerebri,  and  makes  its  exit 
Fig.  141  in  a  bundle  on  the  inner  side  of  the  crus. 

(Fig.  141;  see  also  Plate  XIV.)  It  then 
passes  from  the  cms  to  the  sphenoidal 
fissure  and  so  into  the  orbit,  where  its 
fibres  divide  and  go  to  supply  the  ciliary 
muscle,  the  sphincter  of  the  iris,  the  super- 
ior rectus,  internal  rectus,  inferior  rectus 
and  inferior  oblique  muscle.  (See  Plate 
XIII.)  It  also  sends  fibres  to  the  levator 
palpebrse  muscle.  As  it  is  a  motor  nerve, 
paralysis  follows  its  injury.  The  causes 
of  disturbance  in  its  function  are  num- 
erous. They  may  exist  at  the  base  of  the 
brain,  where  the  nerve  leaves  the  crus, 
in  the  sphenoidal  fissure,  in  the  orbit,  and 
even  in  its  peripheral  filaments  in  the  eye 
itself,  although  change  in  its  functional 
activity  in  the  latter  area  is  usually  due  to 
the  effect  of  drugs.  Of  the  causes  which 
produce  disturbance  of  its  function  at  its 
origin  in  the  crus,  we  find  tuberculous 
meningitis  or  that  due  to  some  acute  in- 
fectious disease,  abscess  of  the  brain,  and 
hemorrhage.  For  this  reason  meningitis 
of  either  form  in  infancy  very  frequently 
involves  this  nerve,  and  so  produces  symp- 
toms which  call  the  attention  of  the  phy- 
sician to  the  existence  of  the  disease  at  the 
base  of  the  brain.  In  adults,  aside  from 
tuberculous  meningitis,  there  may  be 
syphilitic  exudation,  or  the  nerve  itself 
may  be  inflamed,  owing  to  the  presence  of 
this  same  disease.  Tumors  or  abscess  at 
the  base  of  the  brain  may  press  upon  it. 
When  the  nerve  is  injured  in  its  passage  through  the  sphenoidal  fissure,  the  cause 
is  usually  some  traumatism  which  results  in  fracture  of  the  bone,  or  very  rarely  a 
severe  blow  which  damages  the  ncr\e  by  pressure  against  the  bone.  In  a  case 
which  came  to  the  writer's  attention,  a  severe  blow  with  the  hilt  of  a  sword  upon 
the  forehead  caused  paralysis  of  this  nerve,  probably  in  this  manner. 

In  the  orbit  a  tumor  may  press  upon  the  nerve  fibres.     Occasionally  the  nerve 

loses  power  through  the  action  of  the  poison  produced  by  diphtheria  or  typhoid  fever. 

Symptoms. — The  dominant  symptoms  of  paralysis  of  the  oculomotor  nerve 

are  ploni^,  mi/dria-tiis,  and  consequent  loss  of  pupillary  reaction  to  light  and  accommo- 


Shovving  the  nearness  of  origin  of  the  oculo- 
motor (3),  pathetic  (4),  and  abducens  (0). 
The  roots  of  these  nerves  are  shown  by  an 
incision  wliich  has  divided  the  fons.  ///,  tlie 
third  nerve,  arising  from  several  roots.  IV, 
the  fourth  nerve.  VI,  the  sixth  nerve,  arising 
from  three  roots.     (Modified  from  Arnold.) 


PLATE  XIII 


Showing  the  Distr'ibution  of  the  Troehlearis,  Oculomotor,  and 
Trifacial  Nerves.     (Modified  from  Rudinger.) 


1.  The  trochlearis  nerve. 

2,  3,  4,  5,  6,  7.     The  oculomotor  nerve  fibres. 
8.  9,  10,  11.     The  trifacial  fibres. 


DISEASES  OF  THE  CRANIAL  NERVES  871 

dation.  As  it  supplies  the  internal  rectus,  external  squint  may  be  present.  The 
paralysis  of  the  ocular  muscles  also  results  in  diplopia.  If  the  patient  is  directed 
to  look  upward,  downward,  or  inward  he  is  unable  to  do  so.  The  inability  of  the 
pupil  to  contract  when  light  is  thrown  into  the  eye  may  be  due  to  a  lesion  of  the  nerve 
before  it  enters  the  orbit,  or,  as  already  stated,  to  the  action  of  a  drug  upon  its 
peripheral  filaments.  It  will  be  remembered  that  pupillary  contraction,  when 
produced  by  the  entrance  of  light  into  the  eye,  is  due  to  a  reflex  impulse  which  passes 
along  the  optic  nerve  to  the  neighborhood  of  the  corpora  quadrigemina,  thence  to  the 
third  nucleus  and  along  the  fibres  of  the  third  nerve  to  the  ciliary  ganglion,  from 
which,  by  way  of  the  ciliary  nerves,  it  goes  to  the  iris  and  causes  contraction  of 
its  circular  muscular  fibres.  A  lesion  in  any  portion  of  tliis  reflex  arc  interferes  with 
pupillary  reaction.  In  addition  to  those  injuries  of  the  oculomotor  nerve  already 
mentioned  which  cause  paralysis,  a  loss  of  pupillary  reaction  may  occur  in  locomotor 
ataxia,  in  multiple  sclerosis,  in  general  paresis,  in  bulbar  palsy,  and  in  myelitis  when 
that  disease  involves  the  fibres  of  the  arc.  When  these  diseases  are  responsible 
for  the  loss  of  pupillary  reaction,  the  lesion  is  supposed  to  exist,  in  the  majority 
of  instances,  in  fibres  which  connect  the  optic  tracts  in  front  of  the  corpora  quad- 
rigemina with  the  oculomotor  nuclei.  When  drugs  produce  parahi;ic  mydriasis, 
their  action  is  usually  exercised  upon  the  peripheral  ends  of  the  nerve. 

Diagnosis. — The  diagnosis  of  paralysis  of  the  oculomotor  nerve  is  readily  made 
if  the  symptoms  just  described  are  kept  in  mind. 

Prognosis. — The  prognosis  depends  upon  the  underlying  cause  of  the  paralysis. 
In  diphtheria  and  typhoid  fever  recovery  usually  takes  place,  and  unless  the  damage 
produced  by  an  injury  is  very  great,  the  outlook  is  favorable.  On  the  other  hand, 
if  the  cause  is  tuberculous  meningitis,  tumor,  or  abscess,  or  any  one  of  the  progresive 
nerve  diseases  just  named,  recovery  is,  of  course,  impossible. 

The  Fourth  or  Trochlearis  Nerve. — This  nerve  supplies  the  superior  oblique 
muscle  of  the  eye  (1,  Plate  XIII).  Interference  with  the  action  of  this  nerve  is 
not  uncommon  and  is  rarely  recognized  by  the  general  practitioner.  The  symptoms 
are  not  developed  until  the  eye  is  tested  by  means  of  placing  a  colored  glass  over 
one  eye,  when  it  will  be  found  that  the  object  which  is  placed  before  the  patient 
stands  in  its  normal  position  as  seen  by  the  normal  eye,  but  is  displayed  outward 
and  obliquely  when  seen  by  the  eye  supplied  by  the  impaired  pathetic  nerve. 
As  the  nerve  arises  from  an  area  almost  identical  with  that  of  the  third  nerve,  the 
centric  causes  of  trochlearis  paralysis  are  practically  identical  with  the  causes  of 
oculomotor  paralysis.  It  is  important  to  remember  that,  should  paralysis  of  the 
fourth  nerve  be  present  without  involvement  of  the  third  or  sixth  nerve,  it  probably 
indicates  a  growth  in  the  cerebellum  or  an  inflammatory  exudate  upon  the  under 
surface  of  its  middle  lobe. 

The  Fifth  or  Trifacial  Nerve. — The  trifacial  nerve  contains  motor  and  sensory 
fibres,  the  sensory  fibres  being  by  far  the  more  numerous.  The  motor  fibres  have 
their  origin  in  the  pons,  a  little  above  its  middle,  receiving  also  the  root  descending 
from  the  midbrain;  they  pass  out  in  a  bundle  separate  from  the  sensory  fibres  until, 
outside  the  cranial  cavity,  they  take  part  in  forming  the  inferior  maxillary  division 
of  the  nerve,  through  wliich  they  supply  the  muscles  of  mastication. 

The  sensory  fibres  of  the  fifth  nerve  arise  from  a  nucleus  at  about  the  middle 
of  the  pons,  and,  in  addition,  by  the  spinal  root,  from  a  chain  of  cells  descending 
through  the  medulla  as  far  as  the  first  cervical  segment  of  the  cord;  they  emerge 
from  the  pons  in  a  heavy  trunk,  which  passes  to  the  Gasserian  ganglion  (8,  Plate 
XIII)  and  then,  beyond  the  ganglion,  divides  into  three  branches:  ophthalmic 
(9),  superior  (10),  and  inferior  maxillary  (11).  In  addition  to  providing  sens'ation 
to  the  greater  portion  of  the  face,  it  also  supplies  the  anterior  two-thirds  of  the  tongue. 
Symptoms. — When  the  fifth  or  trifacial  nerve  is  paralyzed  in  its  motor  fibres, 
the  patient  is  unable  to  contract  his  masseter  muscles  and  there  is  dropping  of  the 


872  DISEASES  OE  THE  XEh'VOrS  SYSTEM 

lower  jaw.  Unless  the  paralysis  is  bilateral,  however,  it  may  not  ho  easily  dis- 
covered, since  the  muscles  on  the  imaft'ected  side  may  hold  the  jaw  in  position. 
And,  moreover,  if  the  lesion  be  in  tlie  brain  the  function  of  mastication  is  maintained 
from  the  other  side  by  bilateral  innervation.  In  some  instances  of  paralysis  of  the 
fifth  nerve,  deafness  arises  as  the  result  of  interference  with  the  function  of  the 
tensor  tympani  muscle,  for  a  small  branch  from  the  motor  fibres  of  the  fifth  nerve 
passes  through  the  otic  ganglion  and  supplies  this  muscle.  When  this  muscle  is 
paralyzed,  the  tympanic  membrane  is  relaxed  and  this  interferes  with  its  function. 
Motor  paralysis  of  the  fifth  nerve  is  rarely  met  with.  Certain  poisons  like  gelsem- 
ium  may  cause  dropping  of  the  jaw  by  paralyzing  the  muscles  of  both  sides.  Wiien 
the  sensory  portion  of  the  nerve  is  affected  there  is  anesthesia  of  the  skin  of  the  face 
in  the  areas  supplied  by  the  particular  l)ranches  affected. 

If  the  area  be  that  of  the  forehead,  the  upper  eyelid,  the  conjunctiva,  and  the 
nostril,  the  ophthalmic  branch  of  the  fifth  nerve  is  at  fault,  and  the  lesion  is  proI)ably 
at  the  sphenoidal  fissure  or  within  the  orbit,  reflex  winking  of  the  eye  no  longer  takes 
place  because  the  conjuncti\'a  is  anesthetic,  and  for  the  same  reason  a  flow  of  tears 
does  not  occur  upon  irritating  the  conjunctiva,  because  the  lachrymal  reflex  is 
abolished. 

If  the  skin  of  the  upper  part  of  the  face  is  anesthetic,  the  superior  maxillary 
branch  is  involved;  and  if  the  skin  of  the  temporal  region  and  that  of  the  jaw  and 
the  under  lip  are  anesthetic,  the  inferior  maxillary  branch  is  diseased.  When 
both  of  these  branches  are  paralyzed  there  is  probably  a  tumor  of  the  superior 
maxillary  bone;  and  if  the  entire  area  of  the  three  branches  is  anesthetic,  the 
Gasserian  ganglion  may  be  the  part  affected,  and  this  will  be  accompanied  by  trophic 
changes  in  the  anesthetic  parts.  The  most  common  cause  of  anesthesia  of  the 
trifacial  is,  however,  neuritis. 

Romberg  makes  the  following  differential  statement; 

(a)  The  more  the  anesthesia  is  confined  to  single  filaments  of  the  trigeminus, 
the  more  peripheral  the  seat  of  the  cause  will  be  found  to  be. 

{b)  If  the  loss  of  sensation  affects  a  portion  of  the  facial  surface,  together  with  the 
corresponding  faucial  membrane,  the  disease  may  be  assumed  to  invoh'c  the  sensory 
fibres  of  the  fifth  pair  before  they  separate  to  be  distributed  to  their  respective 
destinations;  in  other  words,  a  main  division  must  be  affected  before  or  after  its 
passage  through  the  cranium. 

(c)  When  the  entire  sensory  tract  of  the  fiftli  ner\e  has  lost  its  power,  and  there 
are  at  the  same  time  derangements  of  the  nutriti\e  functions  in  the  affected  parts, 
the  Gasserian  ganglion,  or  the  nerve  in  its  immediate  vicinity,  is  the  seat  of  the 
disease. 

{d)  If  the  anesthesia  of  the  fifth  nerve  is  complicated  with  disturbed  functions 
of  adjacent  cerebral  nerves,  it  may  he  assumed  that  the  cause  is  seated  at  the  base 
of  the  brain. 

When  the  fifth  nerve  is  paralyzed  the  mucous  membrane  of  the  no.se  and  mouth 
are  also  anesthctir  and  usually  drij.  The  sense  of  taste  is  lost  and  trophic  lesions  may 
develop,  although  it  is  questionable  as  to  whether  these  depend  upon  affection  of 
the  sensory  fibres.  These  lesions  consist  in  ulceration  of  the  cornea,  loosening  of 
the  teeth,  atrophy  of  the  gums,  and  the  development  of  herpes  zoster.  As  the  sensation 
in  the  anterior  two-thirds  of  the  tongue  is  impaired,  this  organ  is  often  damaged  by 
the  teeth.  The  dryness  of  the  mucous  memltrane  of  the  nose  also  interferes  witii  the 
sense  of  smell,  and  irritating  substances  may  lie  inhaled  through  the  nostrils  witliout 
pain,  because  of  the  lack  of  sensation  in  the  nasal  mvicous  membrane.  Paralysis 
of  this  nerve  is,  however,  very  rarely  met  with. 

In  the  great  majority  of  instances  in  which  a  physician  is  called  on  to  treat  a 
lesion  of  the  trifacial  nerve,  the  patient  complains  of  .levere  neuralgic  pain,  which 
in  most  cases  arises  from  the  Gasserian  ganglion  (8,  Plate  XIII).     When  trophic 


PLATE  XIV 


Base  of  Brain,  showing  the  Superficial  Origin  of  the  Cranial 
Nerves. 

The  Roman  numerals  refer  to  the  twelve  cranial  nerves. 


DISEASES  OF  THE  CRANIAL  NERVES  873 

changes  are  very  well  marked,  they  result  in  hemiatroijhy  of  the  face.  In  those 
cases  in  which  the  motor  fibres  of  the  fifth  nerve  are  irritated,  there  may  be  lockjaw 
as  in  true  tetanus,  and  so-called  masseter  spasm  may  have  a  reflex  origin  because 
of  the  presence  of  dental  irritation. 

Paralysis  of  the  Sixth  Abducens  Nerve. — The  sixth  nerve  has  its  origin  from 
cells  in  the  floor  of  the  fourtii  ventricle,  passes  through  the  pons,  and  makes  its 
exit  in  the  groove  between  the  pons  and  the  medulla  (Plate  XIV),  whence  it  passes 
through  the  sphenoidal  fissure.  It  is  subject  to  the  same  lesions  at  the  base  of  the 
brain  as  is  the  oculomotor  nerve,  such  as  tuberculous  meningitis  and  syplulitic 
exudation,  tumor  and  fracture  of  the  base  of  the  skull.  Injury  may  occur  to  it  in 
the  sphenoidal  fissure.  The  sixth  nerve  supplies  the  external  rectus  and  its  paralysis 
thus  causes  internal  squint,  the  patient  jjeing  unable  to  rotate  the  eye  outward. 

The  exact  lesion  which  produces  paralysis  of  the  sixth  nerve  can  onlj^  be  deter- 
mined by  a  study  of  the  associated  symptoms.  In  those  cases  in  which  there  is 
facial  palsy  on  the  same  side  as  the  squint,  and  paralysis  of  the  arm  and  leg  upon 
the  opposite  side,  in  other  words,  "crossed  hemiplegia,"  the  lesion  is  in  the  pons 
or  at  the  base  of  the  brain  in  such  a  position  that  it  produces  pressure  on  the  pons 
on  one  side  and  above  its  lower  third. 

Disturbances  of  Motility  in  the  Ocular  Muscles  Depending  on  the  Third,  Fourth, 
and  Sixth  Nerves. — The  movements  of  the  eyeballs  depend,  of  course,  upon  the 
associated  action  of  different  muscles  supplied  by  different  nerves.  When  the 
axes  of  the  eyeballs  converge,  they  do  so  by  the  action  of  the  internal  recti  muscles 
supplied  by  the  third  nerve,  and  when  they  diverge  they  move  in  these  directions 
by  the  external  recti  supplied  by  the  sixth  nerve.  If,  however,  there  is  conjugate 
deviation,  then  a  much  more  complicated  nervous  mechanism  is  brought  into  play, 
for  if  the  axis  of  each  eyeball  is  turned  to  the  right,  for  example,  this  motion  is 
made  by  contraction  of  the  external  rectus  of  the  right  eye  and  the  internal  rectus 
of  the  left  eye,  each  being  supplied  by  different  nerves,  the  right  sixth  and  the  left 
third,  and  yet  it  is  essential  that  they  shall  act  in  accord.  This  is  accomplished 
by  the  presence  of  association  fibres  which,  by  joining  together  the  nuclei  of  the 
nerves,  enable  them  to  act  in  unison.  If  by  disease  these  association  fibres  are 
destroyed  (in  the  posterior  longitudinal  bundle),  conjugate  deviation  of  the  eyes 
becomes  impossible.  When  the  eyeballs  are  deviated  by  reflex  action,  the  pathway 
of  the  nervous  impulse  is  through  the  optic  nerve  by  connecting  fibres  to  the  motor 
nuclei  of  those  nerves  governing  the  ocular  movements,  which  not  only  join  the 
nuclei  of  the  different  nerves  of  one  side,  but  connect  them  with  the  nuclei  of  the 
opposite  side  as  well.  When  they  are  moved  by  voluntary  action,  the  impulse 
leaves  the  motor  centres  in  the  anterior  part  of  the  motor  area  of  the  cortex,  and 
thence  passes  down  through  the  anterior  part  of  the  knee  of  the  internal  capsule, 
thence  through  the  crus  cerebri,  and  finally  crosses  in  the  raphe,  passing  to  the 
nuclei  of  the  oculomotor  nerves  and  of  the  fourth  and  sixth  nerves.  When  the 
impulse  for  conjugate  deviation  arises  in  the  motor  cortex,  it  passes  first  to  the 
nucleus  of  the  opposite  sixth  nerve,  and  thence  is  sent  along  the  association  fibres 
through  the  posterior  longitudinal  bundle  to  the  nucleus  of  the  third  nerve  on  the ' 
opposite  side,  just  as  it  is  in  reflex  deviation.  When  a  nervous  explosion  takes  place 
in  the  motor  cortex,  as  in  cases  of  epilepsy,  it  often  happens  that  there  is  conjugate 
deviation  of  the  eyes  away  from  the  side  on  which  the  lesion  exists,  and,  conversely, 
if  the  ocular  centres  in  the  cortex  are  destroyed,  there  is  conjugate  deviation  of  the 
eyes  toward  the  side  on  which  the  lesion  exists.  This  has  given  rise  to  the  state- 
ment that  in  the  coma  of  ordinary  apoplexy  the  patient  "looks  toward  his  lesion" 
at  least  in  those  instances  in  which  an  apoplexy  destroys  these  centres.  (See 
Apoplexy.) 

There  as  two  states  which  give  rise  to  an  erroneous  diagnosis  in  connection  with 
these  symptoms,  namely,  "rheumatic palsy"  of  the  ocular  muscles,  which  disappears 


874  DISEASES  OF  THE  NERVOUS  SYSTEM 

under  the  free  use  of  the  iodides  and  sahcylates,  and  so-called  "  recurrent  oculomotor 
paralysis,"  which  is  probably  the  result  of  congestion  and  edema,  and  which  is 
accompanied  by  sick  stomach,  diplopia  and  fever. 

Ophthalmoplegia  or  Paralysis  of  the  Internal  and  External  Muscles 
OF  THE  Eyeball. — This  condition  depends  not  upon  disorder  of  function  of  any 
single  cranial  nerve,  but  upon  interference  with  the  action  of  the  third,  fourth,  and 
sixth  nerves.  As  already  stated,  the  third  nerve  supplies  the  ciliary  muscle,  the 
circular  fibres  of  the  iris,  the  superior  rectus,  internal  rectus,  inferior  rectus,  inferior 
oblique,  and  the  levator  palpebral.  The  fourth  nerve  supphes  the  superior  oblique, 
and  the  sixth  the  external  rectus.  When  morbid  changes  take  place  in  the  nuclei 
of  these  nerves  the  normal  co-ordinated  movements  of  the  eye  are  impaired  or 
lost,  that  is  to  say,  ophthalmoplegia  is  developed. 


Patient  suffering  from  chronic  ophthalmoplegia  externa.    The  wrinkling  of  the  forehead  in  the  effort  to 
open  the  eyes  is  noticeable.    The  external  strabismus  can  he  seen.     (Starr.) 

Ophthalmoplegia  is  of  two  forms:  oplithalmoplegia  externa,  when  the  paralysis 
affects  the  external  muscles  of  the  eyeball  and  the  le-vator  papebrne;  and  ophthal- 
moplegia interna,  when  only  the  pupillary  and  ciliary  muscles  are  involved.  Oph- 
ihalriwplegia  interna  is  quite  rare,  although  a  modified  form  of  it  occurs  in  that  state 
called  the  Argyll-Robertson  pupil,  a  condition  in  which  the  pupil  reacts  to  accommo- 
dation, but  not  to  light.  In  this  condition  the  lesion  exists  not  in  the  nuclei  of  the 
nerves,  for  if  it  did  there  would  be  no  reaction  to  accommodation,  but  in  the  associa- 
tion fibres,  whereby  the  reflex  pathway  is  destroyed.  Ophthalmoplegia  externa, 
on  the  other  hand,  is  by  no  means  uncommon.  It  is  a  condition  depending  upon 
a  centric  lesion,  and  occurs  in  an  acute  and  chronic  form  (see  below).  Because  of 
the  fact  that  the  lesion  is  centric  it  is  usually  bilateral,  and  if  all  the  muscles  are 
paralyzed  it  is  said  to  be  complete  external  ophthalmoplegia,  while,  on  the  other 
hand,  if  they  are  simply  impaired  in  function,  or  if  one  ner\e  escapes  while  the  others 
are  involved,  it  is  spoken  of  as  partial  (Fig.  142). 

Etiology  and  Pathology. — Ophthalmoplegia  is  due  to  a  large  number  of  causes, 
such  as  tumors,  areas  of  degeneration,  or  inflammatory  exudations,  where  the 
nerves  take  their  exit  at  the  base  of  the  brain.  (See  Plate  XIV.)  The  additional 
causes  are  small  hemorrhagic  extravasations,  arteritis,  thrombosis,  or  embolism 
of  the  small  ^-essels  which  supply  the  nuclei  of  these  nerves.     In  some  cases  the 


PLATE  XV 


'W' 


Showing  Exit  of  Facial  Nerve  (1)  from  Stylomastoid  Foramien  and 
its  Distribution  to  the  Muscles  of  the  Face.      (Rudinger. ) 


DISEASES  OF  THE  CRANIAL  NERVES  875 

lesions  resemble  those  of  acute  poliomyelitis,  and  belong  to  the  afFection  called  by 
Wernicke  "polio-encephalitis  superior." 

Symptoms. — The  symptoms  of  ophthalmoplegia  externa  vary,  of  course,  with  the 
nerves  which  are  affected  and  with  the  severity  of  the  lesions.  When  the  morbid 
process  is  severe,  there  is  not  onlj'  loss  of  power  in  the  ocular  muscles,  but  in  other 
parts  as  well,  so  that  the  symptom-complex  of  bulbar  paralysis  may  be  present; 
or  if  the  tracts  to  and  from  the  higher  areas  of  the  brain  are  involved,  such  symptoms 
as  hemianesthesia,  hemiplegia,  or  hemiataxia  may  be  present.  The  pathological 
processes  just  described  are  varied. not  only  as  to  cause  and  situation,  but  as  to 
acuteness  as  well.  The  acute  form  is  ushered  in  by  a  train  of  symptoms  w-hich 
necessarily  arise  when  areas  of  the  nervous  system  so  important  to  life  are  affected. 
Thus,  the  patient  suffers  from  vertigo,  headache,  vomiting,  and  even  coma.  Uncon- 
sciousness may  last  for  several  days  and  end  in  death,  or,  after  a  period  of  a  week 
or  ten  days,  consciousness  gradually  returns  and  the  symptoms  connected  with 
the  eyes  alone  remain.  These  consist  in  double  ptosis  and  various  palsies  of  the 
ocular  muscles,  or  total  ophthalmoplegia.  The  chronic  form  arises  when  the  nervous 
lesions  are  gradual  in  onset,  although  it  may  result  from  the  acute  type  just  dis- 
cussed. Here  again  the  degree  of  the  paralysis  depends  upon  the  severity  of  the 
lesions.  In  one  case  a  total  palsy  may  be  present,  in  another  a  partial  palsy,  and 
in  still  a  third  the  palsy  may  be  progressive,  one  muscle  after  another  failing. 
Sometimes  one  muscle  improves  as  another  fails.  Ptosis  and  other  forms  of  ocular 
palsy  may  be  a  part  of  the  transient  and  recurrent  paralysis  in  mj^asthenia  gravis. 
The  prognosis  depends  upon  the  cause.  If  syphilis  is  a  factor  the  outlook  is  fa^•or- 
able  as  compared  to  that  tj'pe  which  is  due  to  disseminated  sclerosis  or  bulbar 
palsy.  In  no  case  is  the  outlook  anything  but  grave  as  to  recovery,  although 
about  one-half  of  the  mild  cases  recover. 

The  treatment  also  varies  with  the  cause,  and  yet  it  may  be  said  that,  be  the 
cause  what  it  may,  the  only  drugs  which  offer  any  promise  of  rehef  in  the  chronic 
form  are  mercury  and  the  iodides.     Hot  baths  may  be  useful. 

In  the  acute  form  freedom  from  any  cause  of  excitement,  the  application  of  cold 
to  the  head,  and  the  use  of  aconite  to  quiet  the  circulation,  if  it  is  excited,  may  be 
of  some  value. 

The  Seventh  or  Facial  Nerve. — The  nucleus  of  the  facial  nerve  is  found  in  the 
lower  part  of  the  pons.  From  this  nucleus  its  fibres  pass  upward  and  backward 
to  the  floor  of  the  fourth  ventricle,  where  they  make  a  sharp  turn  inward  and 
forward  about  the  nucleus  of  the  sixth  nerve,  and  finally  make  their  exit  between  the 
pons  and  the  medulla  (Plate  XIV)  near  the  eight  nerve.  After  leaving  the  pons 
the  seventh  nerve  passes  into  the  internal  auditory  foramen  of  the  petrous  portion 
of  tlie  temporal  bone,  and  after  passing  through  the  aqueduct  of  Fallopius  emerges 
from  the  stylomastoid  foramen  upon  the  surface  near  the  lobe  of  the  ear.  (See 
Plate  XV.)  At  this  point  it  is  divided  into  many  branches  which  supply  the  muscles 
of  the  face  with  motor  impulses.  (See  Plate  XV.)  Upon  the  fibres  of  the  facial 
nerve  just  as  it  enters  the  auditory  foramen  a  ganglion  occurs,  commonly  called 
the  geniculate  ganglion.  This  ganglion  consists  of  an  aggregation  of  cell  bodies 
connected  with  sensory  fibres  from  the  chorda  tympani  nerve,  which  is  a  nerve  of 
sensation  and  is  concerned  with  the  special  sense  of  taste.  The  fibres  of  this  nerve 
do  not,  however,  remain  in  contact  with  those  of  the  facial,  but  leave  it  at  once, 
and  by  way  of  the  Vidian,  or  superficial  petrosal  nerve,  pass  to  the  superior  maxillary 
branch  of  the  trifacial.  In  addition  to  these  sensory  fibres  of  the  chorda  tympani, 
the  facial  nerve  also  has  associated  with  it  the  nerve  of  Wrisberg,  which  is  probably 
sensory  in  function,  and  which  lies  by  the  side  of  the  facial  nerve  as  its  fibres  pass 
from  the  pons  to  the  auditory  foramen,  where  the  ganglion  of  the  chorda  tj-mpani 
just  named  exists.  The  fibres  of  the  nerve  of  Wrisberg  then  pass  to  the  nucleus 
of  the  glossopharyngeal  nerve. 


876  DISEASES  OF  THE  XERVOUS  SYSTEM 

Etiology. — Interference  with  the  function  of  the  facial  nerve  arises  from  many 
causes,  of  wliich  the  chief  and  most  frequent  arc  injuries  in  its  course  after  it  leaves 
the  pons.  These  may  be  called  peripheral  lesions,  and  when  the  paralysis  is  per- 
ipheral it  is  called  Bell's  palsy.  Thus,  it  not  infrequently  happens  that  a  child 
is  born  with  facial  palsy,  which  is  usually  due  to  injury  to  the  nerve  during  labor,  as 
by  the  pressure  of  forceps.  So,  too,  facial  paralysis  is  sometimes  seen  in  children 
and  in  adults  as  a  result  of  a  severe  blow  at  the  lower  part  of  the  ear,  or  of  an  attack 
of  mumps  in  which  the  inflammation  and  swelling  has  been  severe.  Tumors  of 
the  neck  and  inflammation  in  the  middle  ear  also  may  cause  facial  palsy  in  this 
manner. 

In  adults  facial  palsy  is  often  due  to  an  inflammation  in  the  stylomastoid  foramen 
as  the  result  of  exposure.  It  is  thought  by  some  that  this  takes  place  in  certain 
individuals  by  reason  of  the  fact  that  this  foramen  is  so  small  that  very  slight 
swelling  causes  pressure  on  the  nerve  and  ablation  of  its  function.  It  is  this  type 
of  paralysis  following  exposure  to  cold  which  has  given  rise  to  the  belief  among 
certain  ignorant  persons  that  it  is  possible  to  be  "moon-struck,"  because  a  person 
has  slept  out-of-doors  in  the  mooidight  and  has  de^•eloped  facial  palsy  afterward. 
The  real  cause  is,  of  course,  the  exposure  to  cold,  and  not  the  influence  of  the  moon. 
That  cold  cannot  always  be  the  cause  of  this  particular  form  of  facial  palsy  is,  how- 
ever, evident  from  the  fact  that  the  condition  is  no  more  frequent  in  winter  than 
in  summer.     Most  commonly  it  is  due  to  an  acute  otitis  media. 

More  serious  causes  of  facial  palsy  are  disease  processes  inside  the  skull  which 
press  upon  the  nerve  before  it  passes  through  the  aqueduct  of  Fallopius.  These 
conditions  are  tumor,  inflammatory  processes  at  the  base  of  the  brain,  most  com- 
monly arising  from  injury,  syphilis,  or  tuberculosis,  and  occasionally  one  of  the 
acute  infectious  diseases.  So,  too,  a  fracture  of  the  base  of  the  skull  may  produce 
facial  paralysis.  Facial  palsy  due  to  a  lesion  in  the  pons  is  exceedingly  rare  as  a 
single  symptom,  as  is  also  facial  palsy  due  to  a  lesion  in  the  cortex.  On  the  other 
hand,  facial  paralysis  is  usually  present  in  cases  of  hemiplegia,  but  in  hemiplegia 
the  upper  part  of  the  face  escapes  the  paralysis,  being  innervated  from  both  hemi- 
spheres of  the  brairu 

The  pathological  changes  which  take  place  in  the  facial  nerve  in  cases  of  facial 
paralysis  depend,  of  course,  upon  the  situation  of  the  lesion.  If  the  lesion  occurs 
in  the  nucleus  of  the  ner\-e,  or  involves  its  fibres  in  such  a  way  that  it  fails  to 
receive  its  normal  trophic  impulses,  degenerative  changes  at  once  ensue,  the  neuritis 
being  of  the  so-called  parenchymatous  type. 

Symptoms. — The  symptoms  of  facial  paralysis  are  very  characteristic.  The 
paralysis  is  nearly  always  unilateral  and  often  total,  in  the  sense  that  all  the  muscles 
upon  one  side  of  the  face  are  impaired  in  function.  It  sometimes  happens,  however, 
that  the  muscles  of  the. forehead  partly  escape.  Because  of  the  paralysis  of  the 
muscles  of  one  side  of  the  face  the  patient  is  unable  to  wrinkle  the  brow  upon  one 
side,  and  is  not  able  to  close  the  lids,  either  as  a  reflex  act,  as  in  winking,  or  by 
volition.  The  corner  of  the  mouth  on  the  paralyzed  side  is  drooped,  and  if  the 
patient  attempts  to  smile  only  one-half  of  his  visage  is  wrinkled.  The  nasolabial 
fold  is  obliterated  on  the  paralyzed  side  and  is  usually  accentuated  on  the  normal 
side  as  a  result  of  the  contraction  of  the  muscles  which  are  no  longer  counter-balanced 
by  opposing  muscles.  The  condition  is  not  painful.  If  recovery  does  not  promptly 
ensue  the  reactions  of  degeneration  speedily  develop  in  the  paralyzed  muscles, 
and  there  may  be  contractures  in  them. 

Diagnosis. — The  manifest  paralysis  of  the  muscles  of  one  side  of  the  face,  which 
is  particularly  noticeable  when  the  patient  attempts  to  smile  or  frown,  renders  the 
diagnosis  of  facial  palsy  easy  and  the  symptoms  which  the  patient  presents  can, 
moreover,  be  used  very  successfully  in  many  cases  in  determining  the  site  of  the 
lesion.     Thus,  in  some  cases  of  facial  paralysis  the  sense  of  taste  is  modified  or  lost 


DISEASES  OF   THE  CRAXIAL  XERVES  877 

upon  tlie  anterior  two-thirds  of  the  tongue  on  the  side  affected.  If  this  symptom 
is  present,  it  indicates  that  the  lesion  is  one  which  involves  the  facial  nerve  between 
the  geniculate  ganglion  and  the  point  a  quarter  of  an  inch  above  the  stj'lomastoid 
orifice,  where  the  chorda  tympani  fibres  leave  it;  or,  to  put  the  proposition  reversely, 
if  loss  of  taste  does  not  accompany  a  facial  palsy  the  lesion  is  either  in  the  stylo- 
mastoid foramen  within  a  quarter  of  an  inch  of  the  orifice  or  it  may  invoh^e  the 
nerve  before  it  enters  the  bone.  So,  too,  if  there  is  unusual  sharpness  of  hearing 
with  some  buzzing  in  the  ear,  this  also  is  an  indication  of  a  lesion  near  the  pons 
or  in  the  Fallopian  canal,  since  it  is  due  to  paralysis  of  the  stapedius  muscle  which  is 
supplied  by  the  stapedius  ner\-e.  If  deafness  and  vertigo  are  present  it  is  probable 
that  the  condition  is  due  to  middle-ear  disease  or  to  some  lesion  which  also  involves 
the  auditory  nerve  at  the  base  of  the  brain.  A  study  of  the  electrical  reaction  of  the 
paralyzed  muscles  is  also  of  great  value  for  the  purpose  of  localizing  the  lesions. 
Thus,  if  the  lesion  exists  in  the  stylomastoid  foramen,  the  muscles  of  the  face  are 
cut  off  from  the  trophic  impulses  which  they  normally  recei^•e  from  their  nuclei  in 
the  pons,  and  as  a  result  the  reaction  of  degeneration  speedily  de\'elops  and  may 
become  complete;  whereas,  on  the  other  hand,  if  the  lesion  which  causes  paralysis 
is  situated  in  the  motor  tract  above  the  nucleus  of  the  facial  nerve,  or,  in  other  words, 
if  it  involves  the  fibres  which  descend  from  the  motor  area  of  the  cortex,  the  reaction 
of  degeneration  does  not  develop  because  the  muscles  still  receive  trophic  impulses. 
Further  than  this,  in  these  cases  the  paralysis  is  ne\'er  so  complete  as  in  the  periph- 
eral type,  the  patient  usually  being  able  to  wink  and  to  wrinkle  the  forehead, 
the  muscles  of  the  forehead  frequently  escaping.  Centric  facial  paralysis  is,  how- 
ever, exceedingly  rare  unless  associated  with  other  symptoms,  as  already  stated. 
In  those  rare  instances  in  which  the  facial  paralysis  arises  from  damage  to  the 
nucleus  of  the  facial  nerve  in  the  pons,  there  are  other  symptoms  of  a  pontile  lesion 
producing  in  some  instances,  a  crossed  hemiplegia,  as  already  described,  an  asso- 
ciated paralysis  of  the  sixth  nerve,  or  the  symptoms  of  ordinary  bulbar  paralysis. 
In  these  cases,  too,  reactions  of  degeneration  speedily  develop. 

Prognosis. — The  prognosis  in  cases  of  facial  paralysis  varies,  of  course,  with  the 
situation  of  the  lesion  and  with  its  severity.  The  majority  of  instances  get  well 
because  they  have  their  origin  in  an  inflammatory  process  in  the  stylomastoid 
foramen.  The  outlook  when  the  lesions  are  back  of  the  stylomastoid  foramen 
are  not  so  favorable,  and  when  the  nucleus  of  the  nerve  or  the  motor  area  of  the 
cortex  is  diseased,  the  prognosis  is,  of  course,  very  doubtful  as  to  recovery  of  power 
in  the  muscles  of  the  face. 

Treatment. — The  treatment  of  paralysis  of  the  seventh  nerve  depends  somewhat 
upon  the  lesion  which  produces  it.  For  the  relief  of  that  form  which  is  due  to 
inflammation  in  the  stylomastoid  foramen,  it  is  customarj^  to  administer  mild 
alteratives,  such  as  small  doses  of  the  iodide  of  potassium  or  sodium,  in  order  to 
hurry  the  absorption  of  the  inflammatory  exudate.  It  is  also  ad^•isable  to  apply  a 
small  blister,  about  the  size  of  a  postage  stamp,  immediately  in  front  of  the  ear  for 
its  counter-irritant  effect.  In  those  cases  in  which  there  is  a  gouty  or  rheumatic 
diathesis,  the  best  results  are  often  obtained  by  the  use  of  the  salicylates  in  moder- 
ately large  doses,  10  to  15  grains  three  or  four  times  a  day,  or  10  drops  of  wine  of 
colchicum  root  and  10  grains  of  iodide  of  strontium  may  be  administered  three  times 
a  day.  The  use  of  electricity  for  the  purpose  of  maintaining  the  nutrition  of  the 
facial  muscles  in  any  case  of  peripheral  facial  palsy  is  not  only  futile,  but  may  be 
harmful,  for  the  cause  of  the  muscular  wasting  is  lack  of  trophic  impulse,  and  as 
these  impulses  cannot  reach  the  muscle,  it  is  speedily  exhausted  if  stimulated 
by  the  electrical  current,  when  deprived  of  its  ordinary  means  of  recuperation. 
If  middle-ear  disease  is  present,  it  must,  of  course,  be  treated  by  those  measures 
which  are  commonly  employed  by  aurists.  In  cases  where  the  lesion  is  centric, 
counter-irritation  is  useless.     The  only  hope  is  that  nature  aided  by  alterative 


878  DISEASES  OF  THE  NERVOUS  SYSTEM 

drugs,  such  as  the  iodides,  may  cause  an  absorption  of  the  results  of  the  local 
inflammatory  process.  Where  the  lesion  is  severe  enough  to  have  destroyed  the 
nerve  cells,  treatment  is  also  useless. 

Facial  Spasm. — Facial  spasm  due  to  irritation  of  the  facial  nerve  is  a  frequent 
affection.  It  may  be  general  or  localized  in  one  or  two  muscles.  When  the  orbicu- 
laris palpebrarum  is  affected,  the  condition  is  called  "blepharospasm."  As  a  rule, 
the  muscles  about  the  mouth  are  also  affected.  When  this  is  the  case,  the  condition 
is  called  one  of  " blepharofacial  spasm."  To  this  condition  the  French  term  "tic 
convulsif"  is  sometimes  applied.  The  cause  of  facial  spasm  is  unknown.  It 
sometimes  develops  in  nervous  individuals  as  a  result  of  a  severe  nervous  shock. 
In  some  instances  it  seems  to  partake  of  the  nature  of  a  habit  spasm,  and  in  these 
cases  not  infrequently  a  lightning-like  contraction  of  the  muscles  of  tlie  face  takes 
place.  Sometimes  in  addition  to  facial  spasm  there  is  also  torticollis.  Very  rarely 
facial  spasm  is  due  to  an  irritating  focus  in  the  motor  area  of  the  face  in  the  cortex, 
and  sometimes  it  is  the  early  or  first  symptom  of  an  oncoming  epileptic  seizure. 
In  ordinary  facial  spasm  the  muscles  are  not  persistently  contracted,  but  suffer 
from  twitchings  which  come  on  in  paroxysms,  or  which  occur  singly  at  varying 
intervals. 

The  prognosis  in  a  case  of  this  kind  is  not  very  favorable,  although,  as  a  rule, 
there  is  no  organic  lesion  to  maintain  it. 

The  treatment  of  facial  spasm  consists  in  a  careful  investigation  to  determine 
if  there  is  any  localized  focus  which  gives  rise  to  reflex  irritation,  as,  for  example 
disease  of  the  middle  ear.  If  such  an  area  is  found,  it  should  of  course  be  removed. 
In  some  instances  a  hyperesthetic  spot  in  the  nasal  mucous  membrane  may  be 
discovered.  If  no  such  local  area  of  irritation  can  be  found,  there  is  little  left  for 
the  physician  to  do  except  to  administer  nervous  sedatives,  such  as  the  bromides, 
chloral,  and  cannabis  indica,  but  these  in  turn  rarely  do  good  in  this  annoying, 
harmless,  but  persistent  condition.  In  young  persons  who  have  a  tendency  to 
facial  spasm  as  a  result  of  habit,  a  powerful  mental  impression  may  aid  in  breaking 
up  the  habit,  particularly  if  there  is  a  tendency  to  hysterical  manifestations. 

The  Eighth  or  Auditory  Nerve. — Disease  of  the  auditory  nerve  may  result  in 
deafness,  tinnitus,  vertigo,  and  loss  of  equilibrium. 

When  deafness  is  due  to  disease  of  this  nerve  it  commonly  arises  from  some 
degenerative  change,  which  in  turn  may  be  due  to  the  effect  of  an  infectious  disease. 
In  other  instances  the  deafness  is  due  to  a  congenital  defect,  but  in  still  others  it 
occurs  as  a  part  of  the  course  of  locomotor  ataxia,  disseminated  sclerosis,  or  general 
paralysis  of  the  insane.  More  rarely  it  arises  from  a  tumor  of  the  brain  or  from 
cerebral  syphilis.  In  deafness  due  to  these  causes  the  so-called  cochlear  fibres  of 
the  auditory  nerve  are  involved.  The  condition  may  be  differentiated  from  that 
form  of  deafness  which  is  due  to  disease  of  the  middle  ear,  the  peripheral  fibres  of  the 
auditory  nerve  not  being  affected,  and  by  the  fact  that  the  latter  class  of  patients 
possess  the  power  of  perceiving  sound  transmitted  through  the  bones  of  the  head. 
Thus,  if  a  tuning-fork  is  placed  against  the  head,  or  the  teeth,  the  patient  can 
perceive  the  sounds  which  it  generates  if  the  deafness  is  due  to  a  peripheral  cause, 
which  produces  interference  with  aerial  sound  conduction  in  the  external  or  middle 
ear,  but  he  cannot  perceive  its  sound  if  the  deafness  is  due  to  a  centric  cause,  such 
as  a  lesion  of  the  cocUea  of  the  internal  ear,  or  of  the  auditory  nerve  trunk,  or  of  the 
auditory  pathway  to  the  cortex.  Again,  in  those  cases  of  disease  of  the  auditory 
nerve  of  a  centric  character,  the  patient  does  not  find  it  easy  to  hear  in  the  presence 
of  loud  noises,  as  he  often  does  in  cases  of  deafness  due  to  a  peripheral  lesion. 

The  prognosis  in  deafness  due  to  centric  disease  of  the  auditory  nerve  is  very  bad. 

When  tinnitus  is  present,  it  arises  as  the  result  of  irritation  of  the  cochlear  portion 
of  the  auditory  nerve  which  supplies  the  organ  of  Corti  in  the  internal  ear,  or  of 
those  fibres  which  pass  from  this  organ  in  the  nerve  trunk  itself.     The  sound  may 


DISEASES  OF  THE  CRANIAL  NERVES  879 

vary  from  a  slight  buzzing  to  a  roaring,  ringing,  or  explosive  noise  which  may  be 
so  severe  as  to  be  insufferable.  Suicide  is  sometimes  threatened  by  persons  who 
are  not  only  persecuted  by  these  noises  during  the  day,  but  are  unable  to  sleep  by 
night  from  the  same  cause.  Little  can  be  done  for  many  of  these  cases.  In  those 
instances  in  which  tinnitus  arises  from  middle-ear  disease  or  from  anemia  or  from 
the  use  of  drugs,  such  as  quinine  and  salicylic  acid,  the  condition  can  often  be 
relieved,  as  it  depends  upon  an  irritation  and  not  upon  an  actual  lesion,  as  a 
rule. 

The  treatment  depends  upon  the  cause  of  the  tinnitus.  If  it  is  due  to  an  actual 
lesion  of  the  internal  ear  the  prognosis  is  bad  and  treatment  is  futile.  If  it  is  due  to 
gout,  anemia,  or  similar  causes,  the  prognosis  is  fairly  good. 

Vertigo  is  a  condition  in  which  the  patient  loses  the  sense  of  his  normal  relation 
to  surrounding  objects.  In  some  instances  he  seems  to  be  whirled  about  in  space. 
In  other  instances  he  seems  to  remain  stationary,  while  other  objects  are  whirled 
about  him.  As  the  patient's  conception  of  his  relation  to  surrounding  objects  is 
disturbed,  he  frequently  falls,  since  this  conception  has  much  to  do  with  the  motor 
impulses  by  which  he  controls  his  muscles  in  connection  with  the  function  of  muscle 
sense.  The  cause  of  vertigo  may  be  a  functional  disorder  of  the  branches  of  the 
auditory  nerve  which  supply  the  vestibular  portion  of  the  internal  ear,  as  when  it 
occurs  in  the  course  of  indigestion  (autotoxemia)  or  under  the  influence  of  a  drug 
such  as  quinine,  or  it  may  be  due  to  actual  lesions  in  connection  with  these  nerve 
fibres  such  as  hemorrhages  into  the  internal  ear,  or  other  damage  to  the  semi- 
circular canals.  Sometimes  also  it  seems  to  be  due  to  reflex  irritation  produced 
by  disease  in  the  middle  ear  or  in  the  external  meatus.  In  other  instances  the 
presence  of  a  foreign  body  in  the  meatus  produces  vertigo.  When  vertigo  is  severe, 
there  may  be  associated  with  it  great  nausea  and  vomiting,  palpitation  of  the  heart, 
profuse  sweating,  a  sense  of  approaching  syncope,  and  even  collapse.  The  respira- 
tions may  be  rapid.  These  symptoms  are  in  part  doubtless  due  to  the  mental 
distress  or  fright  from  which  the  patient  suffers.  There  is  probably  no  symptom 
which  causes  so  much  fright  and  wliich  is  so  rarely  followed  by  death  as  severe 
vertigo.  Nothing  but  the  awful  apprehension  of  true  angina  pectoris  approaches 
the  mental  distress  of  the  patient  who  suffers  from  this  condition  in  its  well-devel- 
oped form. 

One  form  of  vertigo  arising  as  the  result  of  disease  of  the  internal  ear  is  called 
Meniere's  disease.  It  is  usually  severe  in  its  nature.  Its  onset  is  sometimes  sudden, 
the  patient  being  seized  with  prostration,  pallor,  vomiting,  roaring  in  the  ears,  and 
deafness  immediately  after  hearing  a  loud  report  which  has  not,  of  course,  arisen 
from  any  extraneous  source.  This  form  of  vertigo  is  supposed  to  be  due  to  a 
hemorrhage  in  the  semicircular,  canals,  and  resembles  in  its  onset  an  apoplectic 
stroke,  but  it  is  not  characterized  by  paralysis.  In  some  instances  it  seems  to 
depend  upon  arteriocapillary  fibrosis.  It  may  or  may  not  be  associated  with 
absolute  deafness.  In  the  majority  of  cases  the  patient  suffers  from  recurrent 
attacks,  but  as  the  disease  progresses  the  attacks  last  longer  and  longer,  and  finally 
he  not  uncommonly  has  constant  vertigo. 

The  prognosis  in  cases  of  vertigo  depends  entirely  upon  the  cause  of  the  disorder. 
If  it  is  due  to  an  organic  disease,  unless  that  disease  exists  in  the  middle  or  external 
ear  and  is  removable,  the  outlook  is  serious.  Indeed,  the  condition  may  be  con- 
sidered incurable  if  an  actual  organic  and  centric  lesion  is  its  cause. 

In  Meniere's  disease  the  treatment  consists  in  rest  in  bed,  the  use  of  an  ice-bag 
on  the  head,  or  blister  behind  the  ear,  and  the  employment  of  large  doses  of  nervous 
sedatives,  such  as  the  bromides  and  chloral.  Certain  practitioners  claim  to  have 
obtained  good  results  from  the  administration  of  large  doses  of  quinine,  but  it  is 
difficult  to  see  how  this  drug  can  do  good  under  these  circumstances.  Indeed, 
one  would  expect  it  to  make  the  condition  much  worse.    Babinski  claims  to  have 


cS80  DISEASES  OF  THE  NERVOIS  SYSTEM 

had  good  results  following'  lumbar  puncture,  witli  tiie  withdrawal  of  a  few  cubic 
centimetres  of  cerebrospinal  fluid. 

\'ertigo  which  is  due  to  auto-intoxication  arising  from  an  abnormal  state  of  the 
bowels  or  kidneys  should  be  treated  by  the  administration  of  diuretics,  cholagogues, 
])urgati\-es,  and  free  sweatings. 

The  Ninth  or  Glossopharyngeal  Nerve. — The  ninth  nerve  is  the  ner\e  of  sen- 
sation of  the  pharynx,  the  palate,  and  the  middle  ear.  It  is  also  probably  connected 
with  the  special  sense  of  taste  in  the  posterior  third  of  the  tongue,  although  it  is 
considered  by  some  physiologists  that  those  fil)res  which  are  coiuiected  with  this 
function  join  the  glossopharyngeal  fibres  from  the  fifth  nerxe.  Some  of  its  sensory 
fibres  enter  the  medulla  oblongata  near  the  olivary  body  and  terminate  in  the 
gray  matter  on  the  floor  of  the  fourth  ventricle,  while  another  set  of  fibres  ends  in 
the  subtantia  gelatinosa.  From  the  latter  point  some  of  its  fibres  ascend  into  the 
brain.  In  addition  to  its  sensory  function  it  also  contains  motor  fibres  which  spring 
from  cells  known  as  the  nucleus  ambiguus.  These  fibres  make  their  exit  from  the 
side  of  the  medulla  back  of  the  olivary  body,  and  escape  from  the  skull  through 
the  jugular  foramen.  The  motor  fibres  supply  the  muscles  of  the  larynx,  the 
esophagus,  and  pharynx,  and  are  also  connected  with  the  function  of  respiration, 
deglutition,  and  phonation. 

Paralysis  of  the  glossopharyngeal  nerve  is  exceedingly  rare,  and  therefore  we 
possess  but  little  information,  either  clinical  or  pathological,  concerning  its  condition 
in  disease.  Should  the  nerve  itself  be  damaged,  the  symptoms  consist  in  loss  of 
sensation  in  the  upper  half  of  the  pharynx,  loss  of  the  sense  of  taste  on  the  posterior 
half  of  the  tongue,  and  difficiilti/  in  swallowing  because  of  paralysis  of  the  pharyngeal 
muscles  and  because  of  the  loss  of  reflex  irritability  of  the  mucous  memlirane  of  the 
pharynx.  Such  a  condition  sometimes  develops  during  postdiphtheritic  paralysis. 
When  lesions  of  the  nuclei  of  this  nerve  take  place,  the  sj'mptoms  are  practically 
those  of  bulbar  paralj'sis  (which  see) . 

The  Tenth  or  Vagus  Nerve. — This  nerve,  sometimes  called  the  pncumogastric 
nerve,  is  composed  of  both  sensory  and  motor  fibres.  The  sensory  fibres  pass 
upward  from  the  various  portions  of  the  body  which  they  supply  and  enter  two 
ganglia,  one  of  which,  the  upper,  is  large  and  oval,  and  the  other  is  long  and  irregular 
in  outline.  After  leaving  these  ganglia  the  fibres  pass  to  the  medulla,  some  of  them 
terminating  in  the  gray  matter  which  exists  in  the  floor  of  the  fourth  ventricle, 
thereby  forming  the  sensory  centres  connected  with  respiration  and  the  heart. 
Other  of  these  fibres  join  the  ninth  nerve  and  end  in  the  substantia  gelatinosa  and 
from  this  point  new  fibres  ascend  to  the  brain.  Those  fibres  of  the  pncumogastric 
which  are  motor  in  function  take  their  origin  from  the  cells  of  the  nucleus  ambiguus 
and  escape  from  the  side  of  the  medulla,  forming  the  main  trunk  of  the  nerve.  The 
distribution  of  the  afferent  and  efl'erent  fibres  of  this  nerve  is  well  shown  in  Plate  XVI. 

The  tenth  nerve  has  a  far  larger  distribution  than  any  other  cranial  nerve,  supply- 
ing the  pharynx,  the  larynx,  the  heart,  the  lungs,  esophagus,  stomach,  and  intestines, 
and  even  the  external  ear  through  an  auricular  branch.  According  to  some  physi- 
ologists it  is  the  chief  motor  supply  of  the  palate.  It  joins  the  glossopharyngeal 
or  ninth  nerve,  and  certain  sympathetic  nerve  fibres,  in  the  formation  of  the  pharyn- 
geal plexus  which  supplies  the  pharyngeal  muscles. 

The  sujierior  laryngeal  branch  supplies  the  cricothyroid  muscle,  the  thyro-epiglottic 
and  arycpiglottic  muscles,  and  the  inferior  laryngeal  branch,  sometimes  called  the 
recurrent  laryngeal,  supplies  the  other  laryngeal  muscles.  By  means  of  the  sensory 
fibres  wiiich  exist  in  the  superior  laryngeal  nerve,  the  mucous  membrane  of  the 
epiglottis  possesses  sensation,  and  by  means  of  those  sensory  fibres  which  exist  in 
the  recurrent  laryngeal  the  mucous  membrane  below  the  vocal  cords  is  supplied 
with  sensory  filaments.  If  the  sensory  fibres  in  the  superior  laryngeal  nerve  are 
stimulated,  the  respirations  become  slower  and  deeper,  or  they  may  be  arrested  as 


PLATE  XVI 


The  Vagus  and  Sympathetic  Fibres  of  the  Kight  Side  and  Their 
Anastomoses.     (Modified  fronn  Riidinger.) 

1,  origin  of  vagus;  2,  anastomosis  with  sympathetic;  3,  superior  laryngeal  and  pharyngeal  plexus; 
4,  the  pulmonary  plexus;  5.  the  inferior  cardiac  fibres,  with  sympathetic  fibres;  6,  the  oesophageal  plexus. 
The  course  of  the  optic  nerve  (7),  the  oculomotor  (8),  tlft  trochlearis  (9),  the  abducens  (10),  and  the  facial 
(11)  are  also  shown. 


DISEASES  OF  THE  CRANIAL  NERVES  881 

the  result  of  a  reflex  impulse  which  passes  to  the  centre  in  the  medulla.  Closure 
of  the  glottis  may  also  be  produced  in  this  manner. 

The  pulmonary  branches  of  the  vagus  contain  motor  fibres  which  supply  the 
unstriated  muscles  of  the  bronchi,  and  sensorj'  fibres  for  the  mucous  membrane  of 
the  bronchi.  They  apparently  also  contain  fibres  centripetal  in  character,  which 
when  stimulated  diminish  the  inhibitory  action  of  the  pneumogastric  nerve  upon 
the  heart,  thereby  producing  tachycardia.  Those  branches  of  the  vagus  which 
supply  the  esophagus  innervate  its  muscles,  on  the  one  hand,  and  supply  its  mucous 
membrane  with  sensory  filaments  on  the  other;  while  those  which  pass  to  the 
stomach  contain  not  only  fibres  which  govern  its  mucles,  but  also  other  fibres  which 
control  its  secretion  and  its  blood  supply.  The  same  facts  hold  true  of  those  fibres 
which  pass  to  the  intestines.  Last,  but  by  no  means  least,  the  pneumogastric 
sends  fibres  to  the  heart,  and  through  these  pathways  an  inhibitory  action  is 
exercised  which  if  stimulated  may  temporarily  arrest  the  heart  in  diastole. 

Not  only  is  the  pneumogastric  nerve  of  very  great  importance  because  of  the 
multiple  functions  which  it  possesses,  but  it  is  also  of  great  importance  to  the 
clinician  because  it  not  infrequently  suffers  from  disease.  Though  it  is  rarely 
the  victim  of  primary  neuritis,  cases  of  rheumatic  neuritis  of  both  recurrent  laryn- 
geal nerves  have  been  reported,  and  instances  in  which  this  nerve  has  been  involved 
in  cases  of  multiple  neuritis  due  to  poison,  such  as  alcohol,  for  example,  are  by  no 
means  rare.  So,  too,  it  sometimes  suffers  in  diphtheritic  paralysis,  and  from 
neuritis  arising  from  the  poisons  of  various  infectious  diseases  such  as  typhoid 
fever,  pneumonia,  scarlet  fever,  malaria,  and  influenza,  from  tumors  and  inflamma- 
tion in  the  mediastinum,  disease  of  the  jugular  vein,  tuberculosis  of  the  mediastinal 
glands,  and  from  pressure  upon  the  nerve  exercised  by  reason  of  dilatation  of  the 
left  auricle  in  cases  of  mitral  stenosis.  In  those  instances  in  wliich  the  centres  of 
the  pneumogastric  nerves  are  aft'ected  by  disease,  we  find  that  tumors,  hemorrhagic 
extravasations,  the  lesions  of  locomotor  ataxia,  and  disseminated  sclerosis  are  the 
causes.  In  still  other  instances  the  disorder  of  the  function  of  this  nerve  develops 
as  the  result  of  bulbar  paralysis.  Cases  are  also  on  record  in  which  the  fibres  of 
the  nerve  outside  of  the  medulla  have  been  pressed  upon  by  tumors,  by  the  exuda- 
tions due  to  meningitis,  hemorrhages,  and  by  bone  disease. 

The  symptoms  of  disorder  of  the  function  of  the  vagus  nerve  are,  of  coiu-se,  very 
varied.  If  the  lesion  exists  at  the  base  of  the  brain  it  nearly  always  happens 
that  there  is  paralysis  of  the  other  cranial  nerves,  particularly  of  the  ninth,  eleventh, 
and  twelfth.  In  such  a  case  if  the  fibres  on  one  side  alone  are  aft'ected,  there  is 
unilateral  paralysis  of  the  fauces,  the  palate,  and  the  larynx.  The  speech  is  nasal, 
and  the  act  of  sivallowing  may  be  ivipaired.  There  is  also  interference  with  the 
action,  of  the  vocal  cords.  If  the  recurrent  laryngeal  branch  is  affected,  there  is 
laryiKjeal  paralysis.  The  vocal  cord  on  that  side  remains  midway  between  adduc- 
tion and  abduction,  and  fails  to  move  during  phonation.  If  both  of  the  recurrent 
laryngeal  nerves  are  paralyzed,  the  patient  suffers  from  aphonia,  inspiratory  stridor, 
and  dyspnea.  When  the  pulmonary  fibres  are  affected,  particularly  if  the  lesions 
are  bilateral,  the  respirations  may  become  rapid  and  irregular. 

Irritation  of  the  pulmonary  fibres,  directly  or  indirectly,  may  cause  spasm  of  the 
bronchial  muscles,  and  hyperemia  and  congestion  of  the  bronchial  mucous  mem- 
brane (asthma). 

If  the  gastric  fibres  are  involved,  there  may  be  vomiting,  pain  in  the  stomach, 
and  loss  of  the  sense  of  hunger  and  thirst.  When  the  cardiac  fibres  are  severely 
aft'ected,  the  pulse  rate  may  be  markedly  accelerated.  If  they  are  irritated,  an 
exceedingly  slow  pulse  may  be  present. 

The  treatment  of  disorders  of  the  vagus  nerve  depends  largely  upon  the  cause 
which  underlies  the  disturbance.  If  there  is  reason  to  believe  that  there  is  a  syphi- 
litic exudate  at  the  base  of  the  brain,  or  a  syphilitic  arteritis,  the  iodides  and 
.56 


882  DJSPJASES  OF  THE  XERVOUS  SYSTEM 

mercury  are,  of  course,  indicated.  So,  too,  in  that  form  of  disorder  of  the  vagus 
which  results  from  lead  poisoning,  the  iodides,  hot  baths,  and  purgatives  are 
required.  If  it  is  believed  that  a  gummatous  growth  exists  in  the  thorax  which 
irritates  the  vagus  by  pressure,  antisyphilitic  treatment  is  necessary.  If  there  is  a 
distinct  rheumatic  history  leading  one  to  believe  that  the  recurrent  laryngeal 
nerves  are  sutt'ering  from  rheumatic  paralysis,  already  mentioned,  the  iodides  and 
the  salicylates  are  advisable.  Digitalis  may  also  be  useful  for  the  purpose  of 
stimulating  the  pneumogastric  nerve  in  those  cases  in  which  tachycardia  is  present, 
and  atropine  may  be  used  witii  the  object  of  diminishing  irritation  in  tliis  nerve  by 
depressing  its  peripheral  fil)rcs  wlien  the  pulse  is  unduly  slow. 

Eleventh  or  Spinal  Accessory  Nerve. — The  eleventh  or  spinal  accessory  nerve 
is  composed  of  two  parts,  an  accessory  portion,  which  goes  to  the  pneumogastric, 
and  a  spinal  portion.  The  accessory  branch  is  formed  by  several  fasciculi  which 
spring  from  the  medulla  in  series  with  the  roots  of  the  vagus.  These  fasciculi 
form  a  trunk,  and  to  this  trunk  are  joined  the  fibres  from  the  spinal  portion.  The 
nerve  leaves  the  cranium  with  the  pneumogastric.  In  its  passage  through  the 
jugular  foramen  it  sends  fibres  to  the  root  ganglion  of  the  vagus,  while  others  pass 
over  the  surface  of  this  ganglion  into  the  pharyngeal,  superior  laryngeal,  and  recur- 
rent laryngeal  nerves.  Most  of  the  motor  fibres  of  the  pneumogastric  are  derived 
from  this  accessory  branch.  The  spinal  portion  of  the  nerve  arises  by  a  series  of 
roots  which  spring  from  the  lateral  portion  of  the  spinal  cord,  even  as  low  as  the 
sixth  or  seventh  cervical  nerve  roots.  They  spring  from  the  lateral  column  near 
the  origin  of  the  posterior  nerve  roots  and  form  an  ascending  trunk,  which  enters 
the  skull  and  unites  with  the  accessory  portion,  as  already  described.  Before 
entering  the  jugular  foramen,  however,  certain  of  its  fibres  leave  the  accessory 
portion,  make  a  sharp  turn  backward  near  the  internal  jugular  vein,  and  enter  the 
deep  surface  of  the  sternomastoid  muscle,  which  muscle  it  supplies.  Passing 
tlirough  this  muscle,  it  enters  under  the  trapezius,  a  short  distance  abo\-e  the 
clavicle.  Here  it  anastomoses  with  fibres  from  the  third  and  fourth  cer\-ical 
nerves,  forming  a  plexus,  which  supplies  the  traj^ezius  muscle. 

Symptoms. — Disturbances  in  the  function  of  the  acessory  ner\e,  so  far  as  its 
spinal  part  is  concerned,  result  in  torticollis,  which  occurs  as  congenital  wryneck, 
as  wryneck  due  to  injury,  and  true  spasmodic  wryneck.  The  rouqcvHal  form 
is  due  to  some  defect  in  development  or  to  injury  of  the  sternomastoid  muscle 
at  the  time  of  delivery.  The  right  side  is  affected  in  the  majority  of  cases. 
The  sternomastoid  muscle  is  not  in  the  spasm,  but  the  head  is  drawn  to  one 
side  and  rotated  to  the  opjjosite  side  as  the  result  of  shortening  of  the  muscle 
upon  the  side  to  which  the  head  is  drawn.  Not  rarely  there  is  associated  with 
this  atrophy  some  wasting  of  the  muscles  of  the  face  upon  this  side.  iSpasmodic 
wryneck,  on  the  other  hand,  is  due  to  a  true  sjjasm  of  the  muscles  supi)lied  by  the 
spinal  accessory.  It  is  not  met  with  in  children,  and  \ery  rarely  in  advanced  life, 
but  occurs  most  frequently  in  middle-aged  persons.  In  a  certain  proportion  of 
cases  the  patients  are  distinctly  hysterical,  and  the  spasm  follows  some  nervous 
shock.  In  other  cases  no  hysterical  stigmata  are  present,  and  it  is  thought  that  the 
condition  is  due  to  that  somewhat  indefinite  state  called  "rheumatism."  This 
form  of  wryneck  differs  from  the  congenital  variety  in  that  it  is  usually  accompanied 
by  pain.  The  spasm  may  not  be  constant  but  intermittent.  The  chin  is  often 
protruded  and  raised.  At  times  the  spasm  extends  to  the  muscles  of  the  face, 
and  facial  twitching  may  occur.  Often  the  condition  becomes  one  of  tonic  spasm 
after  having  begun  as  clonic  spasm,  and  if  the  condition  persists  for  any  length 
of  time  the  affected  muscles  may  midergo  liy}iertroj)hy,  and  those  on  the  opposite 
side  may  atrophy  from  disuse. 

Those  forms  of  wryneck  in  adults  which  are  characterized  by  intermittent  or 
clonic  spasms  are  rarely  due  to  rheumatism,  so  called,  but  depend  upon  some 


DISEASES  OF  THE  CRANIAL  NERVES  S83 

neurosis;  whereas,  the  tonic  spasm  may  be  due  simply  to  muscular  fixation  through 
pain.  In  the  latter  class  of  cases  the  prognosis  is  exceedingly  good,  the  condition 
usually  disappearing  under  the  use  of  hot  applications  or  counter-irritant  liniments, 
and  the  internal  administration  of  the  salicylates  and  the  iodides.  Certain  persons 
have  advised  the  intramuscular  injection  of  atropine,  in  the  dose  of  >,V  o^  ^  grain, 
directly  into  the  belly  of  the  afflicted  muscle  in  order  that  it  may  depress  the 
peripheral  motor  nerve  endings.  While  this  is  efficacious  in  some  cases,  it  is  prone 
to  produce  moderate  systemic  symptoms,  and  is  not  to  be  resorted  to  unless  the 
condition  fails  to  yield  to  the  plan  of  treatment  already  suggested. 

The  type  depending  upon  a  neurosis  is  much  more  difficult  to  treat.  It  often 
remains  unchanged  for  many  months,  and  indeed  may  become  a  permanent  con- 
dition.    Sometimes  a  nervous  shock,  or  some  accident,  may  suddenly  end  the  spasm. 

Under  the  unfortunate  name  of  "spurious  wryneck,"  a  condition  of  wryneck 
develops  as  a  result  of  caries  of  the  spine,  the  spasm  of  the  muscle  being  due  to  the 
lesions  in  the  vertebrte,  or  the  distortion  is  due  to  the  fact  that  these  bones  do  not 
properly  support  the  head. 

Under  the  name  of  "spasmus  Nutans,"  or  "nodding  spasm,"  a  condition  is  met 
with  in  which  the  muscles  upon  both  sides  of  the  neck  are  affected  in  such  a  way 
that  there  is  a  nodding  moA^ement.  It  occurs  in  poorly  nourished,  neurotic  indi^'id- 
uals,  and  closely  resembles  habit  chorea.  The  symptoms  become  most  marked 
when  attention  is  called  to  them,  and  are  usually  absent  during  sleep. 

Paralysis  of  the  spinal  accessory  may  be  due  to  injury,  disease  of  the  vertebrae, 
muscular  atrophy,  or  any  form  of  disease  of  the  spinal  cord  in  the  cervical  region. 
As  the  result  of  the  paralysis  there  may  be  loss  of  power  to  rotate  the  head  upon 
the  vertebral  axis.  The  sternomastoid  muscle  does  not  stand  out  prominently 
as  its  does  when  affected  by  spasm,  and  there  is  difficulty  in  raising  the  arm  at  a 
right  angle  to  the  body.  In  those  comparatively  rare  cases  in  which  the  para- 
lysis is  bilateral,  the  head  may  appear  to  be  fixed,  as  if  the  fixation  were  due  to 
spasm. 

Twelfth  or  Hypoglossal  Nerve. — The  twelfth  or  hypoglossal  nerve  arises  from 
a  group  of  cells  in  the  floor  of  the  fourth  ventricle,  at  its  lowest  point.  Its  fibres 
emerge  froii  the  medulla,  and  escape  from  the  skull  through  the  anterior  condyloid 
foramen  of  the  atlas,  and  so  pass  to  the  muscles  of  the  tongue.  Injury  and  disease 
of  this  nerve  rarely  take  place  in  its  peripheral  filaments.  Nearly  always  when 
it  is  affected,  the  lesion  is  in  the  bulb  or  in  the  brain.  Thus,  out  of  79  cases  collected 
by  Ascoli,  in  only  one-third  were  the  peripheral  fibres  affected.  The  causes  of 
centric  disease  of  the  hypoglossal  nerve  are  an  inflammatory  process  or  growth  at 
the  base  of  the  brain,  or  in  the  medulla  oblongata.  When  the  lesion  is  in  the 
medulla,  there  is  usually  bilateral  paralysis  with  wasting  of  the  tongue,  but  as  the 
nuclei  of  all  the  cranial  nerves  have  their  origin  nearby,  it  nearly  always  happens 
that  there  are  evidences  of  paralysis  of  the  other  cranial  nerves  present.  Inside 
the  bony  casement  the  causes  of  hypoglossal  paralj'sis  are  inflammatory  exudates, 
hemorrhages,  and  disease  of  the  bone.  Very  rarely  the  peripheral  filaments  of 
the  nerve,  after  they  take  their  exit  from  the  atlas,  suffer  from  neuritis. 

In  some  cases  of  locomotor  ataxia,  syringomyelia,  and  multiple  sclerosis,  there 
is  hemiatrophy  of  the  tongue  with  paralysis.  The  same  symptom  also  occurs 
when  damage  is  done  to  the  peripheral  fibres  of  the  nerve.  The  tongue  lies  on  the 
floor  of  the  mouth,  and  it  is  impossible  for  the  patient  to  move  the  tongue  upon  the 
paralyzed  side.  If  the  tongue  is  protruded,  it  deviates  to  the  paralyzed  side,  but 
sometimes  while  the  main  body  of  the  tongue  may  be  deviated  in  this  manner,  the 
tip  points  toward  the  sound  side.  Remak  points  out  that  while  the  tongue  lies 
on  the  floor  of  the  mouth  apparently  paralyzed,  it  can  be  easily  pushed  about 
by  the  finger  if  the  paralysis  is  organic;  whereas,  in  hysteria,  all  attempts  to  move 
the  tongue  by  the  finger-tip  cause  eft'orts  to  resist  these  movements.     The  paralysis 


8S4  DISEASES  OF  THE  NERVOUS  SYSTEM 

of  the  toiij;iie  impairs  the  speecli,  and  also  interferes  witli  (lei^hitition  and  mastica- 
tion when  the  paralysis  is  bilateral. 

The  prognosis  varies  with  the  cause  of  the  lesion.  In  syphilitic  cases  recovery 
sometimes  occurs  under  active  mercurial  treatment.  In  the  so-called  rheumatic 
cases,  it  may  take  place  under  the  influence  of  the  iodides  or  salicylates.  If  an 
actual  lesion  at  the  point  of  origin  exists,  the  prognosis  is  had. 


DISEASES  IN  WHICH  THE  CHIEF  MANIFESTATIONS  ARE  IN  THE 

MUSCLES. 

MUSCULAR  DYSTROPHIES. 

Definition. — Under  this  term  are  described  several  related  maladies,  characterized 
by  alterations  in  the  trophic  state  of  the  muscles,  which  are  met  with  almost  always 
in  early  life  and  which  are  not  due  to  disease  of  the  ner\-ous  system — that  is  to  say, 
they  are  primarily  muscular  in  origin.  The  alterations  in  the  muscles  cause  loss 
of  power  and  the  paralysis  may  be  thought  to  be  due  to  a  spinal  lesion,  but  this  is 
not  the  case. 

Muscular  dystrophy  has  been  divided  by  Erb  into  three  forms,  namely,  pseudo- 
muscular  hypertrophy,  Erb's  juvenile  dystrophy,  and  the  Landouzy-Dejerine  type 
of  dystrophy.  Several  other  types  have  been  described  by  other  writers.  (See 
below.) 

Etiology. — The  etiology  of  these  dystrophies  is  not  known,  but  they  are  all 
believed  to  be  dependent  upon  faulty  development  of  the  muscles  affected.  In 
other  words,  it  would  seem  as  if  the  vitality  of  certain  muscles  is  of  such  a  character 
that  they  undergo  senile  changes  early  in  life.  When  injuries  and  the  acute  infec- 
tious diseases  seem  to  be  causative  factors  it  is  probable  that  they  act  only  indirectly 
in  that  they  hasten  the  degenerative  changes  in  the  feeble  parts. 

Pathology  and  Morbid  Anatomy. — The  changes  in  the  muscles  in  cases  in  which 
atrophy  takes  place  consist  in  a  wasting  and  thinning  of  the  muscle  fibrils  within 
the  sarcolemma.  They  become  shortened  and  pigmented.  In  other  cases  a  true 
degenerative  process  goes  on,  the  fibrils  become  swollen,  suffer  from  fatty  or  albu- 
minoid changes,  and  show  fattj^  and  granular  masses  within  the  sarcolemma,  until 
finally  the  sarcolemma  may  contain  nothing  but  fatty  globules.  In  a  third  form 
of  dystrophy  there  is,  in  addition  to  fatty  degeneration  in  the  fibrils,  a  deposit  of 
fat  between  the  sheaths  covering  the  fibrils.  With  these  changes  there  is  also  an 
overgrowth  of  connective  tissue,  and  as  a  consequence  a  muscle  which  is  so  large 
as  to  appear  strong  and  powerful  is  in  reality  feeble  or  powerless. 

Pseudomuscular  Hypertrophy. — This  form  of  muscular  dystrophy  is  essentially 
a  disease  of  early  childhood  l)cginning  between  the  second  and  seventh  year.  It  is 
characterized  by  enlargement  of  the  muscles  of  the  calves  of  the  legs,  which  soon 
are  seen  to  be  proportionately  too  large  for  the  rest  of  the  child.  It  is  then  noticed 
that  these  muscles  lack  power  and  this  weakness  causes  the  patient  to  walk  awk- 
wardly, to  stumble  o\'er  trifling  obstacles,  to  tire  easily,  and  to  have  difficult^' 
in  rising  from  the  prone  to  the  erect  posture,  so  that  the  patient  gets  on  his  feet 
very  much  as  a  dog  does,  largely  by  the  aid  of  the  forelimbs.  But  while  inspection 
of  the  muscles  of  the  calves  and  of  the  anterior  portion  of  the  thighs  reveals  that  they 
are  enlarged,  it  will  also  show  that  the  gluteal  muscles  are  atrophied  and  that  the 
muscles  of  the  back  are  weakened,  with  the  result  that  there  is  de\elopcd  anterior 
curvature  of  the  spine  and  a  protruding  belly.  The  extension  of  the  hips  are 
invariably  affected,  rendering  it  difficult  for  the  patient  to  ascend  steps  and  often 
causing  a  tilting  forward  of  the  pelvis  with  a  compensating  curve  of  the  upper 
part  of  the  trunk. 


MUSCULAR  DYSTROPHIES  885 

When  the  disease  is  still  further  advanced  alterations  in  the  nutrition  of  the 
muscles  about  the  shoulder-blades  is  usually  present.  The  deltoid  and  the  supra- 
spinatus,  the  biceps,  and  the  triceps  undergo  atrophy  and  do  not  a])pcar  to  be 
increased  in  size  because  they  seldom  ha\e  the  dejjosit  of  fat  which  makes  the 
muscles  in  the  legs  seem  unusually  large.  Occasionally,  however,  such  a  fictitious 
hypertrophy  may  be  ]3resent  in  these  muscles,  because  of  loss  of  power  in  the 
rhomboidei,  in  the  levatores  anguli  scapulae,  and  in  the  serrati.  The  shoulder- 
blades  occupy  a  peculiarly  prominent  position,  and  because  of  the  wasting  of  the 
muscles  already  named  there  may  be  great  feebleness  in  the  movements  of  the  upper 
arm.     The  muscles  of  the  forearm  and  hand,  however,  usually  escape. 

Contractures  appear,  which,  like  contractures  in  other  forms  of  muscular  atrophy, 
result  in  deformities  such  as  club-foot  or  flexion  of  the  legs  upon  the  thighs  and  the 
thighs  upon  the  pelvis.  Contractures  may  also  take  place  in  the  arms.  It  is  a 
fact  worthy  of  note  that,  luilike  other  forms  of  muscular  atrophy,  this  disease  does 
not  show  fibrillary  contractions  in  the  muscles,  nor  are  the  reactions  of  degeneration 
present,  even  w'hen  the  muscles  are  considerably  atrophied.  Sensation  is  intact, 
and  the  reflexes  are  preserved,  unless  the  muscles  are  so  completely  wasted  that  they 
are  unable  to  contract. 

Prognosis. — The  prognosis  in  these  cases  is  invariably  unfa^'o^able.  Periods  of 
arrest  in  the  advancement  of  the  disease  may  occur,  but  ultimately  the  patient  is 
ansolutely  helpless.  Death  never  occurs  from  pseudomuscular  hypertrophy 
directly,  being  caused  in  most  cases  by  intercurrent  diseases  which  attack  the 
enfeebled  body. 

Erb's  Juvenile  Muscular  Dystrophy  or  Scapulohumeral  Type. — This  form  of 
dystrophy  begins  at  about  the  time  of  puberty,  usually  between  twelve  and  sixteen; 
rarely  as  late  as  the  twentieth  year.  The  pectoral  muscles,  the  trapezii,  the  latissi- 
mus  dorsi,  the  rhomboidei,  and  the  deltoids  undergo  apparent  hypertrophy  with 
progressive  weakening.  This  results  in  the  falling  forward  of  the  shoulders,  so 
that  very  much  the  same  attitude  is  maintained  as  if  there  was  a  fracture  of  the 
clavicles.  The  scapulae  are  prominent.  In  some  cases  the  disease  ceases  to  develop; 
but  if  it  does  not,  the  loss  of  power  extends  to  the  muscles  of  the  back,  and  various 
forms  of  spinal  curvature  develop.  After  this,  the  gluteal  muscles  and  those  of 
the  thigh  become  enfeebled.  They  may  atrophy  or  may  undergo  seeming  hyper- 
trophy. When  the  muscles  of  the  leg  are  enfeebled  club-foot  may  be  present. 
The  chief  difference,  therefore,  between  pseudomuscular  hypertrophy  and  Erb's 
juvenile  type  of  muscular  dj'strophy  is  the  fact  that  the  latter  disease  develops  later 
in  life,  that  it  affects  the  upper  extremities  before  it  affects  the  lower  extremities, 
and  that  atrophy  is  more  marked  than  hypertrophy. 

Landouzy-Dejerine  Type  of  Muscular  Dystrophy  or  Facioscapulohumeral  Type. 
— This  type  of  muscular  dystrophy  may  appear  in  early  childhood  or  in  adult  life. 
It  is  characterized  by  the  peculiar  fact  that  the  atrophy  develops  in  the  muscles 
of  the  face,  particularly  the  orbicularis  oris,  and  extends  to  the  muscles  of  the  cheeks 
and  those  of  the  forehead,  with  the  result  that  the  lips  lose  power;  the  mouth  cannot 
be  closed,  but  has  a  peculiar  pouting  expression,  and  speech,  at  least  so  far  as  labial 
and  lingual  sounds  are  concerned,  becomes  very  defective.  So,  too,  the  face  loses 
its  power  of  expression  from  a  similar  cause,  and  there  is  dribbling  of  saliva  because 
the  lower  lip  sags.  Both  sides  of  the  face  are  usually  affected.  The  orbicularis 
palpebrarum  usually  escapes,  as  do  also  the  masseter  muscles.  Later,  the  muscles 
of  the  shoulders  become  affected,  and  finally  those  of  the  trunk  and  legs  become 
involved  until  the  case  closely  resembles  either  one  of  the  forms  of  muscular 
dystrophy  just  described,  save  that  the  facial  symptoms  are  prominent. 

In  some  cases  the  symptoms  of  these  three  forms  of  dystrophy  overlap  one  another 
to  such  an  extent  that  it  is  difficult  to  determine  to  which  type  an  individual  patient 
belongs. 


886  DISEASES  OF  THE  XERVOUS  SYSTE]f 

Treatment. — Xo  form  of  special  trratment  can  produce  advantageous  results. 
Till'  hest  that  can  he  done  is  to  order  for  the  patient  an  out-door  life,  if  possible  in 
tiic  country,  and  in  a  climate  where  he  can  remain  for  many  iiours  in  sunshine  and 
in  a  place  where  he  can  receive  excellent  ft)od.  Gentle  massage  and  Swedish 
movements  may  be  employed,  but  care  must  be  taken  not  to  tire  the  wasting 
muscles.  The  most  that  can  be  expected  from  this  i)lan  of  treatment,  however, 
is  the  temporary  arrest  of  the  malady.  Xo  real  improvement  usually  occurs. 
Efl'orts  to  correct  deformities  profluced  by  contractures  are  generally  useless,  since 
the  relief  is  but  temporary. 

MUSCULAR  ATROPHY  OF  THE  PERONEAL  TYPE. 

Definition. — This  is  a  form  of  progressive  muscular  atrophy  wliich  beuins  in  the 
muscles  innervated  by  the  peroneal  nerves,  and  which  does  not  extend  higher 
than  the  knee.  After  the  symptoms  in  the  legs  ha\^e  developed,  a  somewhat 
similar  condition  may  affect  the  muscles  of  the  hand  and  forearms.  It  is  sometimes 
given  the  name  of  the  "Charcot-]\Iarie-Tooth"  form  of  progressive  muscular 
atrophy,  or  is  called  the  "progressive  neural  muscular  atrophy  of  Hoffman," 
or  primary  neuritic  or  neurotic  atrophy.  It  is  an  uncommon  disease,  but  not  so 
rare  as  was  formerly  believed. 

Etiology. — There  seems  to  be  a  distinct  hereditary  predisposition,  since  it  fre- 
quentl\'  affects  several  members  of  a  family,  and  can  be  traced  through  several 
generations.     It  usually  develops  during  the  first  two  decades  of  life. 

Pathology  and  Morbid  Anatomy. — The  condition  depends  upon  degenerative 
changes  in  the  muscles,  in  the  nerves,  and  sometimes  in  the  posterior  columns  of 
the  spinal  cord.  There  is  also  sometimes  a  circumscribed  atrophy  in  the  anterior 
horns  of  gray  matter,  and  perhaps  degeneration  of  the  lateral  columns  of  the  cord. 
Whether  the  disease  arises  in  the  peroneal  nerves  primarily,  or  whether  the  lesion 
begins  in  the  posterior  horns  of  the  gray  matter  in  the  spinal  cord,  is  unknown. 

Symptoms. — The  symptoms  of  this  form  of  muscular  atrophy  consist  in  weakness 
of  the  Dtu.scles  of  the  f out  and  of  the  peroneal  muscles  of  the  leg,  followed  by  atrophy 
in  the  anterior  and  posterior  tibial  muscles,  with  the  production  of  drop-foot,  which 
makes  it  impossible  for  the  patient  to  walk.  Unlike  the  two  forms  of  muscular 
dystrophy  just  described,  fibrillary  contractions  are  present  in  the  affected  muscles, 
and  there  is  a  loss  of  reflex  activity  and  of  electric  excitability,  so  that  the  last  stage 
of  the  reaction  of  degeneration  may  finally  be  present.  The  various  forms  of  club- 
foot may  come  on  as  secondary  conditions.  When  the  upper  extremities  are 
affected,  fibrillary  contractions  can  be  seen  in  the  muscles  of  the  hand,  and  after 
loss  of  power  has  been  present  for  some  time,  deformities  of  the  hand  may  arise 
from  contractures.  In  some  cases  the  progress  of  the  disease  is  exceedingly  rai)id 
but  in  others  it  is  equally  slow.  In  still  others  the  wasting  extends  so  that  all  the 
muscles  of  the  extremities  and  trunk,  and  even  those  of  the  face,  may  undergo 
atrophy. 

Prognosis. — The  prognosis  as  to  recovery  is  hopeless,  but  patients  may  live  for 
many  years  unless  destroyed  by  some  intercurrent  disease. 

Treatment. — Aside  from  hygienic  measures,  no  method  of  treatment  can  arrest 
the  progress  of  the  malady. 

FUNCTIONAL  NERVOUS  DISEASES  AND  DISEASES  OF  DISPUTED 
PATHOLOGY. 

MYOTONIA  CONGENITA. 

Definition. — Myotonia  congenita,  commonly  called  Thomsen's  disease,  is  an 
exceedingly  rare  atVection  not  dependent  upon  disease  of  the  nervous  system,  and 


PARAMYOCLONUS  MULTIPLEX  8S7 

characterized  by  hypertrophy  of  the  miiscuUir  fihres  with  the  proliferation  of  their 
nuclei.  These  changes  result  in  loss  of  power.  The  disease  usually  occurs  in  several 
members  of  the  same  family,  and  appears  in  successive  generations. 

Symptoms. — The  ciiief  symptom  of  Thomsen's  disease  is  a  ruiidity  of  the  muscles, 
which  develops  after  they  have  been  quiescent.  This  spasm  of  the  muscles  comes 
on  when  the  patient  attempts  to  move,  and  may  be  so  severe  as  to  make  walking 
practically  impossible.  Because  of  the  inability  of  the  patient  to  balance  opposing 
muscles  in  different  portions  of  his  body,  he  may  fall.  After  a  time,  if  the  patient 
persists  in  his  endeavor  to  walk  or  to  make  other  movements,  the  spasm  passes 
off,  and  the  muscles  respond  as  in  the  normal  individual  so  that  ordinary  movements 
can  be  carried  on  with  ease;  but  if  the  muscles  are  irritated  by  percussion  or  are 
allowed  to  rest  and  another  attempt  is  made  to  move,  they  instantly  pass  into 
spasm.  The  affected  muscles  develop  electrical  reactions  of  a  peculiar  type,  namely, 
a  tonic  contraction  under  the  galvanic  current,  which  comes  on  sluggishly  and  lasts 
longer  than  in  health.  If  the  electrical  application  is  continued  contraction  waves 
pass  over  the  muscles,  but  there  is  no  marked  atrophy  or  great  loss  of  power  in  so 
far  as  the  spasm  interferes  with  ordinary  muscular  movement.  The  onset  of  the 
malady  is  usually  in  early  childhood,  occasionally  not  appearing  until  puberty 
or  later.  The  disease  is  so  exceedingly  rare  that  less  than  40  cases  ha^•e  been 
reported.  A  physician  named  Thomsen,  himself  a  sufferer  from  the  disease,  first 
described  it. 

PARAMYOCLONUS  MULTIPLEX. 

Definition. — Paramyoclonus  multiplex  is  a  condition  of  the  motor  nervous 
system  in  which  sudden  contractions  of  the  muscles  take  place,  the  contractions 
resembling  those  produced  by  the  use  of  a  slowly  interrupted  faradic  current. 
It  is  sometimes  called  myoclonus,  multiple  myoclonus,  myoclonus  epilepticus, 
spinal  epilepsy,  and  Friedreich's  disease,  but  it  is  not  to  be  confused  in  the  mind 
of  the  student  with  Friedreich's  ataxia,  a  very  different  malady.  It  is  a  rare 
affection. 

Etiology. — The  cause  is  unknown.  In  a  very  few  instances  it  lias  been  thought 
to  be  hereditary,  but  in  all  probability  this  is  the  case  only  in  the  sense  that  the 
parents  or  grandparents  have  suffered  from  neurotic  states.  It  is  not  rarely 
associated  with  epilepsy,  and  it  may  develop  when  a  nervous  system  naturally 
unstable  is  sapped  by  excessive  mental  OAcrwork  or  other  stress. 

The  contractions  may  simultaneously  affect  similar  muscles  in  both  limbs,  or 
may  occur  in  series  involving  first  one  side  and  then  the  otlier,  or  pass  from  muscle 
to  muscle.  Very  rarely  only  one  side  is  affected.  In  most  instances  the  face 
and  trunk  muscles  escape  as  in  Friedreich's  original  case.  The  ocular  muscles 
are  never  affected.  The  arms  are  more  commonly  affected  than  the  legs  and  the 
muscles  about  the  arm  and  shoulder  and  those  of  the  thigh  are  more  frequently 
and  severely  affected  than  those  of  the  forearm  or  leg.  The  muscles  of  the  hands 
and  those  of  the  feet  escape.  The  severity  of  the  contractions  increases  greatly. 
In  some  instances  they  are  so  moderate  as  to  be  noticeable  only  when  the  patient 
is  stripped  of  his  clothing.  In  others  they  are  severe  enough  to  throw  liim  off  his 
feet.  The  motions  or  attitudes  of  the  patient  vary,  of  coiu'se,  with  the  muscles 
affected  and  the  degree  of  their  contractions.  The  effect  of  voluntary  movements 
upon  the  contractions  is  also  varied.  In  some  instances,  as  in  Friedreich's  first 
case,  a  vohmtary  movement  inhibits  or  diminishes  the  contractions,  but  in  other 
cases  voluntary  movement  seems  to  exaggerate  it.  Mental  excitement  increases 
them.  They  cease  during  sleep  and  are  usually  less  severe  when  tlie  patient  is 
standing  than  when  he  is  sitting  or  lying  down.  If  the  affected  muscles  are  irritated 
by  tapping  them  a  spasm  is  induced.     The  deep  reflexes  may  be  increased  or 


888  DISEASES  OF  THE  NERVOUS  SYSTEM 

diminished,  but  electrical  irritability  is  not  altered  nor  do  any  trophic  changes 
occur.     Some  suj)erficial  vasomotor  palsy  may  be  present  in  the  extremities. 

Diagnosis. — Paramyoclonus  multiplex  is  separated  from  chorea  by  the  fact  that 
the  movements  of  chorea  resemble  those  of  the  will  in  that  certain  groups  of  muscles 
act  together  and  do  not  contract  suddenly  as  from  an  electrical  shock.  Voluntary 
movements  are  prone  to  decrease  those  of  myoclonus  and  to  increase  those  of  chorea. 
Chorea  is  usually  a  unilateral  affection,  while  myoclonus  is  usually  bilateral.  The 
facial  muscles,  which  are  so  commonly  affected  in  chorea,  are  rarely  affected  in  the 
malady  under  discussion.  Electrical  chorea,  or  Dubini's  disease,  is  separated  from 
paramyoclonus  multiplex  by  the  fact  that  it  is  accompanied  by  pyexia,  progressive 
muscular  atrophy,  and  paralysis,  and  by  loss  of  response  on  the  part  of  the  muscles 
to  faradic  electricity.  From  hysterical  spasm  paramyoclonus  is  separated  by  the 
presence  in  hysterical  cases  of  the  stigmata  of  that  state,  such  as  disorder  of  the  color 
fields  and  areas  of  hyperesthesia  or  anesthesia.  In  those  cases  of  hysteria  in  which 
these  stigmata  are  absent  the  differential  diagnosis  may  be  impossible. 

Paramyclonus  multiplex  may  be  separated  from  the  "maladie  des  tics  conviikifs," 
described  by  French  neurologists,  by  the  fact  that  in  that  affection  the  movements 
are  more  like  gestures  and  not  infrequently  echolalia  is  present. 

Prognosis. — The  prognosis  as  to  complete  and  permanent  recovery  is  not  good. 
Rarely  death  ensues  in  a  few  months.  More  commonly  the  condition  persists  in 
varying  severity  for  years. 

Treatment. — The  treatment  consists  in  measures  devoted  to  the  improvement 
of  the  general  health  by  out-door  life,  good  food,  and  avoidance  of  all  causes  of 
nervous  irritation  and  exhaustion.  Remedies  like  arsenic,  phosphorus,  iron,  and 
similar  roborants  are  useful  to  this  end,  but  are  not  curative.  Occasionally  a  care- 
fully regulated  course  of  hydrotherapy  at  some  well-equipped  and  well-managed 
sanatariiun  is  serviceable. 

PARALYSIS  AGITANS. 

Definition. — Paralysis  agitans,  sometimes  called  "shaking  palsy,"  or  "Parkinson's 
disease,"  is  a  condition  in  which  different  parts  of  the  body,  especially  the  forearms 
and  hands,  are  affected  by  a  continuous  tremor.  When  the  disease  is  well  advanced, 
the  patient  leans  forward,  assuming  a  peculiar  attitude,  and  may  suffer  from 
festination. 

Etiology. — The  precise  cause  of  paralysis  agitans  is  not  known.  It  has  been 
thought  to  follow  severe  nervous  shock  and  injuries  to  the  central  nervous  system. 
In  other  instances  it  has  followed  excessive  nervous  strain.  Thus,  in  one  case 
under  the  writer's  care,  the  treasurer  of  a  very  large  corporation,  after  many  years 
of  liard  work,  developed  a  well-rnarked  degree  of  paralysis  agitans.  He  was  quite 
certain  that  the  tremor  first  began  in  those  muscles  which  were  employed  in  the 
signing  of  several  hundred  papers  a  day. 

Paralysis  agitans  develops  most  frequently  between  the  ages  of  fifty  and  fifty-five. 
Gowers  analyzed  SO  cases  and  found  the  average  age  incidence  to  be  fifty-two  years, 
and  Wollcnberg  found  that  10  out  of  20  cases  occurred  at  ages  \\arying  from  fifty 
to  fifty-five.  The  disease  also  not  infrequently  develops  during  the  fifth  and  seventh 
decades  of  life.  A  few  cases  occurring  in  early  adult  life  and  in  childhood  have  been 
reported.  Iladden,  Gowers,  Berger,  and  others  have  seen  the  disease  in  individuals 
whose  ages  ranged  from  twenty  to  thirty,  and  Weil  and  Rouvillois  have  reported  a 
case  occurring  in  a  child  of  ten.  Lannois  also  mentions  a  case  occurring  in  a  child 
aged  twelve. 

Men  are  more  frequently  afl'ected  than  women.  Thus,  of  67  cases  collected  from 
the  reports  of  St.  Thomas'  and  St.  Bartholomew's  Hospitals,  London,  47  occurred 
in  men  and  20  in  women.  In  78  American  cases  Dana  found  the  proportion  of 
men  to  women  to  be  as  5  to  3. 


PARALYSIS  AGITANS  889 

The  neuropathic  constitution  may  be  considered  as  a  predisposing  cause,  but 
direct  inheritance  of  the  disease  is  rare.  A  few  instances  of  apparent  direct  trans- 
mission from  parent  to  oft'spring  have  been  reported,  and  Bergcr  cites  one  in  which 
the  disease  appeared  in  three  successive  generations.  Borgiierini  reported  7  cases 
occurring  in  a  family  of  9  brothers  and  sisters.  Three  children  of  these  inrlividuals 
developed  paralysis  agitans  between  their  fortieth  and  fiftieth  years. 

Pathology. — Nothing  is  known  of  the  pathology  of  this  affection  which  throws 
any  light  on  the  cause  of  the  symptoms. 

Symptoms. — The  symptoms  of  paralysis  agitans  are  tremor,  mmndar  rigidity,  a 
retardation  of  ordinary  voluntary  movements,  and  a  change  in  the  gait.  The  tremors 
are  rhythmical  in  character,  amount  to  four  or  five  pet  second,  and  move  the 
part  in  various  directions.  Thus,  when  the  hand  is  aft'ected,  the  fingers  may  be 
flexed  and  extended,  abducted  and  adducted.  The  most  common  movement  is 
a  rubbing  of  the  thumb  against  the  index  finger,  in  much  the  same  way  that  a  pill 
might  be  made  by  such  a  rolling  movement.  In  some  instances,  particularly 
if  the  patient  becomes  excited,  the  amplitude  of  the  movements  becomes  greatly 
increased,  so  that  the  hand  or  the  head  shakes  as  it  does  in  a  severe  rigor.  Unlike 
the  intention  tremors  of  certain  forms  of  organic  nervous  disease,  the  tremor  of 
paralysis  agitans  is  passive.  Be  the  position  of  the  body  and  arms  what  it  may, 
the  trembling  continues,  and  while  certain  attitudes  may  diminish  the  amplitude 
of  the  tremor,  it  is  always  present  except  when  some  definite  and  active  movement 
is  attempted,  when  the  tremor  diminishes  or  even  ceases.  Thus,  if  the  fist  is 
clenched,  or  the  patient  shakes  hands  with  a  friend,  the  movement  may  stop 
momentarily.  On  the  other  hand,  nicely  adjusted  muscular  movements  such  as 
are  involved  in  writing  do  not  stop  the  tremor,  and  for  this  reason  handwriting 
is  usually  impossible  when  the  disease  is  well  developed. 

The  tremor  not  only  involves  the  head  and  arms  but  extends  to  the  legs  as  well, 
and  it  may  affect  the  muscles  of  the  thigh.  Rarely  the  muscles  of  the  jaw  are 
affected.  The  tremor  continues  only  during  the  waking  hours,  and  usually  ceases 
in  sleep.  Not  rarely  paralysis  agitans  is  associated  with  insomnia  because  the 
twitching  movements  keep  the  patient  awake,  or  the  aching  in  the  affected  muscles 
makes  the  patient  so  uncomfortable  that  sleep  is  postponed  until  the  patient  is 
exhausted.  As  the  patient  stands  in  front  of  the  physician,  the  chin  is  usually 
pushed  forward  and  the  body  bent  forward.  The  arms  and  the  elbows  are  slightly 
flexed. 

After  the  disease  is  well  developed,  chronic  muscidar  rigidity  becomes  a  symptom 
which  is  even  more  constant  than  tremor.  It  not  only  involves  the  parts  that  we 
have  spoken  of,  but  also  the  muscles  of  the  neck  and  back,  and  even  those  of  the 
face.  The  muscles  of  facial  expression  become  more  or  less  fixed,  causing  the 
face  to  have  a  peculiar  mask-like  appearance.  As  the  patient  walks,  his  gait 
usually  increases  in  speed  and  the  attitude  is  that  of  a  person  who  is  attempting 
to  progress  rapidly.  It  is  unfortunate  that  the  term  "paralysis  agitans"  is  applied 
to  the  early  stages  of  this  disease,  for  paralysis,  in  the  sense  of  great  loss  of  power, 
occurs  only  in  its  very  last  stages,  and  not  infrequently  the  patient  will  suft'er  from 
the  malady  for  years  without  developing  paralytic  symptoms.  The  speech  is  at 
times  affected  and  may  be  likened  to  the  festinating  gait.  The  patient  has  difficulty 
in  starting  to  talk,  but  having  commenced,  the  words  follow  each  other  rapidly  and 
monotonously,  but  without  scanning.  The  skin  covering  the  parts  affected  is 
not  infrequently  unduly  moist  by  reason  of  profuse  perspiration.  Salivation  is  a 
not  infrequent  symptom.  There  are  no  disturbances  of  sensation,  and  the  mind  is 
unaffected  save  by  the  mental  depression  which  is  produced  by  the  annoyance 
of  the  disease. 

Diagnosis. — Paralysis  agitans  is  to  be  separated  from  multiple  sclerosis  by  its 
onset  late  in  life,  by  the  fineness  of  the  tremor,  by  the  fact  that  it  is  present  when 


890  DISEASES  OF   THE  XERVOUS  SYSTEM 

no  \()Iimtary  movement  is  made,  and  l\y  tlie  presence  of  rigidity.  An  examination 
of  the  eyes  fails  to  reveal  the  nystagmus  or  the  changes  in  the  ojjtic  nerve  which 
are  characteristic  of  multiple  sclerosis.  In  paretic  dementia  the  tremor  is  not 
rhythmical,  occurs  when  the  patient  makes  a  movement  and  not  wiien  at  rest,  and 
there  is  associated  with  the  tremor  tlic  mental  disturbance,  the  scanning  speech, 
and  evidences  of  ])aralysis. 

Sometimes  in  old  persons  a  senile  tremor  develops.  This  chiefly  nfl'ects  the  head, 
and  is  increased  rather  than  decreased  by  active  movements;  but  in  some  instances 
senile  tremor  bears  a  close  resemblance  to  paralysis  agitans.  Indeed,  it  has  been 
suggested  that  the  latter  disease  is  essentially  a  premature  nervous  senility.  It 
should  be  remembered  that  paralysis  agitans  may  occur  without  tremor,  but  the 
muscular  rigidity,  with  the  characteristic  altitude,  gait  and  mask-like  expression 
should  be  sufficient  to  establish  the  diagnosis. 

Prognosis.  —  Paralysis  agitans  does  not  materially  shorten  life.  It  frequently 
lasts  for  twenty  years.  Recovery  practically  never  occurs.  Temporary  remissions 
in  the  se\-erity  of  the  symptoms  may  take  place. 

Treatment. — As  in  many  diseases  which  apparently  depend  upon  functional 
derangement,  treatment  is  not  followed  by  very  satisfactory  results.  The  patient 
should  be  forbidden  to  subject  himself  to  nervous  stress  and  worry,  which  materially 
increase  the  severity  of  the  malady.  Everything  should  be  done  to  reinstate  his 
nervous  balance  by  a  healthy  out-door  life  and  freedom  from  care.  ]\Iassage  and 
electricity,  as  a  rule,  do  little  good.  In  some  cases  they  do  harm  by  increasing  the 
exhaustion  of  the  afl'ected  muscles. 

A  very  large  mmiber  of  drugs  have  been  employed  with  asserted  good  result, 
but  none  have  the  confidence  of  those  members  of  the  profession  who  have  had  large 
experience.  Of  all  the  remedies  which  have  been  recommended,  hyoscine  seems  to 
have  received  the  greatest  amount  of  praise.  It  should  be  given  in  the  dose  of 
j-jTo"  of  <i  grain  once,  twice,  or  thrice  a  day;  the  size  of  the  dose  and  the  frequency 
of  its  administration  being  governed  by  the  severity  of  the  tremor  and  by  the 
susceptibility  of  the  patient  to  drugs  of  this  character.  Duboisine  may  also  be 
given  in  similar  doses.  Where  there  is  much  aching  of  the  affected  muscles,  hot 
compresses  give  relief,  and  if  the  patient  is  in  a  condition  of  nervous  irritation, 
the  bromides  and  chloral  are  advantageous.  The  employment  of  such  powerful 
nervous  and  vascular  sedatives  as  veratrum  viridc  and  gelscmium  must  be  resorted 
to  with  great  caution.  In  doses  large  enough  to  quiet  the  tremor  they  arc  prone 
to  produce  too  much  depression.  Paralysis  agitans  is  unique  among  nervous 
diseases  in  that  it  is  not  benefited,  but  made  worse  by  rest. 


CHOREA  MINOR. 

Definition. — Chorea  minor,  or  acute  chorea,  sometimes  called  "Sydenham's 
chorea,"  or  "St.  Vitus'  dance,"  is  a  nervous  disease  characterized  by  irregular, 
purposeless  movements,  sometimes  limited  to  certain  muscles,  but  at  others  inv'olv- 
ing  all  the  muscles  of  the  limbs,  face,  and  trunk.  It  afi'ects,  in  the  great  majority 
of  instances,  children  between  the  fifth  and  fifteenth  years  of  life. 

Etiology. — That  sex  acts  is  a  predisposing  cause  of  chorea  is  shown  by  the  fact 
that  girls  are  afl'ected  three  times  as  often  as  boys,  and  in  the  period  of  life  from 
the  fifteenth  to  the  twenty-fifth  year  males  escape  almost  entirely.  The  age 
which  predisposes  to  its  development,  or  is  most  susceptible,  is  from  the  fifth  to  the 
fifteenth  year.  After  the  fifteenth  year  it  steadily  decreases  in  frequency  until 
the  twenty-fifth  year  is  reached,  after  which  it  is  very  rarely  met  with.  The  disease 
may,  however,  occur  at  all  ages.  Nervous,  high-strung  children  suffer  from  it 
more  frequently  than  those  of  a  more  plegmatic  temperament,  particularly  if,  in 


CHOREA  MINOR  891 

addition,  they  are  anemic,  and  have  a  family  history  indicating  that  they  are  prone 
to  attacks  of  acute  rheumatism. 

Of  the  exciting  causes  may  be  named  sudden  sJiock  or  acute  mental  excitement, 
but  in  all  such  cases  these  causes  are  indirect,  that  is,  they  serve  to  disturb  the 
nervous  equilibrium,  already  unstable  from  other  causes.  In  some  cases  the 
disease  seems  to  be  acquired  by  association  with  a  choreic  chikl,  and  in  this  way  a 
large  number  of  children  in  homes  and  asylums  may  become  affected.  Whether 
many  of  these  cases  are  true  chorea  or  merely  imitations  of  it,  or  due  to  hysteria, 
is  difficult  to  determine. 

That  there  is  a  very  close  relationship  between  acute  articular  rheumatism  and 
true  chorea  is  certain.  Even  those  physicians  who  deny  that  the  rheumatism 
produces  chorea  are  forced  to  admit  that  the  occurrence  of  chorea  after  attacks  of 
acute  rheumatic  infection  is  remarkably  frequent.  Fraser  has  shown  in  England 
that  in  300  cases  of  chorea  there  was  a  clear  historj-  of  an  acute  articular  rheumatism 
in  150  or  50  per  cent.  Not  rarely  chorea  complicates  the  de\-elopment  and  progress 
of  the  acute  endocarditis  produced  by  this  infection.  Whether  the  poison  of  rheu- 
matism affects  the  nerve  cells  of  the  brain,  or  whether  the  disease  is  due  to  changes 
in  the  finer  capillaries  supplying  the  brain,  or  to  minute  emboli,  is  unknown.  Cer- 
tain clinicians  have  endeavored  to  show  that  chorea  is  due  to  a  specific  infection, 
and  Pianese  isolated  a  diplococcus  which  was  capable  of  producing  an  experimental 
chorea.     There  is  no  proof,  however,  that  such  a  specific  agent  exists. 

Under  the  name  of  chorea  gravidarum,  a  form  of  the  disease  is  met  with  in  pregnant 
women,  usually  only  in  primiparte.  In  these  cases  the  gravid  state  seems  to 
develop  a  condition  of  laclv  of  nervous  equilibrium,  for  the  condition  ceases,  as  a 
rule,  with  the  termination  of  pregnancy.  Occasionally  in  old  age  a  senile  chorea 
develops,  but  it  is  a  distinct  entity  from  the  chorea  of  childhood. 

Frequency. — Chorea  is  much  more  frequently  met  with  in  England  than  in  the 
United  States.  Morris  Lewis  has  shown  that  its  period  of  greatest  frequency  is 
March. 

Pathology  and  Morbid  Anatomy. — Cases  of  chorea  come  to  autopsy  infrequently, 
and  therefore  we  have  not  as  much  information  in  regard  to  postmortem  findings 
in  this  disease  as  is  desirable.  In  most  of  those  instances  in  which  death  occurs 
during  an  attack  of  chorea,  the  autopsy  reveals  acute  endocarditis,  or  chronic 
endocarditis  with  an  acute  exacerbation,  and  not  rarely  some  degeneration  of  the 
myocardium.  In  the  great  majority  of  instances  the  results  of  examining  the  brain 
have  been  negative,  and  if  the  positive  results  which  have  been  obtained  are  com- 
pared, they  are  found  to  be  most  variable.  In  some  instances  an  intense  hyperemia 
has  been  present;  in  others  minute  hemorrhages;  in  still  others  there  have  been 
small  areas  of  inflammation  and  softening;  while  other  cases  have  shown  signs  of 
meningitis,  or  thrombosis  of  the  smaller  bloodvessels  supplying  the  brain.  So, 
too,  the  changes  which  have  been  found  in  the  spinal  cord  have  been  too  varied 
to  lead  one  to  believe  that  they  are  in  any  way  closely  connected  with  the  disease. 
Some  observers  have  considered  that  they  were  the  result  rather  than  the  cause 
of  the  condition.  Choreiform  movements  sometimes  develop  in  persons  who  have 
suffered  from  an  organic  brain  lesion,  but  there  is  no  reason  to  believe  that  this  form 
of  chorea  and  chorea  minor  have  any  close  anatomical  relationship. 

Symptoms. — The  onset  of  chorea  may  be  either  sudden  or  gradual.  In  those 
cases  in  which  it  is  gradual,  it  is  first  noted  that  the  child  is  restless,  and  seems  unable 
to  keep  still.  Not  rarely  it  is  awkward  in  its  movements,  and  falls  over,  or  bumps 
into  articles  of  furniture.  When  the  disease  is  developed  the  child  is  continually 
restless,  the  arm  or  arms  being  moved  in  every  possible  direction.  Sometimes  the 
muscles  of  the  shoulders  are  worked  as  if  the  child  was  uncomfortable  by  reason  of 
ill-fitting  clothes.  The  body  is  rotated  from  one  side  to  the  other,  and  the  chin 
drawn  first  to  one  shoulder  then  to  the  other,  then  elevated,  then  depressed.     When 


892  DISEASES  OF  THE  NERVOUS  SYSTEM 

the  movements  are  marked,  walking  is  interfered  with  and  it  may  be  difficult  for 
the  patient  to  stand.  UnHke  most  invokintary  movements,  tiie  movements  of 
chorea  are  not  confined  to  one  gronp  of  muscles,  i)ut  usually  attack  different  groups 
alternately.  Neither  is  the  movement  in  the  nature  of  a  tremor.  It  is  like  a 
voluntary  movement,  but  is  jjurposejeas  and  incomplete.  Not  infreqviently  the  child 
laughs  and  cries  without  adequate  cause.  The  movements  affect  the  upper  extremi- 
ties more  than  the  lower  extremities.  The  tonj^ue  is  sometimes  involveil,  and  for 
this  reason  the  speech  may  be  disturbed.  'J'he  child  also  frec|ucntiy  <;ives  vent  to 
curious  guttural  or  smacking  sounds,  due  to  tlie  action  of  the  muscles  of  the  mouth, 
pharynx,  and  tongue.  The.se  sounds  may  also  be  increased  by  s])asm  of  the  dia- 
phragm. Occasionally,  chorea  may  be  limited  to  one  limb,  when  it  is  called  mono- 
chorea, or  when  it  is  confined  to  one  side  of  the  body  it  is  called  hemichorea.  These 
motions  distinctly  interfere  with  ordinary  voluntary  mo\'ement,  and  it  becomes 
almost  impossible  for  the  child  to  perform  an  ordinary  act  slowly;  if  it  is  to  be 
successfully  carried  out,  it  must  be  done  with  great  rapidity.  Any  cause  which 
produces  mental  excitement  in  the  patient  greatly  increases  the  severity  of  the  jerk- 
ing. Some  clinicians  have  recorded  an  exceedingly  severe  form  of  chorea  in  which 
the  patient  has  such  violent  muscular  movements  that  he  bites  his  tongue,  cannot 
eat,  and  is  thrown  about  from  side  to  side  as  if  he  were  in  a  violent  convulsion. 
The  twitchings  of  chorea  may  or  may  not  stop  with  sleep.  In  those  cases  in  which 
the  movements  continue  at  night,  the  disease  is  usually  severe,  and  it  is  in  this  type 
of  cases  that  death  sometimes  occurs  from  exhaustion. 

The  mental  state  of  the  patient  is  one  of  irritablity  and  peevishness.  In  adults 
there  may  be  hallucinations,  and  even  a  A-iolent  delirium.  Some  have  thought  that 
those  cases  in  which  insanity  develops,  and  to  which  the  name  chorea  insaniens 
is  applied,  do  not  belong  to  ordinary  chorea  minor.  These  mental  disturbances 
not  rarely  complicate  the  chorea  of  pregnancy. 

Except  for  the  exhaustion  of  the  general  system  which  is  produced  by  the  move- 
ments, there  is  no  impairment  of  strength,  nor  is  the  electric  reaction  of  the  muscles 
altered.  In  some  cases  of  a  severe  type,  leading  to  a  fatal  issue,  hyperpyrexia 
has  been  noted,  which  is  probably  due  to  endocarditis.  ]\Iany  years  ago  I  reported 
a  case  of  monochorea  in  which  the  temperature  of  the  affected  part  was  raised. 
In  some  instances  weakness  or  even  marked  paralysis  occurs  in  one  or  more  of  the 
affected  limbs,  and  to  this  type  of  cases  is  applied  the  term  "paralytic  chorea." 

Complications. — As  already  stated,  chorea  is  a  disease  which  is  associated  with  a 
lack  of  nervous  stability.  It  is  manifest,  therefore,  that  it  may  often  be  complicated 
by  symptoms  of  hysteria.  Indeed,  it  may  be  difficult  to  determine  whether  the 
patient  is  hysterical  or  choreic.  That  endocarditis  frequently  precedes,  or  accom- 
panies, or  complicates  chorea,  has  also  been  stated,  but  every  case  of  chorea  that 
presents  a  cardiac  murmur  is  not  necessarily  suffering  from  endocarditis,  since  the 
murmur  is  not  infrequently  due  to  anemia,  or  to  relaxation  of  the  fibres  surrounding 
the  mitral  orifice. 

Diagnosis. — Ordinary  cases  of  chorea  in  childhood  are  easily  diagnosed,  particu- 
larly if  the  history  of  the  patient  is  borne  in  mind,  lietwcen  the  ages  of  fifteen  and 
twenty-five  care  must  be  taken  that  it  is  not  confused  with  hysteria.  Sometimes, 
too,  choreiform  movements  develop  in  those  parts  which  are  afi'ected  by  infantile 
cerebral  jJalsy,  but  in  such  cases  paralysis  is  present  and  muscular  rigidity  is  notice- 
able, while  the  movements  are  really  different  (athetosis). 

Duration  and  Prognosis. — Chorea  minor  usually  lasts  from  two  to  three  months, 
and  sometimes  extenrls  o\'er  a  year.  ]\Iild  cases  may  continue  for  only  a  few  weeks. 
The  prognosis  as  to  recovery  is  good,  the  mortality  being  about  3  per  cent.,  if  all 
cases  are  included,  death  being  due  to  complications  rather  than  to  the  disease 
itself.  Relapses  are  not  infrequent  in  chorea.  Unfavorable  sjTuptoms  are  rapid 
loss  of  flesh,  fever,  and  delirium.     The  prognosis  is  worse  as  to  duration  in  adults 


CHOREA  MINOR  893 

than  in  children.  In  the  chorea  of  pregnancy  the  prognosis  is  very  much  more  grave 
than  in  any  other  form  of  the  disease,  the  mortaHty  varying  from  20  to  25  per  cent. 
Senile  chorea  is  often  a  permanent  affection  and  is  rarely  fatal. 

Treatment. — From  what  has  been  said  in  regard  to  the  general  condition  of  the 
patient  who  suffers  from  chorea,  it  is  evident  that  mental  and  nervous  quiet  are 
absolutely  essential.  The  child  should  not  be  exposed  to  the  excitement  or  mental 
stress  of  school-work,  neither  should  it  be  subjected  to  punishment  or  to  criticism 
because  of  its  movements.  On  the  contrary,  the  fact  that  it  is  sufi'ering  from  choreic 
movements  should  be  ignored  unless  the  physician  is  convinced  that  the  case  is 
one  of  hysteria  and  not  of  chorea.  Iron  and  arsenic  are  to  be  given  if  anemia  is 
present,  and  the  salicylates  are  useful  if  there  is  a  rheumatic  history.  If  the  move- 
ments are  severe  enough  to  exhaust  the  child,  it  should  be  kept  in  bed  and  sleep 
should  be  obtained  by  the  use  of  hypnotics.  These  drugs,  however,  must  be  used 
cautiously  lest  they  produce  general  depression,  and  it  should  always  be  remembered 
that  a  hot  pack  will  often  put  a  choreic  child  to  sleep  and  temporarily-  or  permanently 
arrest  the  choreic  movements.  I  have  seen  life  saved  in  at  least  two  instances  by 
the  hot  pack. 

Although  there  is  no  specific  remedy  for  chorea,  arsenic  nearly  approaches  the 
position  of  a  specific.  How  it  acts  is  not  known.  The  best  way  to  administer  it 
is  in  the  form  of  Fowler's  solution,  starting  with  2  drops  three  times  a  day  for  a 
child  of  ten,  and  increasing  it  a  drop  a  day  until  some  puffiness  about  the  eyes  and 
nose  or  gastro-intestinal  irritation  indicates  that  the  f idl  physiological  effect  of  the 
drug  is  present,  when  it  should  be  stopped  or  cut  down  to  one-half  the  quantity. 
If  this  is  not  done  an  arsenical  neuritis  may  develop. 

Next  to  arsenic  in  value  are  the  salicylates.  They  must  be  gi\'en  in  full  doses 
to  be  efficient.  Antipyrin  and  acetanilid  have  also  been  employed  with  success. 
Bromides  shoidd  be  tried  after  the  other  drugs  have  failed. 

If  the  chorea  of  pregnancy  becomes  severe  it  may  be  necessary  to  induce  labor. 


Other  Forms  of  Chorea. 

Huntington's  Disease. — Under  the  name  of  "hereditary  chorea,"  or  Hunting- 
ton's disease,  an  affection  is  met  with  which  must  be  clearly  differentiated  from 
chorea  minor.  It  is  a  rare  condition  which,  as  its  name  indicates,  is  hereditary, 
although  it  does  not  always  affect  consecutive  generations,  sometimes  passing  from 
the  grandparent  to  the  child,  although  in  such  cases  the  parent  is  usually  excessively 
neurotic.  Both  sexes  suffer  from  it  equally.  The  disease  begins  between  the 
thirtieth  and  fortieth  year  of  life  in  most  instances,  and  no  exciting  cause  can  usually 
be  discovered. 

Its  early  symptoms  consist  in  twitchings  of  the  muscles  of  the  face  and  upper 
extremities,  which  gradually  increase  in  severity  and  in  the  area  which  they  involve, 
imtil  the  entire  muscular  system  may  be  affected.  The  patient,  under  these  cir- 
cumstances, carries  on  a  series  of  grimaces  and  gesticulations,  but  it  is  a  noteworthy 
fact  that  he  or  she  can  inhibit  these  movements  at  least  for  a  period  long  enough 
to  permit  the  voluntary  movement  which  it  is  desired  to  make.  When  the  muscles 
of  the  trunk  and  legs  are  involved  the  body  is  tossed  hither  and  thither  with  rapid 
movements.  Sensation  is  not  involved.  Paralysis  of  a  hemiplegic  type  develops 
very  rarely.  The  mind  gradually  fails,  the  mental  failure  being  preceded  by  depres- 
sion and  irritability. 

Huntington's  chorea  is  an  incurable  disease.  It  usually  ends  in  the  patient 
becoming  bedridden  and  dying  from  some  intercurrent  malady.  It  may,  however, 
last  for  many  years.  Cases  are  on  record  in  which  the  patient  has  lived  thirty 
years  after  the  disease  began  to  manifest  itself.    The  progressive  character  of  the 


894  DISEASES  OF  THE  XEIiVOUS  SYSTEM 

malady,  tlic  jjeriofl  of  life  at  which  it  develo])s,  the  progressive  dementia,  ami  the 
history  of  heredity  all  aid  in  separating  it  from  chorea  minor. 

The  morbid  anatomy  is  not  understood.  In  some  cases  the  lesions  in  the  hrain 
have  resembled  those  of  paretic  dementia. 

The  treatment  consists  in  a  healthy  out-door  life,and  the  use  of  nervous  sedatives, 
and  tonics,  with  the  object  of  maintaining  the  patient's  general  health.  Cases 
ai)parently  identical  with  Huntington's  chorea,  but  occurring  singly,  are  spoken 
of  as  chronic  chorea. 

Dubini's  Disease. — Under  the  name  of  "electrical  chorea,"  or  "Dubini's 
disease,"  a  form  of  chorea  characterized  by  severe  muscular  contractions  resembling 
those  produced  by  electricity  has  Ijcen  described  by  Dubini  as  affecting  peasants  in 
northern  Italy.  Occasionally,  the  movements  may  be  eiiileptiform  in  character. 
Paralysis  soon  develops;  pain  is  suffered  in  the  head,  neck,  and  liack,  and  death 
results,  as  a  rule,  form  exhaustion.  A  few  cases  have  been  reported  as  having 
recovered. 

Another  form  of  electrical  chorea  seen  in  children  has  been  described  by  Bergero. 
Such  cases  usually  recover.  I  showed  such  a  case  before  the  Neurological  Society 
of  Philadelphia  many  years  ago.  The  patient,  a  boy,  a  little  past  puberty,  sufl'ered 
from  violent  contractions  which  were  electrical  in  character. 


HYSTERIA. 

Definition. — Hysteria  is  a  chronic  functional  disturbance  of  the  nervous  system 
in  which  the  motor  nervous  system  may  manifest  its  disorder  by  convulsions,  palsies, 
or  contractures,  the  psychical  nervous  apparatus  by  emotional  disturbances,  and 
the  sensory  apparatus  by  lost,  diminished,  or  increased  sensibility.  It  is  manifest, 
therefore,  that  the  disease  involves  both  the  central  and  peripheral  portions  of  the 
nervous  system,  but  there  can  be  no  doubt  that  the  dominating  condition  is  a 
psychosis.  Hysteria  undoubtedly  depends  upon  a  condition  of  disturbed  nervous 
ecjuilibrium. 

Etiology. — There  can  be  no  doubt  that  this  affection  is,  to  some  extent,  hereditary; 
that  is,  a  parent  or  parents  who  possess  an  unstable  nervous  system  naturally 
transmit  a  similar  condition  to  their  offspring,  and  in  a  very  large  proportion  of 
cases  it  will  be  found  that  the  patient  is  a  child  of  parents  who  have  at  times  mani- 
fested neurotic  or  hysterical  disorders.  Age  has  a  distinct  influence  upon  the 
disease.  Its  most  frecjuent  period  of  occurrence  is  from  fifteen  to  twenty-five  years 
of  age  in  women,  although  in  males  it  usually  appears  at  from  twenty  to  thirty. 
Occasional!}',  however,  children  suffer  from  it,  particularly  just  before  puberty,  and 
sometimes  much  earlier  than  this.  The  condition  is  met  with  far  more  frequently 
in  females  than  in  males,  but  statistics  vary  from  40  to  1  to  4  to  1  or  even  2  to  1, 
according  to  different  writers.  It  is  much  more  common  in  the  very  poor  and  in 
the  rich  than  in  the  middle  classes,  and  in  the  Latin  races  than  in  the  Anglo-Saxon 
race.  In  America  it  is  most  frecjuently  met  with  in  the  poorer  class  of  Jews,  who 
are  often  underfed,  poorly  housed,  much  confined,  and  under  great  nervous  excita- 
tion and  stress.  It  is  much  more  common  in  France  and  Italy  than  in  Germany 
and  England. 

If  it  be  true  that  the  underlying  cause  of  hysteria  is  a  lack  of  nervous  control 
or  balance,  it  is  evident  that  a  number  of  conditions  may  be  considered  as  direct 
causes  of  the  malady.  In  other  words,  any  condition  which  upsets  the  nervous 
balance  may  jjrovoke  the  disease.  It  is,  therefore,  frequently  found  that  some 
great  grief  or  intense  joy  has  been  productive  of  the  first  manifestation  of  the  disease, 
or,  again,  that  some  injury  or  fright  has  acted  in  a  similar  manner.  Great  worry 
in  business,  or  over  a  love  affair,  may  produce  a  similar  result.     None  of  these 


HYSTERIA  895 

causes  would  so  profoundly  afi'ect  a  healthy  nervous  system.  AH  of  them  are 
sufficient  to  disturb  the  balance  of  a  nervous  organization  already  abnormal. 

Any  discussion  of  the  etiology  of  one  of  the  functional  neuroses  would  be  incom- 
plete without  a  reference  to  Freud's  ideas  on  the  subject.  In  1S9.5  Breuer  and  Freud 
announced  their  belief  that  hysterical  manifestations  were  the  result  of  repressed 
psychic  traumata,  acting  like  foreign  bodies  on  consciousness  and  struggling  to  come 
to  the  surface.  Later  Freud  reached  the  conclusion  that  the  repressed  psychic 
traumata  represented  sexual  experiences  of  childhood,  and  formulated  the  hypo- 
thysis  that — "In  a  normal  vita  sexualis  no  neurosis  is  possible." 

At  first  using  hypnotism  as  the  means  of  investigating  his  patient's  psychosexual 
past,  Freud  later  discarded  this  method  and  devised  a  special  technique  for  psycho- 
analysis. The  patient  reposes  on  a  couch  and  is  encouraged  to  seciu-e  muscular 
relaxation.  The  physician  seats  himself  behind  the  patient's  head  and  instructs 
her  to  tell  whatever  comes  into  her  mind,  repeating  all  the  thoughts  that  occur 
to  her  in  the  order  in  which  they  arise,  no  matter  how  distasteful  or  embarrassing 
the  narrative  may  be.  The  physician  from  time  to  time  offers  suggestions  and 
endeavors  to  help  fill  up  the  gaps  until  the  patient  completely  unbosoms  herself 
and  the  supposed  underlying  sexual  basis  for  the  malady  is  discovered.  Dreams  are 
said  to  contain  the  fidfilment  of  a  wish  and  we  are  told  that  sexual  ideas  are  repre- 
sented by  dreams  in  sj'mbols,  due  to  the  restraining  normal  influence  of  what 
Freud  terms  a  "psychic  censor."  The  interpretation  of  dreams  is  said  to  be  a  very 
important  part  of  psycho-analysis. 

At  present  some  eminent  neurologists  are  enthusiastic  followers  of  Freud  and 
others  are  equally  inclined  to  put  aside  his  views. 

Pathology. — As  already  stated,  hysteria  is  a  purely  functional  disease,  and  the 
central  and  peripheral  nervous  systems  show  no  alterations  which  can  be  considered 
as  responsible  for  the  maladj^ 

Symptoms. — Hysterical  individuals  usually  present  evidences  of  nervous  irritability 
which  may  manifest  itself  in  great  excitement,  in  violent  anger,  in  vndzie  anxiety,  or 
in  great  mental  depression.  All  of  these  manifestations  may  follow  one  another 
with  extraordinary  rapidity.  The  patient  also  manifests  distinct  lack  of  self-control, 
both  in  regard  to  her  emotions  and  her  impulses,  and  a  markedly  increased  suscep- 
tibility to  suggestion  is  conspicuous.  x\t  times  she  may  seem  utterly  incapable  of 
accomplishing  anything  which  ought  to  be  done.  At  another  time  she  can  develop 
an  amount  of  energy  and  persistence  which  is  surprising,  provided  that  she  conceives 
it  to  be  her  duty  or  her  wish  to  accomplish  such  an  end.  The  power  of  thought  is 
in  no  way  impaired,  but  judgment  is  warped  and  uncertain.  Not  infrequently 
the  patient  has  perverse  ideas  which  may  seem  to  amount  to  delusions,  but  which  do 
not  remain  constant  as  in  cases  of  insanity. 

In  some  instances  the  first  symptoms  of  the  malady  are  manifested  by  a  hyper- 
sensitiveness,  so  that  the  girl  cries  easily,  and  perhaps  laughs  more  readily  and  for  a 
longer  time  than  is  necessary  in  the  appreciation  of  a  remark  which  is  amusing. 
Restless  sleeping  also  may  be  present.  As  the  condition  develops,  attacks  of  head- 
ache and  vomiting  may  come  on,  and  she  may  suffer  from  somnambulism. 

When  the  condition  becomes  still  more  severe,  so  that  it  amounts  to  that  state 
which  is  sometimes  called  "hysteria  major,"  the  disturbances  of  sensation  and 
motion  become  intense.  In  addition  to  attacks  of  crying  and  laughter,  the  patient 
may  pass  into  a  trance  or  into  a  condition  of  catalepsy.  Or,  again,  the  patient 
may  suddenly  fall  and  be  seized  by  a  convulsion  which  is  distinctly  epileptiform  in 
character.  Often,  however,  the  convulsion  is  more  largely  tonic  than  clonic,  the 
hands  and  fingers  being  flexed  and  the  forearm  flexed  on  the  arm,  while  the  legs 
and  feet  are  extended  and  the  eyes  closed.  If  the  eyelids  are  lifted,  the  eyeballs 
are  often  found  to  be  fixed  in  convergence  or  undergo  irregular  movements.  The 
pupils  are  dilated.    The  surface  of  the  body  is  more  or  less  anesthetic.    iVs  a  rule 


896  DISEASES  OF  THE  NERVOUS  SYSTEM 

the  patient  does  not  froth  at  the  mouth  as  much  as  in  true  epilepsy,  nor  does  she 
bite  her  tongue  as  is  done  in  epilepsy.  So,  too,  she  rarely  hurts  herself  when  in 
the  convulsive  seizure.  The  attack  may  last  from  a  few  minutes  to  several  hours, 
or  even  longer  than  this,  and  may  vary  in  its  intensity  from  semiconsciousness 
with  slight  twitchings  of  the  muscles  to  apparent  total  vmconsciousness  and  severe 
convulsive  seizure.  The  expression  of  the  face  is  often  quite  characteristic.  In 
some  instances  it  is  remarkably  peaceful  after  the  convulsion  passes  by.  In  others 
it  is  ecstatic  or  terror-stricken.  In  very  young  patients  curious  guttural  and  other 
sounds  may  be  made,  and  the  patient  may  bark  like  a  dog  or  mew  like  a  cat. 

It  is  noteworthy  that  many  of  these  patients  are  conscious  of  what  is  going  on 
around  them  during  the  attack,  although  at  the  time  they  may  manifest  no  evidence 
of  this.  Not  rarely  a  sharply  spoken  word  of  command  may  bring  the  attack 
to  a  close,  or  the  threat  of  applying  some  instrument  which  is  capable  of  causing 
pain  may  do  likewise.  When  the  patient  returns  to  consciousness,  it  may  be  found 
that  there  is  loss  of  power  in  an  arm  or  leg,  or  upon  one  side  of  the  body,  with  or 
without  loss  of  sensation.  Frequently  the  so-called  hysterogenic  zones  may  be 
discovered,  pressure  upon  which  causes  pain  and  may  provoke  an  hysterical  attack, 
or  if  pressure  on  these  parts  is  used  during  the  attack  it  may  arrest  it. 

The  sensory  sjonptoms  of  hysteria,  in  distinction  from  those  just  described  in 
connection  with  a  critical  period,  consist  in  anesthesia  in  all  its  forms,  particidarly 
analgesia  of  the  cutaneous  and  mucous  surfaces  and  disturbances  in  the  special 
senses.  The  most  common  form  of  cutaneous  anesthesia  is  hemianesthesia  involving 
exactly  one-half  the  body.  After  this,  the  most  common  type  is  segmental  anes- 
thesia, in  which  an  arm,  or  leg,  or  part  of  the  face  is  anesthetic,  the  margin  of  the 
anesthetic  area  being  sharply  defined,  while  the  disturbance  of  sensation  does  not 
correspond  to  the  distribution  of  any  one  nerve  trunk.  jMuch  more  rarely  patches 
of  anesthesia  occur  in  different  portions  of  the  body.  In  these  anesthetic  areas 
the  senses  of  touch  and  of  heat  and  cold  are  usually  preserved  to  some  slight  extent. 
Occasionally,  the  affected  part  has  a  subnormal  temperature.  AVhen  the  anesthesia 
is  limited  to  one  side  it  affects  the  left  far  more  frequently  than  the  right  half  of  the 
body.  If  the  anesthesia  is  of  the  hemianesthetic,  or  segmental,  type  there  is  usually 
more  or  less  complete  loss  of  motor  power  in  the  same  limb. 

The  disturbances  of  special  sense  consist  in  an  anesthetic  condition  of  the  retina 
whereby  the  visual  field  is  greatly  narrowed,  particularly  for  certain  colors  and 
often  for  those  colors  which  normally  have  the  widest  field,  and  the  color  sense  is 
disturbed  or  reversed.  These  disturbances  may  or  may  not  complicate  those  just 
named.  When  hemianesthesia  is  present,  the  eye  upon  the  affected  side  is  some- 
times partly  or  even  totally  blind,  not  as  in  organic  hemianopic  hemianesthesia. 
So,  too,  the  acuity  of  the  auditory  nerve  may  be  diminished,  particularly  upon 
that  side  of  the  body  which  is  most  affected.  The  sense  of  taste  may  also  be  per- 
verted and  the  sense  of  smell  may  be  lost. 

Neuralgic  pains  are  not  common  in  hysteria  except  when  there  is  present  grave 
anemia  and  other  common  causes  of  neuralgia.  In  certain  portions  of  the  body, 
however,  hyjieresthesia  of  the  skin  may  be  ]>resent  as  in  the  hysterogenic  zones 
described.  These  zones  are  most  frequently  foimd  in  females  in  the  groin,  whence 
the  name  "ovarian"  tenderness,  and  under  the  mammary  glands,  and  in  males  on 
the  scrotum,  also  along  the  spine,  but  they  may  be  found  in  any  part.  Paralysis 
of  the  extra-ocular  muscles  is  sometimes  met  with.  Usually  the  internal  rectus  is 
affected,  and  sometimes  the  external  rectus.  Speech  may  be  impaired  by  paralysis 
of  the  adductors  of  the  vocal  cords.  The  development  of  this  condition  is  called 
"hysterical  aphonia,"  the  patient  being  speechless,  or  able  to  converse  only  in  a 
whisper.     The  onset  of  this  condition  is  usually  sudden. 

The  jxiralysis  of  ^notion  already  referred  to  often  persists  for  a  long  period  of 
time,  and  in  association  with  this  paralysis  it  not  rarely  happens  that  other  muscles. 


HYSTERIA  897 

often  those  which  are  antagonistic  to  the  ones  which  are  paralyzed,  suffer  from 
contractures.  At  first  these  muscles  may  be  simply  abnormally  irritable  and  the 
contractures  may  be  fleeting,  or  they  may  last  as  long  as  the  paralysis  of  motion 
and  sensation,  and  in  this  way  resemble  the  contractures  which  are  sometimes  met 
with  in  cerebral  diplegia.  Tremors  may  also  affect  the  muscles  of  an  arm,  of  the 
face,  or  of  a  leg,  and  these  tremors  may  resemble  those  of  paralysis  agitans  or  other 
diseases  characterized  by  tremor,  particularly  if  the  patient  has  been  associated 
with  such  a  case.  The  amoimt  of  atrophy  or  wasting  which  occurs  in  a  paralyzed 
part  is  usually  very  slight,  and  depends  almost  entirely  upon  lack  of  use.  Of  the 
internal  viscera  it  may  be  said  that  the  functions  are  not  gravely  impaired  in 
most  instances,  unless  perchance  these  viscera  suffer  from  the  chief  manifestations 
of  the  disease.  A  very  common  symptom  of  hysteria,  present  in  the  majority  of 
cases  is  the  sensation  as  if  a  ball  or  small  orange  rose  into  the  pharjTix.  This  is 
called  "globus."  In  other  instances  violent  attacks  of  vomiting  develop.  In 
still  others,  the  "rifting"  of  large  quantities  of  gas,  or  of  air  which  has  been  swal- 
lowed, takes  place,  accompanied  by  much  rumbling  in  the  abdomen.  In  still 
other  instances  rumination,  or,  as  it  is  sometimes  called,  "merycismus,"  occurs; 
that  is,  the  patient  regurgitates  food,  which  has  been  swallowed,  into  the  mouth 
for  a  second  chewing.  At  other  times  intestinal  disorders  are  present.  I  have  seen 
a  large  phantom  tumor  of  the  intestine,  in  a  patient  who  had  constantly  refused 
food  until  she  was  emaciated  to  the  last  degree,  give  rise  to  the  belief  that  a  malig- 
nant growth  was  present.  At  times  these  patients  have  a  perverse  appetite,  eating 
chalk  or  other  materials  not  commonly  swallowed.  The  vu^ine  is  sometimes  very 
limpid  and  free.  At  other  times  it  is  scanty  and  high  colored.  After  an  acute 
attack  of  hysteria  it  is  usually  limpid. 

Of  the  circulatory  disorders  attacks  of  tachycardia  are  by  no  means  uncommon. 
Sometimes  the  patient  will  complain  of  severe  pain  in  the  neighborhood  of  the  heart. 
This  pseudoangina  is  characterized  by  a  sensation  of  distention  of  the  heart  in 
distinction  from  the  pain  of  true  angina,  which  is  usually  described  as  if  the  heart 
were  being  tightly  compressed.  The  peripheral  vascular  system  may  also  be 
disturbed.  Abnormal  flushing  or  blushing  or  local  anemia  and  pallor  may  be 
present.  At  times  even  edema  may  develop.  In  other  instances  the  part  becomes 
so  pallid  or  slate-like  in  color  that  it  resembles  Raynaud's  disease,  but  true  gangrene 
does  not  develop.  Very  rarely,  indeed,  a  sharp  febrile  movement  may  take  place. 
Sometimes  hysterical  patients  suffer  from  attacks  of  hiccough  or  of  sneezing,  or  of 
rapid  breathing,  cough,  or  difficulty  in  swallowing. 

Under  the  name  of  "  hystero-epilepsy,"  a  form  of  hysteria  characterized  by 
violent  convulsions  closely  resembling  those  of  true  epilepsy  is  described  by  many 
foreign  authors.  It  is  rare  in  this  country.  In  some  instances  the  convulsive 
seizure  is  not  epileptoid,  but  cataleptoid  or  tonic.  The  patient  may  lie  in  bed  with 
the  arms  extended,  as  in  ecstacy,  or  with  the  hands  tightly  clinched,  as  in  terror 
or  anger,  or  the  state  may  resemble  simple  stupor  or  even  coma.  At  other  times  a 
psychical  disturbance  is  manifested  so  that  the  patient  develops  a  delirium.  Often 
several  of  these  processes  are  combined.  At  first  the  patient  experiences  an  aura 
as  in  epilepsy.  This  is  followed  by  the  epileptoid  form  of  convulsion,  and  this 
again  by  the  contortions  and  emotional  attitudes  just  described.  An  emotional 
confusion  is  not  rare;  hallucinations  and  delusions  may  occur  and  confinement  in 
an  asylum  may  be  necessary.     Finally  a  stage  of  delirium  may  develop. 

Diagnosis. — Under  some  circumstances  there  is  no  more  difficult  diagnosis  than 
the  differentiation  of  hysteria  from  organic  nervous  disease,  particularly  if  the 
patient  has  had  an  opportunity  of  studying  the  symptoms  presented  by  patients 
with  organic  nervous  lesions.  The  important  points  in  differentiation  are  the  con- 
traction of  the  visual  fields  and  the  alterations  in  the  color  fields,  the  fact  that  the 
areas  of  anesthesia  are  not  confined  to  any  given  distribution  of  sensory  nerves, 
57 


898  DISEASES  OF  THE  NERVOUS  SYSTEM 

the  presence  of  hysterogenic  or  hyperesthetic  spots,  the  fact  that  wasting  does  not 
develop  to  any  degree  in  the  paralyzed  muscles,  the  absence  of  the  reaction  of  degen- 
eration, the  maintenance  or  persistence  of  the  deep  reflexes,  and  the  peculiar  emo- 
tional state.  Again,  the  anesthetic  area  may  be  moved  from  the  first  place  affected 
by  the  mere  placing  of  a  coin  or  a  magnet  over  the  afl'ected  part.  Hysterical 
contractures  also  usually  disappear  in  sleep  or  when  the  patient  is  under  the  influence 
of  an  anesthetic.  In  the  epileptoid  form  of  attack  the  tongue  is  never  bitten  nor 
the  limbs  injured. 

Prognosis. — The  prognosis  as  to  life  is  good.  The  attacks  usually  diminish  in 
frequency  and  severity  with  advancing  years,  but  the  question  of  prognosis  is  always 
governed  by  the  degree  of  nervous  instability  in  the  patient  and  in  her  parents. 
When  the  hereditary  influence  is  bad  and  the  surroundings  of  the  patient  are 
unfavorable  the  malady  may  last  a  lifetime.  In  those  who  are  well-to-do  and  who 
can  afford,  to  take  the  treatment  required  by  such  cases,  the  outlook  is  better  than 
in  those  who  are  continually  exposed  to  bad  surroundings,  with  nervous  stress  and 
strains. 

Treatment. — The  treatment  consists  in  the  remoA'al  of  the  patient  from  those 
causes  which  tend  to  produce  nervous  irritability  and  stress.  If  the  home  surround- 
ings of  the  patient  are  such  as  to  increase  nervous  irritation,  the  patient  must  be 
removed  from  those  surroundings.  Such  a  patient  should  always  be  taken  from 
school  and  given  lessons  under  a  private  instructor.  If  the  symptoms  are  severe 
the  Weir  Mitchell  rest  cure  is  essential.  If  they  are  not  severe  enough  for  this,  an 
out-door  life  with  a  moderate  amount  of  healthy  exercise  carried  to  the  point  of 
fatigue,  but  not  of  exhaustion,  is  needful.  If  anemia  is  present  it  must  be  overcome 
by  proper  tonics.  Insomnia  and  peripheral  nervous  irritation  should  be  treated 
by  hot  and  cold  packs  and  the  various  forms  of  hydrotherapy.  Sedatives  may 
be  needed,  but  it  must  be  remembered  that  the  administration  of  hypnotics  to 
neurotic  patients  frequently  produces  a  drug  habit.  Local  anesthesia,  in  addition 
to  being  treated  by  hyrlrotherapy,  will  also  be  benefited  by  the  use  of  the  rapidly 
interrupted  faradic  current  administered  by  means  of  the  ordinary  wet  sponge,  or, 
if  the  anesthesia  is  marked,  through  the  dry  wire  lirush.  The  physician  must 
exercise  a  dominant  influence  over  the  patient,  and  she  must  be  put  under  the 
charge  of  a  trained  nurse  of  strong  character,  who,  on  the  one  hand,  will  not  be 
irritated  by  peculiarities,  but  will  tactfully  discourage  them.  This  mental  side  of 
the  treatment  is  too  frequently  overlooked,  when  it  is  the  most  valuable  and  impor- 
tant therapeutic  factor  at  our  command.  While  the  abnormal  reaction  of  the 
patient  to  suggestion  is  responsible,  as  pointed  out  by  Babinski,  for  the  development 
of  symptoms,  this  susceptibility  can  be  taken  advantage  of  in  removing  the  symp- 
toms. The  whole  atmosphere  of  the  sick  room  should  be  one  of  encouragement  and 
optimism.  The  patient's  symptoms  should  not  be  ridiculed  nor  should  undue 
sympatliy  be  expressed.  Psychotherapy  should  always  be  practised,  no  matter 
what  otiier  measures  are  resorted  to. 

The  treatment  of  the  hysterical  attack  itself  consists  in  tlie  administration  of 
nitrite  of  amyl.  There  are  few  cases  of  true  hysteria  that  will  not  be  at  once 
relaxed  if  convulsed,  and  the  attack  stopped  by  this  drug,  which,  on  the  one  hand 
is  perfectly  safe,  and,  on  the  other,  produces  so  powerful  a  mental  imiiression  that 
its  use  is  appreciated  by  tiie  ])atient.  If  nitrite  of  amyl  cannot  be  employed,  ether 
may  be  used  and  pushed  freely,  but  chloroform  is  usually  too  agreeable  to  the 
patient  to  be  ad\-antageous.  Not  rarely  the  use  of  the  dry  electric  brush  or 
even  of  the  actual  cautery,  which  may  be  touched  at  various  points  on  cither 
side  of  the  si)ine,  is  advantageous  through  the  powerful  mental  im])rcssi()n  it 
produces. 

The  Freudian  school  claim  that  by  their  method  of  psycho-analysis,  the  bringing 
to  the  surface  of  the  buried  sexual  complex  will  establish  a  cure  for  the  neurosis. 


NEURASTHENIA  899 

In  this  connection  it  may  be  well  to  remember  that  psycho-analysis,  as  it  is  practised, 
is  a  powerful  and  prolonged  method  of  suggestion  and  may  act  in  much  the  same 
way  as  other  forms  of  suggestion. 


NEURASTHENIA. 

Definition. — Neurasthenia  is  a  condition  in  which  the  nervous  system  suffers 
from  various  functional  disorders  due  to  excessive  mental  and  nervous  stress  and 
strain  whereby  the  energies  of  the  patient  are  exhausted.  For  this  reason  it  is 
often  called  nervous  exliaiistion. 

Etiology. — Heredity  plays  a  very  important  role  in  the  etiology  of  neurasthenia. 
An  individual  with  a  neuropathic  ancestry  does  not  have  the  normal  amount  of 
nervous  energj'  to  begin  with  and  therefore  will  become  nervously  exhausted  from 
causes  which  would  be  inadequate  to  produce  s^'mptoms  in  one  more  fortunate 
in  his  nervous  inheritance.  The  most  common  cause  of  neurasthenia  in  men  is 
prolonged  mental  strain  produced  by  business  reverses  or  the  carrying  through 
of  some  important  and  difficult  enterprise.  The  severity  of  this  strain  is  by  no 
means  always  in  direct  proportion  to  the  size  of  the  undertaking.  The  condition 
is  not  met  with  in  the  lower  classes  except  occasionally,  and  is  largely  dependent 
upon  the  nervous  temperament  of  the  individual  and  the  condition  of  his  general 
health  and  surroundings.  In  women  the  condition  is  commonly  met  with  as  a 
result  of  excessive  social  duties,  as  after  a  winter  season  devoted  to  late  balls  and 
receptions,  or  it  occurs  in  those  who  have  passed  through  a  long  period  of  nervous 
strain  resulting  from  the  niu-sing  of  a  sick  husband,  child,  or  some  near  relative, 
whereby  there  is  not  only  physicial  exliaustion  but  mental  anxiety  to  exhaust 
reserve  energy.  It  is  evident,  therefore,  that  many  causes  may  produce  this  con- 
dition provided  they  result  in  a  great  expenditure  of  nervous  energy  with  so  little 
sleep  that  rest  cannot  be  obtained. 

Every  individual  may  be  said  to  possess  two  funds,  or  sources,  of  nervous  energy. 
From  one  of  these  he  takes  daily  that  force  which  is  necessary  for  the  performance 
of  his  physiological  functions  and  labor.  The  second  fund  is  kept  in  reserve  to  meet 
the  demands  of  extraordinary  occasions  and  is  maintained,  as  is  the  reserve  fund  of 
a  bank,  to  meet  conditions  which  are  abnormal.  The  patient  who  suffers  from 
neiuasthenia  is  one  who  has  not  only  expended  his  ordinary  fmad,  but  drawn  so 
largely  upon  his  reserve  fund  that  he  is  a  nervous  bankrupt,  and  he  suffers  from  a 
large  number  of  more  or  less  serious  symptoms  because  the  various  parts  of  his  body 
do  not  receive  enough  nervous  energy  to  cause  them  to  perfectly  perform  the 
normal  functions.  If  the  strain  has  been  very  profound  and  severe,  and  the  patient 
is  one  whose  nervous  balance  is  not  very  stable,  it  can  be  readily  understood  that 
a  very  serious  state  may  develop,  and  that  the  life  of  the  patient  may  be  jeopardized 
if  any  intercurrent  disease  develops. 

Symptoms. — The  symptoms  of  neurasthenia  are  exceedingly  varied,  depending 
in  many  instances  upon  the  organ,  or  organs,  which  are  chiefly  affected  by  the  state 
of  nervous  exhaustion.  In  some  cases  the  mental  condition  of  the  patient  suffers 
chiefly  and  the  symptoms  may  vary  from  mere  irritability  of  temper  to  great  mental 
depression  and  even  to  mental  aberration.  Sometimes  persistent  insomnia  devel- 
ops. In  other  instances  the  functions  of  the  digestive  tracts  suffer  chiefly,  and  in 
others  the  heart  displays  the  greatest  evidence  of  distiubed  nerve  supply,  so  that 
attacks  of  palpitation  ensue,  or  instead  a  lack  of  vasomotor  control  results  in 
attacks  of  vertigo  or  syncope.  In  addition  to  these  definite  and  specific  symptoms 
the  patient  often  complains  of  a  host  of  subjective  symptoms  which  are  quite 
extraordinary  in  character.  Headache,  dull  in  character,  and  backache,  are 
frequently  complained  of.     Walking  or  other  physical  exercise  rapidly  produces 


900  DISEASES  OF  THE  NERVOUS  SYSTEM 

fatigue  from  which  the  patient  does  not  recover  as  readily  as  does  the  normal  individ- 
ual. In  fact,  tlie  complaint — "I  am  tired  all  the  time"  is  a  common  one.  In 
the  morning  they  wake  unrefreshed  and  are  usually  at  their  best  in  the  evening. 
Mental  exertion  becomes  equally  exhausting,  and  application  and  concentration 
are  difficult.  Except  in  advanced  cases,  the  appetite  is,  as  a  rule,  good.  In  spite 
of  the  variability  of  symptoms  the  following  are  constantly  met  with:  sense  of 
chronic  fatigue,  of  exhaustion,  and  irrLtal)ility.  Hysteria  is  not  infrequently 
associated  with  neurasthenia. 

Diagnosis. — The  physician  should  never  reach  a  diagnosis  of  neurasthenia  until 
by  repeated  examinations  and  study  of  the  patient,  and  her  secretions,  he  is  con- 
vinced that  no  grave  organic  disease  exists  which  may  be  responsible  for  the  sj-mp- 
toms  presented.  If  cardiac  and  renal  disease  are  excluded,  and  no  other  organic 
malady  can  be  found  of  sufficient  gravitj'  to  produce  the  illness,  and  if  the  history 
of  the  patient  reveals  the  existence  of  some  cause  capable  of  producing  nervous 
exhaustion,  the  diagnosis  of  neurasthenia  may  be  reached. 

Prognosis. — The  prognosis  of  neurasthenia  depends  upon  the  ability  of  the 
jihysician  to  remove  the  patient  from  exposure  to  the  causes  which  have  produced 
the  condition,  upon  the  aljility  or  willingness  of  the  patient  to  follow  those  methods 
of  life  which  are  conductive  to  the  re-establishment  of  nervous  balance  and  reserve 
energj',  and  upon  the  age  and  general  physical  state,  for  if  the  patient  be  one  who 
is  far  advanced  in  years,  or  who  by  reason  of  disease  or  heredity  is  possessed  of  low 
recuperative  power,  it  is  manifest  that  complete  recovery  may  be  impossible. 
Given  a  case  of  neurasthenia  in  which  all  the  conditions  which  are  unfavorable 
may  be  excluded  the  prognosis  is  favorable,  but  the  physician  must  he  cautious  in 
stating  the  duration  of  the  period  of  recovery,  for  the  progress  toward  health  is 
governed  not  alone  by  the  skill  displayed  in  treatment,  but  by  the  recuperative 
power  of  the  individual,  a  power  which  e\^ery  physician  of  experience  recognizes 
as  a  very  variable  quantity.  Not  rarely  a  seemingly  frail  person  recovers  speedily, 
whereas  another  patient  of  a  more  powerful  build  and  physique  makes  progress  so 
slowly  as  to  cause  great  discouragement. 

Treatment. — From  what  has  been  said  of  the  causes  of  this  condition  it  is  manifest 
that  the  chief  aim  of  the  physician  must  be  the  re-establishment  of  the  normal 
nervous  energy  or  power.  As  first  pointed  out  by  Weir  Mitchell,  this  can  only  be 
obtained  by  the  accmnulation  of  energy,  and  this  accumulation  of  energy,  is  to  be 
had  only  by  absolute  mental  and  physical  rest  on  the  one  hand  and  proper  feeding 
on  the  other,  the  circulatory  and  other  vital  functions  being  maintained  by  passive 
exercises  and  electricity.  The  patient  must  so  arrange  his  or  her  affairs  that  no 
business  worries  or  family  cares  will  be  experienced.  For  this  it  is  essential  that 
the  treatment  shall  be  carried  out  in  a  health  resort  far  removed  from  the  home  and 
office,  or  in  a  hospital  or  "rest-cure  house,"  where  the  patient  will  be  absolutely 
isolated  from  ordinary  surroundings.  An  attempt  to  carry  out  the  "cure"  at  home 
nearly  always  ends  in  failure,  because  the  needed  degree  of  mental  discipline  is  not 
obtainable  and  the  sounds  made  by  the  rest  of  the  family  annoy  the  patient  or 
develop  curiosity  or  worry  as  to  their  cause.  It  is  also  essential  that  a  skilled 
trained  nurse  shall  be  in  absolute  control  of  the  patient  without  any  interference 
by  members  of  the  family.  The  patient  is  not  allowed  to  sit  up,  but  is  required  to 
remain  in  bed  at  perfect  rest.  The  action  of  the  kidneys,  bowels,  and  skin  is  care- 
fully looked  after  by  suitable  remedies,  and  once  every  day  massage  is  given  over 
the  entire  body  to  give  the  effects  of  passive  exercise.  In  many  cases  it  is  well 
to  give  massage  in  the  afternoon  and  faradic  electricity  in  the  morning,  the  slowly 
interrupted  current  being  employed  to  exercise  the  muscles,  and  this  in  tiu-n  followed 
by  a  general  application  of  the  rapidly  interrupted  current  from  the  head  to  the 
feet  for  fifteen  minutes.  These  measures  combined  with  a  cool  sponging  in  the 
early  morning  and  au  alcohol  rub  at  bedtime,  with  the  administration  of  small 


EPILEPSY  901 

quantities  of  food  every  three  hours,  will  usually  cause  the  patient  to  complain  of 
being  "too  busy"  instead  of  feeling,  as  they  state  they  will  feel  at  the  beginning 
of  the  "cure,"  that  time  hangs  heavily  on  their  hands.  The  patient  must  not 
receive  or  write  letters  nor  must  she  read,  since  this  requires  not  only  nervous 
but  muscular  strain.  In  some  cases  the  nurse  is  permitted  to  read  aloud  to  the 
patient  for  an  hour  a  day.  Under  such  a  plan  of  treatment,  in  which  all  the  nervous 
energy  which  it  is  possible  to  conserve  is  secured,  and  in  which  every  opportunity 
is  offered  for  the  addition  of  units  of  force  by  proper  feeding,  lasting  and  complete 
recovery  is  usually  obtained. 

EPILEPSY. 

Definition. — Epilepsy  is  a  disease  characterized  by  attacks  of  unconsciousness, 
which,  in  the  well-developed  form  of  the  malady,  are  accompanied  or  followed 
by  convulsions.  The  convulsions  at  the  moment  of  onset  are  usually  tetanic  or 
tonic  in  type,  but  almost  immediately  become  clonic.  Indeed,  so  typical  of  epilepsy 
are  clonic  convulsions  that  all  convulsions  of  this  class  are  called  "epileptiform." 
Epilepsy  separates  itself  from  other  convulsive  conditions  associated  with  uncon- 
sciousness by  the  fact  that  it  is  a  chronic  malady,  whereas  epileptiform  convulsions 
arising  from  other  causes  occur  but  a  few  times  in  the  lifetime  of  the  individual, 
as,  for  example,  in  puerperal  eclampsia  or  uremic  poisoning.  Hysterical  convul- 
sions, however,  closely  resemble  it. 

Etiology. — The  etiology  of  epilepsy  is  unknown,  although  in  a  certain  proportion 
of  cases  injuries  to  the  brain  substance  arising  from  external  or  internal  causes 
undoubtedly  predispose  to  or  produce  the  disease.  In  some  instances  it  has  been 
thought  that  the  condition  is  hereditary,  and  this  is  certainly  true  in  the  sense 
that  epileptic  parents  often  have  epileptic  children.  By  far  the  largest  number 
of  cases  collected  by  any  one  writer,  so  far  as  the  author  is  aware,  are  those 
of  Gowers,  who  analyzed  no  less  than  1450  cases  of  epilepsy,  finding  that  an  inherited 
tendency  was  indicated  by  the  presence  of  insanity  or  epilepsy  in  ancestors  or  collate- 
ral relations  in  rather  more  than  one-third  of  the  cases  (35  per  cent.),  and  rather 
less  frequently  in  males  than  in  females,  for  there  was  this  history  in  33  per  cent. 
of  the  males  and  37  per  cent,  of  the  females.  There  was  a  family  history  of  epilepsy 
in  two-thirds  of  the  inherited  cases,  of  insanity  in  one-third,  and  of  both  disorders 
in  one-tenth  of  the  cases.  In  the  56  cases  recorded  by  Sieveking  heredity  was  the 
cause  in  11.  Reynolds,  in  his  collection  of  cases,  found  the  proportion  to  be  31 
per  cent.  Hasse  has  collected  1000  cases,  and  has  found  heredity  the  cause  in 
no  less  numbers  than  the  others.  If  we  take  the  average  result  of  the  conclusions 
reached  by  the  clinicians  just  named,  who  give  exact  figures,  we  find  that  we  have 
to  deal  with  4300  cases  of  epilepsy,  of  which  a  little  over  26  per  cent,  were  due  to 
heredity.  Whether  epilepsy  can  be  induced  in  a  child  by  hereditary  influences 
arising  from  chronic  alcoholism  or  chronic  lead  poisoning  is  open  to  debate.  Certain 
neurologists  are  firmly  convinced  that  these  factors  are  active. 

In  other  instances,  apparently  healthy  children  develop  epilepsy  after  suffering 
from  some  of  the  infectious  diseases  such  as  scarlet  fever.  In  these  cases  the 
infection  has  either  produced  some  definite  lesion  in  the  brain  or  has  so  impaired  the 
normal  growth  of  certain  cells  in  the  cerebral  cortex  that  their  natural  balance  is 
destroyed,  with  the  result  that  periodic  explosions  of  nervous  energy  take  place. 

Syphilis  acts  as  a  cause  of  epilepsy  in  two  ways.  When  the  parent  is  syphilitic, 
the  child  may  suffer  from  hereditary  syphilis  or  from  a  syphilitic  disease  of  the 
nervous  system,  with  imperfect  cerebral  development.  In  other  cases  acquired 
syphilis  produces  epilepsy  in  adults.  Indeed,  more  than  one  writer  has  expressed 
the  belief  that  an  epilepsy  beginning  after  the  twenty-fifth  year  is  syphilitic  in 
origin.  This  is  rather  an  exaggerated  statement,  but  it  is  nevertheless  true,  that 
more  than  three-fourths  of  all  cases  of  epilepsy  begin  before  the  twentieth  year. 


902  DISEASES  OF  THE  XERVOUS  SYSTE^^ 

About  half  of  them  begin  in  the  second  decade  of  life.  Quite  a  large  proportion 
begin  between  the  seventh  and  tenth  years. 

In  some  instances  the  epilepsy  dates  from  the  reception  of  some  severe  injury 
to  the  head.  Cases  that  have  a  traumatic  origin,  those  which  are  due  to  syphilitic 
gumma  or  other  form  of  brain  tumor,  usually  belong  to  that  type  which  is  called 
"Jacksonian"  or  "localized"  epilepsy,  although  they  may  ultimately  develop  all 
the  characteristics  of  the  so-called  idiopathic  form. 

For  many  years  it  was  considered  that  a  host  of  conditions  tended  to  produce 
epilepsy  by  reflex  irritation.  Such  causes  as  foreign  bodies  in  the  ear  or  in  the  nose, 
intestinal  worms,  and  uterine  disorders  have  been  considered  as  causative  factors, 
but  in  all  such  cases  these  agents  act  only  indirectly  in  the  sense  that  they  provoke 
an  irritation  which  reflexly  upsets  the  nerve  balance  or  equilibrium  of  an  unstable 
motor  area  of  the  brain.  In  other  words,  in  any  case  of  epilepsy  it  is  to  be  under- 
stood that  the  underlying  factor  is  a  lack  of  stability  or  nervous  balance. 

The  influence  of  sex  is  not  very  great,  but  males  are  affected  somewhat  more 
frequently  then  females.  Althaus  has  examined  an  enormous  amount  of  statistics 
to  obtain  results  bearing  on  this  point.  He  found  that  in  54,442  cases  there  were 
28,9G0  males  and  25,482  females. 

Posthemiplegic  epilepsy  due  to  cerebral  injury  may  occur  at  any  age,  l^ut  there 
can  be  no  doubt  that  it  far  more  commonly  occurs  in  infants  than  in  adults.  In 
at  least  two-thirds  of  the  cases  the  onset  is  before  the  fifth  year  of  age,  and  in  nearly 
one-half  it  is  during  the  first  two  years  of  life.  It  is  not  uncommon  for  the  paralysis 
to  occur  in  infancy  and  the  epilepsy  to  begin  at  puberty.  This  prolonged  interval 
is  rare  in  adults,  in  whom  the  epileptic  seizures  usually  begin  in  less  than  one  year. 

The  frequency  with  which  epilepsy  comes  on  after  the  hemiplegia  of  childhood 
has  been  very  exhaustively  studied.  Thus,  in  Osier's  cases,  20  children  out  of  97 
suffered  from  it.  In  the  SO  cases  collected  by  Gaudard  11  children  had  hemi- 
plegic  epilepsy,  and  66  children  out  of  160  cases  collected  by  Wallenberg  were 
epileptic  after  hemiplegia.  In  another  series  of  cases  collected  by  Osier  15  chil- 
dren out  of  23  were  thus  affected. 

Pathology. — The  pathology  of  epilepsy  is  not  known.  It  is  true  that  at  autopsy 
many  cases  of  epilepsy  show  atrophic  or  degenerative  changes  in  the  cerebrum 
but  this  holds  true  of  only  a  certain  proportion,  and  not  of  those  instances,  of 
so-called  idiopathic  epilepsy  in  which  there  is  no  history  of  syphilis,  or  of  injury,  or  of 
damage  to  the  brain  through  disease  of  its  bloodvessels.  In  this  idiopathic  form  the 
most  careful  macroscopic  and  microscopic  examinations  of  hundreds  of  cases  have 
failed  to  reveal  any  alteration  which  can  be  considered  as  responsible  for  the  malady. 
Some  of  the  microscopic  lesions  which  have  been  described  by  certain  investigators 
are  without  doubt  present,  but  in  these  cases  the  question  arises  whether  they  arc 
not  the  result  rather  than  the  cause  of  the  affection. 

That  epilepsy  is  a  result  of  an  explosive  discharge  of  nervous  energy  from  the 
motor  areas  of  the  cortex  is  proved  by  the  fact  that  similar  convulsions  can  be 
produced  in  man  and  in  the  lower  animals  by  irritating  these  areas,  and  that  growths 
and  injuries  which  irritate  them  produce  similar  symptoms.  The  somewhat 
ancient  theory  that  the  convidsive  disturbance  is  the  result  of  lesions  in  the  medulla 
and  the  pons  is  no  longer  accepted. 

Symptoms. — One  of  the  first  and  most  marked  symptoms  of  an  oncoming  attack 
of  epileiisy  is  a  peculiar  sensation  felt  in  some  portions  of  the  body,  generally  below 
the  head,  which  gradually  rises  up  over  the  patient,  either  rapidly  or  slowly,  like 
an  oncoming  cloud,  until,  the  head  having  been  reached,  the  patient  is  immediately 
convulsed  and  unconscious,  and  almost  instantly  is  seen  to  be  in  the  very  acme 
of  the  nervous  storm.  Simultaneously  with  the  arrival  of  this  aura  in  the  cervical 
region  the  person  utters  a  peailiar  cry  or  scream,  so  characteristic  that  it  has  been 
called  the  "epileptic  cry,"  being  probably  due  not  so  much  to  a  voluntary  impulse 


EPILEPSY  903 

as  to  a  sudden  expulsion  of  the  air  from  the  thorax  by  the  convulsive  contraction 
of  the  abdominal  muscles,  as  well  as  those  of  the  thorax,  and  its  rapid  passage 
through  the  glottis  narrowed  by  rapid  spasm  of  the  muscles  governing  this  opening. 
Synchronously  with  this  cry  the  muscle.s  of  the  whole  body,  in  a  widespread  attack, 
become  strongly  contracted  until  they  are  in  a  tonic  spasm,  and  then,  having  momen- 
tarily relaxed,  pass  into  alternating  relaxations  and  contractions,  which  tlirow  the 
patient  now  to  this  side,  now  to  that. 

During  the  tonic  spasm  the  muscles  of  the  face  often  produce  marked  distortions 
of  the  features,  in  some  cases  bringing  about  the  so-called  risus  sardonicus;  the  head 
may  be  drawn  to  one  side,  and  under  these  circumstances  the  eyes  are  generally 
turned  in  the  same  direction;  the  jaws  are  locked  one  against  the  other,  and  the 
lower  jaw  may  also  be  drawn  away  from  the  median  line  of  the  face  in  the  same 
direction  as  the  eyeballs.  Sometimes  the  whole  body  is  rotated.  In  970  cases 
analyzed  by  the  writer,  complete  rotation  to  the  right  is  mentioned  as  being  present 
in  49  persons,  and  the  left  in  52  cases.  There  is,  therefore,  no  difference  worthy  of 
note  in  these  numbers. 

The  arms  are  stronglj^  flexed  at  the  elbows,  while  the  hand  is  still  more  strongly 
flexed  at  the  wrist;  the  fingers  are  also  so  bent  into  the  palm  of  the  hand  that  not 
unfrequently  the  skin  in  this  region  is  found  indented  by  the  nails.  The  arms,  legs, 
and  body  are  drawn  and  jerked  in  the  direction  of  the  most  powerful  muscles,  and, 
as  a  consequence  of  this,  opisthotonos,  during  the  tonic  stage,  is  by  no  means 
uncommon.  Exceptions  to  this  rule  do,  however,  frequently  occur,  and  when 
present  show  that  the  paroxysm  is  exerting  its  chief  influence  on  the  weaker  muscles, 
while  the  stronger  ones  are  affected  at  least  to  a  less  degree.  As  a  general  rule,  too, 
the  muscles  of  one  side  suffer  more  than  those  of  the  other.  Unfortimately,  in 
the  cases  collected  by  me,  in  only  158  instances  were  any  remarks  on  this  point 
made.  In  these  158  the  right  side  was  most  affected  in  77  cases,  and  the  left  side 
in  81  cases.  It  is  evident,  therefore,  that  both  sides  suffer  about  equally.  The  legs 
may  be  firmly  flexed  on  the  abdomen,  while  the  fingers  are  rigidly  extended. 

The  change  in  the  color  of  the  face  is  very  marked  and  almost  tj-pical  of  the 
disease,  being  at  first  pale,  then  flushed,  the  flushing  deepening  often  into  a  livid 
purple,  owing  to  the  asphjTcia  produced  by  the  convulsive  contraction  of  the 
thorax.  In  some  cases  the  eyelids  are  widely  drawn  apart  so  that  the  eyes,  owing 
to  their  fixation,  have  a  staring  appearance ;  in  others  they  are  so  tightly  closed  that 
the  fingers  of  the  onlooker  can  scarcely  force  the  lids  apart.  The  staring,  but 
blank,  expression  of  the  eyes  is  also  increased  by  the  slow  dilatation  of  the  pupils 
which  always  accompanies  the  asphyxia. 

The  duration  of  the  tonic  contractions  rarely  exceeds  two  minutes,  and  in  most 
cases  is  limited  to  but  a  few  seconds.  It  is  followed  by  the  clonic  spasms,  already 
described,  which  are  ushered  in  by  more  or  less  violent  tossings,  but  whose  onset 
is  forewarned  by  peculiar  vibratory  thrills,  which  run  through  all  the  affected 
muscles.  The  eyelids  tremble,  the  body  changes  its  position  never  so  slightly, 
and  then,  as  if  the  vibrations  gained  greater  and  greater  power  with  each  moment, 
the  fibrillary  tremors  give  way  to  muscular  contractions.  The  expression  of  the 
face,  which  in  the  preceding  stage  was  set  and  firm,  is  now  constantly  changed  by 
the  movements  of  the  facial  muscles;  the  jaws,  no  longer  locked  together,  are 
gnashed  and  crunched  one  upon  the  other;  the  tongue  is  alternately  protruded  and 
drawn  back,  and,  as  a  consequence,  is  often  caught  between  the  teeth  and  bitten 
and  lacerated.  The  excessive  movements  of  the  muscles  of  mastication  force  the 
increased  quantities  of  liquid  secreted  by  the  salivary  glands  from  the  mouth  in  the 
form  of  froth,  which  is  often  stained  with  blood  by  reason  of  the  injuries  to  the 
tongue.  The  constancy  of  the  convulsive  movements  now  becomes  less  and  less 
marked;  well-developed  remissions  occur  between  each  toss  of  the  body  and  the  next, 
until  the  movements  cease  entirely;  but  it  should  be  constantly  borne  in  mind  that 


904  DISEASES  OF   THE  XEliVOrS  SYSTEM 

tlie  prolongation  of  the  remissions  does  not  produce  any  decrease  in  the  severity  of 
the  intervening  spasm,  the  final  spasm  often  being  even  more  violent  than  the  first. 

The  intense  discoloration  of  the  face  begins  to  pass  away  as  soon  as  the  remissions, 
by  their  length,  permit  the  blood  to  be  oxygenated,  its  disappearance  being  tem- 
porarily arrested  by  each  paroxysm.  Finally,  the  spasms  having  ceased,  the  patient 
lies  before  us  relaxed,  unconscious,  and  exhausted,  and  passes  into  a  deep  sleep  or 
coma,  which  lasts  a  variable  length  of  time,  and  from  which  he  cannot  be  aroused 
except  very  rarely,  and  then  with  great  difficulty. 

One  of  the  most  interesting  and  important  of  all  the  sjTnptoms  is  the  so-called 
aura.  Difference  of  opinion  has  arisen  as  to  the  frecjuency  of  its  occurrence,  some 
autliors  stating  it  to  be  very  rare,  while  others  see  it  very  constantly.  There  can 
be  little  doubt  that  in  many  cases  it  is  as  constantly  present  as  in  others  it  is  absent, 
and  it  would  appear  that  the  nationality  of  the  patient  has  something  to  do  with  the 
occurrence  of  this  signal  of  the  attack;  at  least,  if  we  may  judge  by  the  statements 
of  the  chief  authors  of  each  nation.  Thus,  in  America,  Wood  states  that  "the 
aura  is  wanting  in  a  very  large  proportion  of  the  cases  of  true  epilepsy,"  and  Ham- 
mond agrees  with  him.  In  England,  Gowers  stated  it  to  occur  in  about  one-half 
of  the  cases,  and  Bristowe  states  it  to  be  not  uncommon.  In  France  and  Belgium 
the  aura  appears  to  be  present  in  more  than  half  the  cases,  in  one  form  or  another, 
as  it  is  also  in  Germany,  according  to  Nothnagel.  In  970  cases  collected  by  the 
writer  it  was  found  that  the  aura  was  recorded  as  present  in  362  cases  and  absent 
in  138  cases. 

The  aura,  or  warning,  while  possessing  general  characteristics  common  to  all 
cases,  is  by  no  means  identical  in  each  individual.  By  far  the  largest  number  of 
cases,  when  it  is  present,  have  it  in  an  extremity,  and  if  it  be  not  there,  then  it  is 
often  in  the  stomach;  and  it  is  not  uncommon  to  see  persons  suffering  from  epilepsy 
who  have  as  an  aura  a  general,  indefinable  sensation  all  over  the  body.  In  much 
more  rare  instances  the  aiu-ffi  are  situated  in  the  organs  of  special  sense,  and  are 
evidenced  by  sudden  attacks  of  blindness,  visual  hallucinations  or  deafness.  It  is 
worthy  of  note,  however,  that  whereas  the  aura  may  differ  in  every  case  in  origin, 
seat,  and  limitation,  they  are  remarkably  constant  in  the  same  individual,  rarely, 
if  ever,  changing  in  kind,  although  they  may  vary  in  degree.  A  careful  analysis 
of  an  enormous  number  of  cases  by  hundreds  of  observers  shows  that  the  aura  most 
commonly  met  with  is  that  beginning  in  the  hand;  next,  that  beginning  in  the  leg 
or  foot;  next  most  common,  that  arising  in  some  of  the  viscera,  and,  after  these,  those 
which  arise  in  the  face  and  tongue.  The  rarest  form  of  aura  is  that  which  arises 
m  the  sides  of  the  trunk. 

Not  only  may  the  seat  of  the  aura  be  varied,  but  its  sensations  may  be  even  more 
aberrant.  Undoubtedly  the  most  common  sensation  is  the  indescribable  sensation 
of  a  vapor  or  cloud,  already  spoken  of;  but  in  a  large  number  of  cases  the  sensations 
are  described  as  being  quite  painful,  or  perhaps  as  partaking  of  the  feeling  that  the 
part  is  in  active  movement  when  in  reality  it  is  still  quiet.  Others  speak  of  it  as  a 
sensation  of  cold,  others  of  heating  and  burning,  and  still  others  of  trembling  and 
indescribable  distress.  In  certain  cases  the  sensation  is  confined  to  the  spot  where 
it  is  first  noticed,  and  fails  to  travel  upward  or  toward  the  central  nervous  system. 

Status  epilepticus  is  a  condition  in  which  convulsion  follows  convulsion  so  rajjidly 
that  consciousness  is  not  regained.  In  some  instances  the  patient  dies  within  a 
few  hours  as  a  result  of  exhaustion  or  asphjrxia.  As  the  case  goes  on  the  convulsions 
are  replaced  entirely  by  coma,  or,  in  rare  cases,  violent  attacks  of  mania  may 
develop.  In  this  state  the  body  rapidly  emaciates,  bed-sores  develop,  and  death 
ensues  from  exhaustion. 

An  extraordinary  number  of  fits  may  occur  in  a  brief  space  of  time  without 
causing  death,  or  even  very  great  exhausion.  A  very  good  example  of  this  fact  is 
that  of  a  case  reported  by  Newington,  which  is  as  follows:  On  the  twentieth  day 


EPILEPSY  905 

of  the  month,  at  5  a.m.,  the  fits  began  in  the  woman  under  his  care.  By  5  p.m. 
the  same  day  she  had  had  274  fits,  and  by  5  a.m.  on  the  21st  she  had  .384  more,  or 
622  fits  in  twenty-four  hours.  This  makes  a  rate  of  one  nearly  every  minute. 
By  5  A.M.  on  the  22d  she  had  400  more;  by  5  a.m.  on  the  23d,  525;  by  5  a.m.  on  the 
24th,  355,  and  from  5  a.m.  on  this  day  to  .5  a.m.  on  the  25th  she  had  214  fits.  Alto- 
gether she  had  2156  fits  in  five  days  and  yet  survived,  being  fed  by  the  rectum. 

Motor  paralysis  may  succeed  epileptic  paroxysms,  and  this  is  particularly  the 
case  in  those  instances  where  the  convulsive  movements  are  largely  unilateral  in 
character. 

A  very  important  question,  connected  not  only  with  the  prognosis  of  epilepsy, 
but  also  with  its  relation  to  medical  jurisprudence,  lies  in  the  influence  which  the 
disease  may  exercise  on  the  mental  condition  of  the  sufl'erer.  Russell  Reynolds 
has  arrived  at  the  following  conclusions  in  regard  to  the  effects  of  the  disease  on  the 
intellect: 

1 .  That  epilepsy  does  not  necessarily  involve  any  mental  change. 

2.  That  great  mental  impairment  exists  in  some  cases,  but  this  is  the  exception 
rather  than  the  rule. 

3.  That  females  sufi'er  (in  mental  vigor)  more  frequently  than  males,  and  also 
more  severely. 

4.  That  the  commonest  failure  is  loss  of  memory,  and  that  this,  if  regarded  in 
all  degrees,  is  more  frequent  than  integrity  of  that  faculty. 

5.  That  apprehension  is  more  frequently  preserved  than  lost. 

6.  That  ulterior  mental  changes  are  rare. 

7.  That  depression  of  spirits  is  common  in  males,  rare  in  females,  but  excit- 
ability of  temper  is  found  in  both  sexes 

Not  only  may  mental  deterioration  result  in  epilepsy  of  long  duration,  but  tran- 
sient qualitative  mental  change  may  occur.  Thus — delirium  may  precede,  replace 
or  follow  the  convulsion — and  the  so-called  "postepileptic  confusion,"  which  may 
last  for  days  or  even  weeks,  is  a  familiar  picture  to  every  alienist. 

It  is  to  be  recalled  that  primary  mental  weakness  is  often  associated  with 
epilepsy. 

Complications. — Naturally  enough,  a  very  common  variety  of  complication  is 
some  traumatism,  severe  or  mild,  which  is  suffered  as  the  result  of  the  fall  accom- 
panying the  fit,  whereby  the  head  is  struck  against  some  hard  or  sharp  object. 
The  severity  of  the  injury  may  be  anything  from  fracture  to  a  slight  abrasion  or 
bruise.  When  such  an  accident  happens  it  should  not  be  forgotten  that  the  coma 
of  the  fit  may  be  dangerously  deepened  by  the  concussion,  and  also  that  the  coma 
may  mislead  the  physician  so  that  it  is  regarded  as  the  natural  sequence  of  the 
attack  rather  than  the  result  of  the  injury.  Fractures  of  the  clavicle  are  very 
common.  In  the  same  manner  various  dislocations  may  ensue.  The  presence 
of  a  fracture  in  an  epileptic  is  a  very  much  more  serious  matter  than  would  appear 
at  first  glance,  for  even  if  the  fits  are  not  frequent  they  are  almost  sure  to  cause  a 
fresh  solution  of  continuity,  or  even  to  convert  a  simple  into  a  compound  fracture 
by  the  jerkings  of  the  muscles.  Splints  are,  of  course,  of  value,  and  the  limb  may 
be  wrapped  in  a  pillow.  Careful  watching  with  quiet  rest  in  bed  must  always  be 
insisted  upon,  since  under  these  circumstances  a  second  fall  is  avoided  on  the  advent 
of  a  new  attack. 

In  other  cases  apoplexy  may  occur,  due  to  the  sudden  strain  upon  the  cerebral 
bloodvessels  during  the  fit,  and  if  the  coma  following  an  attack  is  prolonged  or 
peculiar,  this  fact  should  be  called  to  mind.  The  inequality  of  the  pupils,  the  ster- 
torous respiration,  the  fact  that  the  tongue  cannot  be  protruded  straight  from  the 
mouth,  all  point  to  a  cerebral  lesion;  but  the  rise  of  temperature,  the  coma,  and, 
last  of  all,  the  hemiplegia,  are  charactertistic  of  both  states,  and  cannot  be  used  for 
differential  diagnosis. 


906 


DISEASES  OF  THE  NERVOUS  SYSTEM 


Diagnosis. — Unrloubtedly,  the  most  similar  convulsive  condition  that  we  have 
is  that  due  to  hysteria,  and  the  diagnosis  of  one  from  the  other  is  as  difficult  in  some 
cases  as  it  is  essential  and  necessary  for  treatment  and  cure.  The  other  conditions, 
with  which  it  might  be  confused,  arc  uremia,  alcoholic  epilepsy,  tetanus,  and 
syncope.  In  the  accompanying  table  are  arranged  all  these  disorders,  which 
briefly  and  succinctly  shows  the  different  points  between  them,  although  of  necessity 
it  is  somewhat  arbitrary  on  account  of  the  lack  of  space. 


I'aule  of  Dipfebential  Diagnosis  op  Epilepsy  frcm  Hysteria,  etc. 


Signs. 

Epilepsy. 

Hysteria. 

Uremia. 

None 

Petit  mal. 

Alcoholic 
epilepsy. 

Tetanus. 

Syncope. 

Apparent 
cause 

None 

Emotion 

None 

None 

None 

Mental 
shock. 

Aura  or  pro- 
dromata 

Generally 
present, 
but  short 

Globus 
hystericus, 
palpitation, 
choking 

Headache, 
vomiting, 
and  dys- 
pepsia 

Faintness 
and    dim- 
ness of 
vision 

Tremors 

Nervous- 
ness 

Not  so  well 
defined   as 
in  epilepsy 

Onset 

Sudden 

Often 
gradual 

Often 
gradual 

Sudden 

Sudden  or 
gradual 

Gradual, 
begins  in 
jaw 

Sudden  or 
gradual. 

Scream 

At  onset  and 
sudden 

During 

attack 

Frequently 
none 

Frequently 
none 

May  or 
may  not 
be  present 

None 

None. 

Convulsion 

First  tonic, 
then  clonic 

Rigidity 
more  pro- 
nounced, 
with  more 
aching 

Rigidity 
generally 
absent 

No  rigidity 

Movements 
more  clonic 
than  tonic 

Always 
tonic 

None. 

Biting 

Tongue 

Tongue,  lips, 
and  hands 

Tongue 

None 

Rarely 

None 

None. 

Micturition 

Frequent 

Never 

Never 

Rarely,  ex- 
cept when 
bladder  is 
affected 

Rarely 

Sometimes 

Never. 

Defecation 

Occasionally 

Never 

Never 

Never 

Rarely 

Rarely 

Never. 

Talking 

Never 

Frequent 

Muttering 

Never 

Never 

Never 

None. 

Duration 

A  few 
minutes 

Generally 
many 
minutes 

From  a 
minute  to 
hours 

Momen- 
tary 

May  be 
prolonged 

Hours 

Indefinite 
time. 

Conscious- 
ness 

Lost 

Generally 
preserved 

Lost 

Not  lost 
always, 
but 
clouded 

Lost 

Preserved 

Lost. 

Termination 

Spontaneous 

May  be 
induced 
by  shock 

Spontane- 
ous 

Spontane- 
ous 

Spontane- 
ous 

Spontane- 
ous 

Gradual, 
wth  no 
somno- 
lence. 

The  very  irregularity  of  true  epilepsy  makes  it  extremely  difficult  to  give  clear 
and  well-defined  outlines  of  it  against  another  disease,  particularly  when  we  remem- 
ber that  epilepsy  and  hysteria  often  go  hand  in  hand. 

By  far  the  mo.st  important  dift'erential  point  between  the  two  disorders  just 
named,  when  not  complicated  with  still  another  flisease,  is  the  character  of  the  move- 


EPILEPSY  907 

ments.  As  already  pointed  out,  in  epilepsy  they  are  typically  at  variance  with 
those  of  dailj'  life,  wliile  in  hysteria  they  are  often  equally  typical  of  ordinary  muscu- 
lar contractions,  or,  in  other  words,  are  more  purposive  in  character;  and  fre(iuent]y 
there  is  prolonged  tonic  contraction  of  the  muscles,  giving  rise  to  the  taking  of 
positions  which  bear  more  or  less  resemblance  to  assumed  attitudes.  In  hysteria, 
also,  consciousness  is  impaired  sometimes,  but  never  so  completely  as  in  true 
epilepsy.  Indeed,  most  commonly  the  individual  knows  all  that  goes  on  around 
her,  for,  while  she  may  give  no  sign  of  consciousness  by  words  or  looks  during  the 
attack,  she  may  afterward  be  able  to  narrate  all  that  has  occurred.  Less  commonly, 
however,  a  condition  known  as  automatic  consciousness  exists,  in  which,  during 
the  paroxysm,  the  patient  understands  all  that  is  said,  but  forgets  everything 
on  the  return  to  quietness. 

The  fact  that  the  patient  is  a  female  cannot  be  regarded  as  affirmative  evidence 
of  hysteria  in  the  least,  but  if  the  fit  occurs  in  a  male  it  may  be  taken  as  fairly 
positive  evidence  of  epilepsy;  and  yet  it  should  always  be  remembered  that  males 
may  sufFer  from  hysteroid  attacks. 

The  movements  of  the  hysterical  patient  after  the  tonic  condition  has  passed  away 
are  clonic  as  are  those  of  epilepsy,  but  still  possess  some  purposive  characteristics, 
and  are  not  so  bizarre  as  are  those  of  the  true  disease.  Thus,  the  head,  arms, 
and  legs  are  struck  with  evident  endeavor  against  the  floor  or  surrounding  furniture. 
Another  point,  which,  when  it  occurs,  is  very  distinctive,  is  the  onset,  toward  the 
close  of  a  hysterical  convulsion  of  a  second  stage  of  tonic  spasm  such  as  occurred 
at  the  beginning.  It  will  be  remembered  that  this  does  not  occur  in  epilepsy; 
although  it  must  be  borne  in  mind  that  in  cases  of  the  "status  epilepticus"  the 
rapid  onset  of  another  attack  may  show  a  second  tonic  stage.  This  can  be  sepa- 
rated, however,  by  the  fact  that  it  is  followed  by  clonic  movements,  whereas  the 
secondary  tonic  stage  of  hysteria  is  usually  followed  by  relaxation  and  temporary 
recovery. 

Finally,  too,  in  hysteria,  some  peculiar  emotional  position  is  often  assumed, 
as  of  the  crucifix,  or  of  intense  grief,  or,  perhaps,  immoderate  laughter,  with  corre- 
sponding movements  of  the  trunk.  If  the  patient  is  quiet  at  this  time,  a  smile 
may  float  across  the  face,  while  the  eyes,  with  a  look  of  pleasure,  pain,  or  entreaty, 
may  seem  to  be  gazing  at  some  object  verj^  far  off.  In  some  very  well  developed 
cases  the  expression  of  pleasure  is  followed  by  a  look  of  pain,  with  painful  move- 
ments, or  an  appearance  of  voluptuous  entreaty,  with  sensual  and  venereal  desire 
evidenced  by  gestures.  Very  commonly  areas  of  anesthesia  and  hj-peresthesia 
occur  in  these  patients  and  are  of  all  degrees  of  intensity  and  limitation.  Search 
for  them  generally  shows  their  presence  after  attacks  of  convulsions,  but  they  may 
persist  from  one  attack  to  the  other,  or  develop  spontaneously.  In  nearly  all 
cases  these  areas  are  imilateral,  and  may  extend  over  one-half  of  the  body,  the  line 
of  demarcation  of  the  anesthesia  or  hyperesthesia,  from  the  sound  area,  being 
clearly  and  abruptly  defined,  generally  at  the  median  line  of  the  front  and  back  of 
the  trunk.  It  will  be  called  to  mind  that  such  conditions  are  absent  in  true  epilepsy. 
Hallucinations  are  far  more  common  after  the  fit  in  hysteria  than  in  epilepsy,  and 
sometimes  they  occur  even  during  the  attacks. 

A  very  useful  differential  point,  strongly  insisted  upon  by  Charcot  and  Bourne- 
ville,  is  that  in  true  epilepsy  there  is  generally  a  very  considerable  rise  of  temperature 
during  an  attack,  while  in  hystero-epilepsy  the  temperature  remains  normal  or  only 
slightly  raised.  Not  rarely  malingerers  simulate  attacks  of  epilepsy,  and  very 
serious  injuries  are  sometimes  submitted  to  by  these  persons  to  carry  out  their 
designs.  The  points  to  be  looked  into  are:  the  condition  of  the  pupils,  which,  in 
the  simulated  attack,  always  react  normally;  nor  can  the  corneal  reflexes  be  held 
back;  the  color  of  the  face  is  rarelj'  changed,  and  the  thumbs  are  rarely  flexed  as 
they  should  be.     Marc  has  pointed  out  that  in  malingerers  the  bystander  can 


908  DISEASES  OF  THE  NERVOUS  SYSTEM 

readily  straighten  out  the  thumbs,  and  that  they  remain  so;  whereas  in  epilepsy 
they  instantly  become  flexed  again. 

Suggestions  as  to  movements  are  sometimes  followed  by  malingerers,  and  the 
movements  generally  lack  the  bizarre  character  so  typical  of  epilepsy. 

If  sulphur  fumes  or  ammonia  be  held  to  the  nose  of  the  fraud,  he  generally  is 
forced  to  disclose  his  true  condition.  The  fact  that  in  malingerers  there  is  no  rise 
of  temperature  is  a  differential  point. 

Prognosis. — The  physician  can  always  assure  the  patient  and  friends  that,  so  far 
as  the  disease  itself  in  its  ordinary  form  is  concerned,  there  is  little  danger  of  death, 
since,  as  a  general  rule,  imless  the  attacks  are  very  severe,  death  rarely  occurs, 
imless  indirectly  by  the  fall  of  the  body  into  a  stream  or  well,  or  when  in  some 
position  where  a  steady  head  is  necessary  for  safety.  Accidental  asphj-xia,  due 
to  the  burying  of  the  face  in  the  pillow  at  night,  or  to  the  impaction  of  food  in  the 
larynx,  may  occur,  but  even  this  accident  is  uncommon. 

The  question  which  the  friends  will  always  ask  is:  What  is  the  prospect  of 
ultimate  recovery,  or,  at  the  least,  will  there  be  any  progress  toward  an  improve- 
ment? Unfortunately,  the  reply  ought  not  in  anj-^  case  to  be  favorable,  even  for 
ultimate  improvement,  for  the  experience  in  the  past  of  every  practitioner  has  been 
that  cures  rarely  occur. 

Treatment. — By  far  the  most  valuable  drug  in  use  today  for  the  relief  of  epilepsy 
is  bromide  of  strontiiun.  In  many  cases  the  remedy  undoubtedly  gives  relief  when 
it  is  pushed  in  a  suitable  manner,  and,  in  the  majority  of  instances,  the  seizures 
are  so  decreased  both  in  violence  and  frequency  that  its  use  may  be  said  to  be 
indicated  in  nearly  every  case  of  the  disease.  In  a  very  small  minority,  however, 
it  signally  fails. 

A  very  important  point  to  be  borne  in  mind  is  that  the  drug  often  seems  to  have 
produced  a  complete  ciu-e,  and  this  results  in  carelessness  in  the  regidarity  of  admin- 
istration. The  patient  should  be  impressed  by  the  fact  that  every  day  passed 
without  a  fit  is  a  step  forward,  and  that  every  fit  carries  him  many  steps  backward. 
He  should  also  be  made  to  use  the  drug  in  moderation  for  at  least  three  years  after 
all  fits  have  ceased,  and  to  watch,  after  that  time,  for  the  slightest  sign  of  their 
return.  The  quantity  taken  each  day  should  be  gradually  decreased,  not  suddenly 
stopped.  It  has  been  shown  that  if  ordinary  table  salt  is  restricted  in  the  diet  a 
smaller  amount  of  the  bromide  salt  is  recjuired  to  control  the  convulsions. 

The  iodide  of  potassiiun  is  entirely  useless  in  epilepsy,  unless  it  is  due  to  syphilis, 
when  it  is  of  the  greatest  service.  Under  this  condition  the  bromides  and  all  other 
drugs  should  be  set  aside  while  it  is  pushed  to  the  utmost.  As  is  well  known, 
syphilitics  usually  bear  the  drug  extremely  well,  and  the  writer  knows  of  one 
instance  where  no  less  than  800  grains  were  taken  every  twenty-four  hours,  with 
rapid  improvement  as  a  result. 

When  the  convulsions  are  due  to  a  gumma  the  iodide  of  potassium  is,  however, 
too  slow  in  its  action,  and  should  be  replaced  by  mercury  in  order  to  break  down  the 
growth  without  delay,  lest  a  seizure  end  the  scene  by  asph^-xia  or  some  similar 
accident. 

In  every  case  the  physician  should  make  careful  inquiry  as  to  the  presence  of 
an  aura,  and,  if  it  is  present,  he  should  order  that  the  patient  be  provided  with 
pearls  of  amyl  nitrite,  one  of  which  is  to  be  broken  and  its  contents  inhaled  the 
moment  the  warning  of  an  approaching  fit  develops.  By  this  means  attacks  can 
often  be  aborted. 

Crotalin,  a  protein  found  in  the  venom  of  rattlesnake,  has  of  late  been  exploited 
as  a  cure  for  epilepsy,  but  is  only  mentioned  here  that  it  may  be  condemned  as 
being  both  inaffective  in  relieving  the  malady  and  at  times  dangerous  to  the 
patient. 

As  constipation  and  indiscretion  in  diet  arc  potent  factor?  in  l)ringing  on  the 


ECLAMPSIA  909 

individual  attacks,  the  patient  should  be  instructed  to  keep  the  bowels  open  freely 
and  to  avoid  overloading  the  stomach. 

Petit  Mai  or  Minor  Epilepsy. — Petit  mal  differs  in  no  way  in  its  essential  char- 
acters from  epilepsy  of  a  much  more  highly  developed  form,  but  in  its  minor  char- 
acteristics it  is  sufficiently  at  variance  with  haiii  mal,  or  grand  mal,  to  separate 
it  in  the  minds  of  clinicians.  In  its  most  common  form  petit  mal  consists  of  a 
momentary  loss  of  consciousness,  accompanied  by  pallor,  or,  more  rarely,  flushing 
of  the  face.  The  man  who  is  subject  to  the  disease  suddenly  stops  what  he  is  doing 
for  a  moment  or  two,  and  then  takes  up  his  work  or  subject  as  soon  as  he  recovers, 
and  at  the  point  where  he  ceased,  being  often  unconscious  of  the  break  in  his  con- 
versation or  labor.  Reynolds  has  divided  this  minor  form  of  the  affection  into 
two  divisions.  In  the  first  he  places  those  who  are  attacked  and  have  no  evident 
spasm,  and  in  the  second  group  are  those  who  have  evident  spasm.  The  seizures 
are  characteristically  fugacious,  and  if  any  spasm  is  present  it  is  nearly  always  of 
the  tonic  variety.  Sometimes  the  disorder  of  motility  lies  chiefly  in  an  inhibition 
of  an  act  about  to  be  performed.  The  fork  in  a  man's  hand  at  a  dinner-table  may 
be  raised  half-way  to  the  mouth,  then  held  in  mid-air  for  a  moment,  and  then 
as  the  attack  passes  away,  continue  on  its  journey  to  the  mouth;  or,  a  woman 
playing  the  piano  may  suddenly  pause  with  her  fingers  raised  from  the  keys,  miss 
the  time  of  three  or  four  bars,  and  then  go  on  exactly  where  she  left  off,  as  if  no 
interruption  had  occurred. 

Jacksonian  Epilepsy. — By  the  term  Jacksonian  epilepsy  we  mean  an  affection 
which  separates  itself  from  true  or  ordinary  idiopathic  epilepsy  by  several  peculiari- 
ties. By  far  the  most  important  of  the  peculiar  signs  is  the  character  of  the  onset, 
which  always  begins,  in  the  typical  Jacksonian  disease,  in  some  peripheral  portion 
of  the  body,  and  most  frequently  in  the  muscles  of  the  thumb  or  hand,  so  that  for 
the  moment  the  movements  are  localized  and  may  remain  localized  at  the  point 
of  origin,  or  immediately  diffuse  themselves  o^-er  muscle  after  muscle  until  all  the 
arm,  leg,  or  other  groups  of  muscles  are  involved.  It  is  of  the  greatest  importance, 
however,  that  the  reader  should  keep  the  aura  of  an  attack  separated  in  his  mind 
from  the  onset,  remembering  that  the  term  onset  is  here  used  by  the  writer  to 
designate  the  beginning  of  the  period  following  the  aiu-a,  if  there  be  one.  Jacksonian 
epilepsy  may  be  of  almost  any  degree  of  severity,  for  in  rare  cases  but  one  muscle 
maj^  suffer  throughout  an  entire  attack,  or  in  others  the  entire  body  may  be  finally 
convulsed.  There  may  or  may  not  be  loss  of  consciousness,  its  presence  or  absence 
being  dependent  upon  the  severity  of  the  attack.  In  those  instances  in  which  only 
a  few  localized  muscles  are  involved,  consciousness  is  more  commonly  preserved 
than  lost. 

ECLAMPSIA. 

The  term  "eclampsia"  is  applied  to  convulsions  affecting  children  and  pregnant 
women,  or  women  who  have  just  been  delivered. 

Infantile  Eclampsia. — In  infantile  eclajnpsia  the  attacks  are  epileptiform  in  char- 
acter and  seem  to  depend  upon  a  condition  of  undue  irritability  of  the  nervous 
system,  which  is  still  further  disturbed  by  some  reflex  cause.  Thus,  it  is  commonly 
supposed  that  gastric  and  intestinal  indigestion  may  produce  infantile  eclampsia, 
and  certainly  the  presence  of  foreign  bodies  in  the  stomach  and  intestines  may  act 
in  this  manner.  Again,  many  physicians  believe  that  the  first  dentition,  by  reason 
of  the  irritation  in  the  gums,  may  result  in  such  a  seiziu'e.  This  is  doubtful.  A 
host  of  other  sources  of  peripheral  irritation  have  also  been  held  responsible.  Not 
rarely  the  underlying  cause  is  rickets.  It  is  often  stated,  in  text-books  on  medi- 
cine, that  the  acute  infectious  fevers  are  frequently  initiated  by  a  convulsive 
seizure.  As  a  matter  of  fact  this  rarely  occurs  in  an  ordinary  child  when  infected 
in  this  manner. 


910  DISEASES  OF  THE  NERVOUS  SYSTEM 

The  convulsive  attack  varies  in  severity  from  a  mere  clinching  of  the  fingers  and 
the  drawing  of  the  thumb  into  the  palm  of  the  hand  to  a  severe  clonic  or  tonic 
convulsion  closely  resembling  epilepsy  or  hysteroepilepsy.  In  many  instances 
the  child  has  a  single  attack  and  no  more.  In  other  cases  several  attacks  occur 
within  a  few  days.  In  still  others  the  occurrence  of  one  or  more  attacks  of  convul- 
sions seems  to  develop  a  convulsive  habit,  and  in  these  instances  the  child  may 
become  a  confirmed  epileptic.  In  such  cases,  however,  it  is  probable  tliat  the  con- 
dition of  indigestion,  or  other  direct  cause,  simply  induces  a  nervous  explosion  on 
the  part  of  a  brain  which  has  an  impaired  stability. 

Diagnosis. — The  condition  must  be  separated  from  the  convulsions  produced 
by  organic  cerebral  disease  (which  see). 

Prognosis. — The  prognosis  in  infantile  eclampsia  is  good  for  single  attacks,  and 
becomes  grave  in  direct  proportion  to  their  severity  and  repetition.  Such  attacks 
occurring  in  feeble,  poorly  nourished  children  are  more  grave  than  in  those  who  are 
better  able  to  withstand  an  illness. 

Treatment. — This  consists  in  removing  the  cause  of  local  irritation,  if  it  can  be 
found.  If  it  exists  in  the  stomach  or  the  bowels,  it  should  be  removed  by  an  emetic 
or  a  purge.  If  the  gimis  are  inflamed  they  should  be  lanced.  If  rickets  is  the  cause 
it  must  be  cured  if  possible. 

The  treatment  of  the  attack  itself  consists  in  the  administration  by  the  mouth, 
if  swallowing  is  possible,  of  5  or  10  grains  of  bromide  with  from  2  to  4  grains  of 
chloral,  or  by  the  use  of  20  grains  of  sodium  bromide  with  5  grains  of  chloral  in 
starch-water,  by  the  rectmu.  If  laryngeal  spasm  is  marked,  and  is  a  dangerous 
symptom  an  inhalation  of  nitrite  of  amyl  may  be  used,  or  chloroform  may  be 
employed  if  the  heart  is  not  weak. 

Puerperal  Eclampsia  usually  occurs  in  young  primiparae.  The  convulsions 
are  tonic  and  clonic.  The  pathology  of  the  condition  is  not  understood.  Without 
doubt  the  condition  is  toxic.  In  some  instances  it  is  probably  due  to  perverted 
functional  activity,  or  actual  disease,  of  the  liver  or  kidneys.  In  other  instance's 
it  seems  to  be  dependent  upon  perverted  metabolism.  Not  infrequentlj',  in  asso- 
ciation with  the  albiuninuria  of  pregnancy,  there  is  albumimiric  reiiniiis,  and  even 
blindness  with  general  anasarca.  That  the  presence  oi  fetus  in  utero  exercises  some 
influence  is  shown  by  the  fact  that  not  infrequently  the  convulsions  cease  as  soon  as 
the  uterus  is  emptied. 

Puerperal  eclampsia  is  an  exceedingly  dangerous  condition.  The  mortality 
varies  from  20  to  30  per  cent.,  or  even  more  than  this.  In  a  certain  proportion  of 
cases  it  can  be  prevented,  and  for  this  reason  the  physician  should  repeatedly 
examine  the  urine  of  the  pregnant  woman  for  several  months  before  the  termination 
of  pregnancy  to  determine  that  the  kidneys  are  carrying  out  their  eliminative 
function  properly.  The  blood  pressure  if  above  K)0  systolic  is  to  be  taken  as 
threatening  eclampsia. 

Treatment. — The  uterus  must  be  emptied,  the  poisons  must  be  eliminated,  and 
the  nervous  system  must  be  quieted.  For  the  best  method  of  emptying  the  uterus, 
the  reader  is  referred  to  books  upon  obstetrics.  If  arterial  tension  is  high  and  there 
is  much  cyanosis,  the  patient  should  be  freely  bled  and  the  intravenous  injection 
of  normal  saline  solution  employed,  unless  there  is  a  tendency  to  pulmonary  edema, 
when  the  intravenous  injections  should  not  be  used.  Copious  irrigation  of  the  large 
bowel  or  the  injection  of  an  ounce  of  magnesium  sulphate  dissolved  in  a  half-pint 
of  water  and  2  ounces  of  glycerin  are  also  useful.  If  the  convulsions  are  severe 
in  these  cases  ma.y  physicians  treat  the  condition  by  the  use  of  large  doses  of  20  to 
30  minims  of  the  tincture,  or  even  of  the  fluid  extract,  of  veratrum  viride,  giving  it 
in  some  cases  hypodermically.  A  useful  preparation  for  hypodermic  use  is 
strophanthone.  This  drug  lowers  arterial  tension  quiets  the  spinal  cord,  and 
produces  sweating.  Pilocarpine  is  never  to  be  employed,  as  it  almost  invariably 
causes  pulmonary  edema. 


AMOK  ,  911 


LATAH. 


Latah  is  a  state  very  closely  allied  to  the  saltatory  spasm  described  by  Bam- 
berger, and  the  patients  described  by  Beard  as  "jumpers."  The  chief  symptom 
of  latah  is  involuntary  and  uncontrollable  mimicry  by  the  patient  of  everything 
she  sees  or  hears.  There  is  also  frequent  coprolalia  or  the  spasmodic  ejaculation  of 
filthy  words.  The  disease  is  common  among  the  Malay  races,  and  its  geographical 
distribution  corresponds  with  the  countries  inhabited  by  these  people.  It  occurs 
commonly  enough  among  the  Filipinos  and  is  known  by  the  Tagalogs  as  "mali- 
mali."  It  is  seen  in  Cejdon  and  Burmah,  and  the  disease  known  in  Siberia  as 
"myriachit"  is  probably  identical  with  it.     Kraepelin  allies  latah  with  hysteria. 

The  subjects  of  latah  are  almost  invariably  women  in  early  adult  life.  JNIen 
rarely,  if  ever,  suffer  from  the  disease.  There  is  a  distinct  hereditary  tendency, 
but  the  cases  show  no  evidence  either  of  hysteria  or  epilepsy.  It  is  a  very  common 
spectacle  indeed,  in  Malay  villages,  to  see  one  of  these  unfortunate  women  pursued 
by  a  crowd  of  tormenting  boys.  They  dance  in  front  of  her,  going  through  all  sorts 
of  grotesque  and  obscene  movements,  and  the  unfortunate  victim,  apparently 
struggling  to  the  utmost  to  resist  the  impulse,  exactly  imitates  all  their  actions  to 
her  own  great  rage  and  mortification.  Besides  such  examples  of  complete  echo- 
chinesia,  or  mimicry  of  motion,  there  frequently  is  echolalia,  or  mimicry  of  speech. 
When  startled  or  frightened  these  patients  utter  irrelevant  words  or  incoherent 
noises  and  make  involuntary  movements.  Consciousness  is  never  lost  during  these 
attacks.  This  latter  type  closely  resembles  the  "jiunping  Frenchmen"  of  INIaine 
and  Canada,  who  jump  violently  and  suddenly  with  a  loud  cry  when  startled  or 
when  under  strong  emotion.  Jumpers,  and  latah  patients  as  well,  will  frequently 
obey  any  sharp,  sudden  command  given  them.  Undoubtedly,  this  represents  some 
form  of  psychic  suggestion  acting  on  a  weak  and  unstable  will.  The  Malay  is 
notoriously  unstable  in  his  mental  makeup.  Such  patients  are  markedly  neurotic. 
They  are  pusillanimous  and  easily  startled.  As  a  rule,  both  the  superficial  and 
deep  reflexes  are  increased.  Many  of  these  patients  suffer  later  from  serious  mental 
disorders.  Among  the  Philippine  natives  "mali-mali"  patients  are  believed  to  be 
particularly  prone  to  the  outbreaks  of  maniacal  furor  known  as  amok. 

AMOK  (RUNNING  AMOK). 

This  term  is  used,  in  Malayan  countries,  to  designate  cases  of  maniacal  fiu-or 
in  which  a  native  rushes  out  in  the  streets  of  his  village  with  kris  or  barong,  cutting 
down  everyone  in  his  path,  until  he  himself  is  dispatched  or  commits  suicide. 
It  is  a  question  whether  these  outbreaks  should  be  considered  as  evidences  of  a 
specific  disease.  Preceding  the  attack  the  patient  is  in  a  stupid,  morose,  or  melan- 
cholic condition  for  several  days.  During  this  period  there  frequently  is  amnesia, 
and  during  the  attack  itself  complete  amnesia  is  the  rule.  The  exciting  causes  of 
the  outbreak  are  usually  psychical;  grievance  over  some  real  or  fancied  wrong, 
over  financial  losses,  marital  difficulties,  fear  of  disgrace  or  punishment,  and  the 
sight  or  smell  of  blood.  The  disease  almost  always  attacks  young  adult  males. 
Various  causes  have  been  advanced  for  this  condition.  Alcoholism  may  be 
excluded,  as  the  Malay,  although  not  a  total  abstainer,  is  very  frugal  in  the  use 
of  liquors.  So,  too,  opium  smoking  cannot  be  considered  the  cause  of  the  disease. 
Bevan  Lewis  believes  it  to  be  a  psychical  epilepsy,  and,  indeed,  transitory  furor 
very  much  resembling  the  attacks  of  amok  are  frequently  seen  in  epileptics.  Earlier 
travellers  and  writers  ascribed  these  attacks  to  religious  mania.  Schuebe  discredits 
this  idea  on  the  ground  that  the  Koran  does  not  justify  the  killing  of  unbelievers, 
and  he  quotes  Ellis  to  the  effect  that  amok-running  occurred  among  Malays  before 
they  were  converted  to  Mohammedanism.     The  Malayan  races  chiefly  subject 


912  DISEASES  OF  THE  XERVOUS  SYSTEM 

to  amok  are  the  Bugis,  Illanums,  and  the  SiUiis,  or  Joloanos,  in  the  Southern 
Philippines.  In  many  instances  among  this  last  tribe  the  motive  is  undoubtedly 
religious.  During  the  service  of  the  United  States  army  in  the  Philippines  a  most 
melancholy  case  occurred  in  an  officer,  corresponding  exactly  to  the  typical  amok 
cases.  This  man,  an  excellent  soldier,  and  a  man  of  exemplary  personal  habits, 
after  a  few  days  of  brooding  and  melancholy,  suddenly  appeared  on  the  veranda  of 
his  cpiarters  with  a  rifle  and  began  to  shoot  into  his  company  formed  up  in  close 
proximity.  lie  could  not  be  secured,  and  after  wounding  a  nunil)cr  of  his  men  he 
was  shot  and  killed  by  one  of  his  own  sergeants.  With  regarfl  to  the  responsibility 
of  these  cases  no  general  rule  can  be  laid  down.  The  responsibility  cannot  be 
affirmed  in  all  cases,  nor  can  it  be  denied.  I\Iost  of  the  cases  of  amok  are  clearly 
irresponsible.  Mention  has  been  made,  under  Latah,  of  the  occasional  outbreaks 
of  furor  resembling  amok  that  take  place  in  that  disease. 

According  to  Kraepelin,  who  has  studied  this  condition  in  Java  very  completely, 
amok  is  not  an  entity,  but  embraces  a  variety  of  conditions  in  which  sudden, 
violent,  impulsive  acts  are  committed  while  consciousness  is  clouded.  Some  cases 
belong  to  the  class  of  the  "insanity  of  adolescence,"  some  are  epileptics,  a  few  may 
be  instances  of  "malarial  psychosis,"  but  there  are  rare  cases  of  amok  that  Kraepelin 
cannot  explain.  Latah  is  distinguished  from  it  by  the  complete  preservation  of 
consciousness  in  that  state. 

ASTASIA-ABASIA. 

Definition. — Astasia-abasia  is  a  symptom  of  hysteria.  It  occasionally  follows 
disturbance  of  the  nervous  system  produced  by  injury,  and  in  that  sense  might 
be  considered  a  traumatic  neurosis.  Occasionally  it  has  followed  the  acute  infect- 
ious diseases. 

Symptoms. — The  symptoms  consist  in  a  partial  or  complete  inability  to  iise  tlie 
lower  limbs  in  standing  or  in  walking,  although  if  the  patient  lies  upon  her  back  in 
bed  she  can  move  her  legs  perfectly.  Examination  fails  to  reveal  any  alteration 
from  the  normal  as  to  motion,  co-ordination,  or  sensation.  When  the  condition 
simply  interfers  with  walking,  it  is  called  "dysbasia."  Patients  who  may  be  quite 
unable  to  walk  can,  nevertheless,  swim  perfectly. 

The  prognosis  is  as  favorable  as  that  of  ordinary  hysteria,  and  the  treatment  is 
the  same  as  that  which  is  employed  for  patients  who  are  suffering  from  hysteria 
or  neurasthenia. 

TRAUMATIC  NEUROSES. 

Definition. — Under  the  term  traumatic  neuroses  there  is  described  a  condition  in 
which  an  individual,  after  exposure  to  some  severe  mental  shock  or  physical  injury, 
develops  a  train  of  symptoms  which  do  not  depend  upon  any  demonstrable  lesion  of 
the  nervous  system.  As  the  result  of  functional  disorder  of  the  nervous  system  in 
various  parts  of  the  body,  following  the  accident,  the  patient  presents  sjiiiptoms 
which  are  chiefly  subjective,  though  they  may  be  somewhat  objective,  and  he  may  be 
actually  and  completely  inca])acitated  from  performing  the  ordinary  acts  of  life  for  a 
long  period  of  time.  Rarely  the  disability  may  be  permanent,  but  in  these  cases  the 
question  always  arises  as  to  whether  there  has  not  been  in  addition  to  the  functional 
disturbance  an  actual  organic  lesion.  It  is  evident,  therefore,  that  cases  of  this 
character  may,  and  do,  present  to  the  physician  very  difficult  problems  in  diff'erential 
diagnosis,  for  not  only  may  functional  disorders  exist  side  by  side  with  those  due 
to  true  organic  change,  but  in  addition  the  fmictional  disturbances  may  simulate 
organic  disease  so  closely  as  to  cause  great  confusion  in  symptomatology.  When  to 
these  natural  difficulties  are  added  the  desire  of  the  patient  to  obtain  heavy  damages 
from  the  indi\idual  or  corporation  responsible  for  the  injury,  it  at  once  becomes 


TRAUMATIC  NEUROSES  913 

evident  that  malingering  or  unintentional  and  sul)Consci()us  [jrodnction  ol'  s\  in[>toms 
may  be  commonly  met  witli. 

Etiology. — Tlie  most  common  cause  of  traumatic  neiu-oses  are  railroad  accidents, 
trolley-car  accidents,  falls,  and  injuries  received  from  falling  bodies.  As  a  result 
of  exposure  to  one  of  these  causes,  with  associated  mental  shock  due  to  terror  or 
horror,  the  nervous  system  develops  the  perversions  about  to  be  descriljed. 

Symptoms. — It  is  manifest  from  what  has  already  been  said  that  the  synii^toms 
may  be  most  varied  as  to  severity,  distribution,  and  duration.  Probably  the  most 
common  statement  of  the  patient  is  that  he  has  lost  power  in  one  or  more  i)arts  of 
his  body,  or  he  may  suffer  from  disturbances  of  sensation,  with  or  without  loss  of 
power.  In  males  it  is  not  infrequently  claimed  that  the  injury  has  resulted  in  a 
loss  of  sexual  power,  particularly  if  the  back  has  received  a  blow  or  strain,  even  if 
the  genital  apparatus  is  itself  entirely  unaffected.  In  women  the  most  common 
complaint  is  of  pain  or  weakness  in  the  back,  of  pelvic  pain  or  displacement  of  the 
pelvic  organs,  and  of  vesical  disorders.  In  other  cases  the  chief  claim  is  that  more 
or  less  violent  pain  or  tingling  in  the  limbs  is  suffered.  AYhen  loss  of  power  is 
suffered  from  it  appears  usually  as  a  hemiplegia  or  a  brachial  monoplegia,  but  if  it 
be  a  hemiplegia  the  face  nearly  always  escapes.  Paraplegia  is  very  rare  and  the 
sphincters  of  the  bladder  and  rectimi  always  escape. 

Those  paralyses  which  are  not  truly  organic  can  be  separated  from  those  that 
are  such  by  the  facts  that  the  reactions  of  degeneration  do  not  develop  in  the 
paralyzed  parts  and  the  deep  reflexes  are  usually  preserved.  Anesthesia  is  practic- 
ally always  present  if  the  paralysis  of  motion  is  complete,  and  it  is  of  the  type  of 
hysterical  paralysis  in  that  it  has  often  a  sharp  line  of  degeneration  which  is  not 
coincident  with  the  distribution  of  the  sensory  nerves  of  the  part.  Paraplegic 
cases  do  not  suffer  from  anesthesia  of  the  genital  organs.  Again,  it  sometimes 
occurs  that  the  symptoms  complained  of  are  not  constantly  in  the  same  part  or 
that  positive  suggestions  may  cause  their  development  elsewhere.  Not  rarely  an 
examination  of  the  color  fields  of  such  a  patient  will  reveal  the  reversals  commonly 
found  in  hysteria.  Disorders  of  all  the  special  senses  may  also  occur  and  total 
disappearance  of  these  functions  may  take  place — as  complete  deafness,  blindness, 
or  loss  of  taste  or  smell.  Occasionally  the  patient  may  develop  attacks  which 
resemble  to  some  degree  ordinary  epilepsy  or  catalepsy,  but  these  attacks  are 
separated  from  true  epilepsy  by  the  points  already  named  when  discussing  that 
disease. 

If  we  carefully  exclude  from  any  case  of  nervous  disorder  following  an  injury  the 
presence  of  an  actual  organic  lesion,  we  may  unhesitatingly  state  that  the  patient 
is  suffering  from  hysteria  or  neurasthenia  due  to  injury,  and  we  can  treat  him 
accordingly.  On  the  other  hand,  it  is  not  to  be  forgotten  that  the  patient  who 
suffers  from  the  symptoms  he  describes  is  often  a  most  miserable  and  unfortunate 
individual,  as  deserving  of  our  pity  as  if  we  found  him  the  victim  of  an  incurable 
malady  due  to  destruction  of  a  part  of  his  body.  His  functional  disorders  are  as 
real  to  him  and  cause  him  as  much  suffering  as  if  they  depended  upon  organic 
causes,  and  a  nervous  system  functionally  perverted  may  be  as  useless  as  one 
actually  grossly  diseased,  just  as  a  watch  which  needs  regulating  may  be  as  useless 
to  its  owner  as  one  in  which  a  spring  is  broken.  AVhile,  therefore,  it  is  our  duty 
to  relieve  such  patients  by  every  means  in  our  power,  and  to  bear  in  mind  that  their 
sufferings  are  often  very  real,  we  are  forced  to  recollect  that  the  condition  may  not 
be  permanent,  as  it  would  be  after  a  destructive  injurj',  and  so  when  the  case  has 
become  one  of  medicolegal  importance  it  may  not  be  possible  to  testify  that  the 
patient  is  incurable  and  permanently  disabled.  Not  only  is  this  true,  but  it  is  also 
a  fact  that  the  very  continuance  of  litigation,  and  the  frequent  appearance  of  the 
patient  before  attorneys  and  experts  for  both  sides  and  before  a  crowded  court-room, 
may  make  recovery  impossible  by  still  further  exciting  and  disturbing  nervous 
5S 


914  DISEASES  OF  THE  NERVOUS  SYSTEM 

balance,  for  aside  from  this  form  of  excitement  the  description  of  the  scene  of  the 
accident  impresses  its  terrors,  over  and  over  again,  upon  a  mind  already  horror- 
stricken  by  the  original  occurrence.  Perfectly  sincere  persons  often  sufl'er  all  the 
symptoms  they  describe  up  to  the  period  when  the  trail  of  the  case  is  finished  and 
then  speedily  improve. 

Treatment. — The  treatment  varies,  of  course,  with  the  character  of  the  symptoms, 
but  it  may  be  said  to  be  practically  identical  with  that  already  advised  in  cases  of 
hysteria  and  neurasthenia. 

OCCUPATION  NEUROSES. 

An  occupation  neurosis  is  a  state  in  which  the  innervation  of  a  part  becomes 
functionally  disturbed  by  the  exhaustion  of  the  nervous  centres  supplying  it,  and 
in  all  probability  by  exhaustion  of  the  nerve  endings  as  well.  The  causes  of  this 
exhaustion  are  exceedingly  numerous.  Almost  every  pursuit  in  life  which  involves 
the  continuous  use  of  muscles  of  the  hand  and  wrist  may  produce  an  occupation 
neurosis  of  these  parts.  As  a  result  we  find  spasm,  cramp,  or  palsy  developing  to 
such  a  degree  as  to  incapacitate  the  patient.  The  most  common  neurosis,  because 
the  pursuit  is  most  common,  and  because  small  and  accurate  movements  are 
required,  is  that  due  to  writing,  the  so-called  scriveners'  palsy  or  writers'  cramp. 
Another  form  is  telegraphers'  cramp,  and  a  third  is  hammerers'  palsy.  Less  com- 
mon forms  are  violinists'  cramp,  pianists'  cramp,  flute-players'  cramp,  and  "sewing 
spasm."  Milkers  and  cigarmakers  sometimes  suffer  from  neuroses  of  this  character. 
In  writers'  cramp  the  flexor  muscles  suffer  chiefly,  while  in  telegraphers'  cramp 
the  extensors  are  the  ones  most  involved.  Various  disorders  of  sensation  in  the 
hands  are  also  present  and  consist  in  sensations  of  tingling,  tension,  or  numbness. 
Localized  sweating  or  excessive  dryness  of  the  skin  may  be  present.  Occasionally 
the  condition  depends  upon,  or  is  associated  with,  a  true  neuritis,  which  may  involve 
the  entire  brachial  plexus  and  cause  pain  in  the  upper  arm  and  even  in  the  muscles 
of  the  neck  and  head  on  the  affected  side.  The  history  of  the  case  in  many  instances 
is  that  the  patient  first  experiences  for  some  days  a  feeling  of  stiffness  and  lack  of 
pliability  in  his  fingers,  which  is  generally  accompanied  by  a  certain  lack  of  co-ordi- 
nation in  the  movements  required.  This  inability  to  move  the  fingers  rapidly  and 
accurately  is  only  present  when  the  sufferer  attempts  to  perform  the  movements 
which  are  the  cause  of  the  trouble,  and  almost  all  other  motions  can  be  gone  through 
with  without  difficulty.  If  the  patient  now  insists  on  keeping  on  with  his  duties, 
the  stiffness  is  replaced  by  violent  cramps,  more  or  less  painful,  which  come  on 
suddenly  and  with  considerable  power.  Co-ordination  is  still  further  disordered 
and  all  attempts  at  a  repetition  of  the  offending  act  are  resented  by  the  affected 
centres  and  muscles  in  such  a  positive  manner  as  to  make  all  movements  irregular 
and  often  jerking  in  character.  Unless  absolute  rest  and  avoidance  of  former 
movements  is  permitted,  the  cramps,  etc.,  are  followed  by  loss  of  power,  deepening 
into  partial  paralysis.  Even  when  paralysis  exists,  however,  it  is  surprising  to 
see  how  many  unoffending  movements  can  be  performed  without  discomfort  and 
failure. 

Some  discussion  has  arisen  as  to  whether  the  several  symptoms  which  the  disease 
presents  are  each  in  their  turn  an  indication  of  a  more  advanced  stage  in  the  disorder 
or  are  merely  more  prominent  in  one  case  than  another  by  chance  or  tendency  on 
the  part  of  the  individual  to  any  one  of  them.  Thus,  some  observers  have  held 
that  the  first  sign  of  the  disorder  was  the  feeling  of  distress  or  fatigue  in  the  over- 
worked extremity,  and  that  the  tremors  followed  because  the  warning  given  by  the 
fatigue  was  not  heeded.  Finally,  the  disregard  of  this  second  sjTnptom  brought 
about  the  spasm  or  cramp,  or,  in  other  cases,  the  palsy.  Other  writers,  especially 
those  of  the  present  day,  have  attempted  to  prove  that  there  is  no  distinct  onward 


OCCUPATION  NEUROSES  -  915 

marcli  of  the  symptoms  from  fatigue  to  tremor  and  from  tremor  to  palsy  or  cramp, 
but  rather  than  the  disorder  is  to  be  divided  into  four  varieties,  each  one  of  whicii 
may  assert  itself  without  the  development  of  another. 

Thus,  Lewis  tells  us  that  in  some  cases  cramps  come  on,  in  others  palsy,  and  in 
others  tremors,  while  still  another  variety  is  separated  from  its  fellows  by  the 
predominance  of  certain  symptoms  associated  with  disturbances  of  sensation. 
He  states,  however,  that  the  disorder  of  sensation  is  always  present  in  all  forms  of 
the  trouble  in  some  degree,  and  that  it  is  only  in  cases  where'the  trouble  consists  in 
a  neuritis  that  the  symptom  rises  to  the  importance  of  marking  a  separate  variety. 

Many  very  prominent  writers  on  scriveners'  and  hammerers'  palsy  assert  that 
predisposition  is  one  of  the  prime  factors  in  the  causation  of  these  maladies.  While 
this  is  doubtless  true  to  a  certain  extent,  it  is  nevertheless  a  fact  that  all  persons, 
be  their  temperaments  nervous  or  otherwise,  are  affected,  and  in  view  of  this  fact 
the  writer  thinks  that  predisposition  should  not  be  accorded  the  leading  position 
in  the  causation  of  the  maladJ^  It  is,  of  course,  probable  that  persons  whose 
temperaments  are  nervous  and  excitable  are  naturally  susceptible  to  nervous  dis- 
orders, whereas  the  phlegmatic  temperament  is  rather  opposed  to  the  conditions 
which  are  necessary  for  the  presence  of  this  disease. 

Rosenthal  calls  attention  to  the  fact  that  the  loss  of  power  is  limited  entirely 
to  those  centres  which  are  the  directors  of  the  particular  muscles  involved,  and 
states  in  substantiation  of  this  assertion  that  the  surrounding  centres  for  other 
groups  of  muscles  always  escape,  as  is  proved  by  the  fact  already  mentioned,  that 
other  acts  can  be  performed  without  difficulty.  While  it  is  true  that  the  surroimd- 
ing  centres  are  not  affected,  it  is  also  true  that  the  centre  governing  like  movements 
in  the  opposite  hand  is,  by  sjTnpathy  or  other  cause,  affected  with  its  fellow  to  a 
certain  extent.  This  is  proved  by  the  fact  that  if  the  operator  learns  to  send 
messages  with  this  well  hand,  that  hand  very  soon  follows  the  fate  of  its  fellow. 

Experiments  performed  by  the  late  Dr.  N.  A.  Randolph  bear  so  strongly  on  this 
subject  that  they  may  be  quoted  at  this  point.  His  object  was  to  discover  if 
exhaustion  of  one  centre  in  the  brain  produced  anj^  effect  on  the  corresponding 
centre  on  the  opposite  side  of  the  brain;  and  to  this  end  he  proceeded  as  follows: 
He  attached  a  small  lever  to  a  meter,  and  resting  the  hand  of  the  subject  on  the 
table,  as  when  writing,  he  directed  him  to  place  the  tip  of  his  forefinger  on  the  end 
of  the  lever  and  to  depress  it  as  often  as  he  could.  Each  depression  was,  of  course, 
registered  in  this  way.  Dr.  Randolph  found  that,  normally,  the  right  forefinger 
possessed  power  for  100  movements,  the  left  forefinger  for  75  movements.  Having 
decided  this  primary  point  he  proceeded  to  search  after  the  main  object  of  his 
examination.  He  found  that  if  the  left  forefinger  was  set  to  work  after  the  right 
forefinger  had  performed  its  100  depressions,  it  became  exhausted  at  50  movements, 
and  that  if  the  right  hand  was  set  to  work  after  the  left  forefinger  had  moved  75 
times  it  could  only  move  75  times.  In  other  words,  exhaustion  of  one  centre 
produced  exhaustion  of  the  corresponding  centre  on  the  opposite  side  of  the  brain. 

Careful  tests  prove  that  in  most  instances  exaggerated  reflexes  are  present, 
denoting  a  hj-perexcitability  of  the  spinal  cord,  and  in  other  cases  evidences  of 
neuritis  of  the  nerve  trunks  have  undoubtedly  been  observed.  In  some  cases  of 
the  disease  a  species  of  pseudomuscular  hypertrophy  comes  on,  due,  probably,  to 
some  centric  nervous  lesion,  and,  perhaps,  in  part  to  the  congested  condition  which 
is  nearly  always  present  in  the  affected  muscles.  Thus  we  find  the  bellies  of  the 
muscles  hard,  firm,  and  projecting,  yet  devoid  of  power. 

Treatment. — In  the  way  of  treatment  rest  is  the  best  measiu-e  that  we  possess 
for  the  cure  of  the  affection;  but  although  absolute  rest  from  the  exciting  cause  is 
one  of  the  essential  factors  for  a  complete  recovery,  the  afi'ected  arm  should  be 
used  in  every  other  motion  which  is  natural  and  easy,  so  that  it  may  not  become 
useless  from  disuse.    Next  to  rest  we  have  as  a  therapeutic  agent  electricity, 


91(3  Disi'JASKs  OF  Till':  XKinnrs  systhm 

wliich  is,  liowevcr,  inrlicated  only  in  tliosc  cases  where  very  slifjlit  or  no  inflaniniiitory 
conditions  are  jjrcscnt,  cither  in  the  muscle,  nerve,  or  nerve  centre;  and  it  should 
he  the  invarialile  rule  to  use  that  current  which  causes  the  most  contraction  with 
the  least  pain.  Galvanization  of  the  att'ccted  muscles  should  be  performed  in  such 
a  way  that  the  disordered  nerve  centres  are  not  disturbed,  anrl  care  should  be  taken 
to  gradually  increase  the  exercise,  so  as  not  to  exhaust  or  overfatigue  the  muscles 
which  are  out  of  order.  Movements  which  are  slowly  j)erformcd  with  the  affected 
parts  are  also  useful,  following  the  method  of  muscle  training  proposed  by  Fraenkel 
in  the  treatment  of  locomotor  ataxia. 

Finally,  tlie  administration  of  tonics,  such  as  arsenic,  iron,  and  strychnine,  is 
to  be  resorted  to,  and  these  measures  combined  with  massage  are  the  best  methods 
we  ha\'e  for  effecting  a  cure. 

RAYNAUD'S  DISEASE. 

Definition. — Raynaud's  disease  is  a  condition  in  which  one  or  more  of  the  fingers 
or  toes,  and  rarely  the  nose  and  ears,  suffer  from  a  disorder  of  the  local  bloodvessels, 
witli  tile  result  that  these  parts  become  bloodless  and  pallid  or  slate  colored  and 
mottled  in  ai)])earance.  The  afl'ected  parts  are  cold  and  sometimes  painful.  The 
malady  usually  affects  persons  under  thirty  years  of  age,  and  females  more  com- 
monly than  males.  The  cause  is  unknown  save  that  it  seems  to  be  of  the  nature 
of  a  paroxysmal  neurosis  involving  the  bloodvessels  of  the  parts  affected.  Various 
conditions,  all  of  them  capable  of  causing  a  loss  of  normal  nerve  tone,  have  been 
considered  as  etiological  factors,  varying  from  diabetes  and  neurasthenia  to  fright 
and  exposure  to  cold  air  or  cold  water. 

Etiology. — The  onset  begins  with  a  sense  of  tingling,  or  of  heat  or  cold,  in  the 
parts  which  are  to  suffer  from  the  well-developed  state.  The  skin  looks  siirunken 
and  ashen  in  hue  and  numbness  is  present  to  a  more  or  less  well-de\-eloped  <legree, 
but  complete  anesthesia  does  not  occur.  The  condition  may  last  for  a  few  hours 
or  for  weeks.     When  it  disappears  it  nearly  always  returns  in  a  short  time. 

When  the  disease  occurs  in  its  severe  form  local  gangrene  may  ensue.  The 
part  becomes  livid  and  dusky  and  small  blebs  develo]!  on  tiic  fingers.  These  may 
dry  up  and  recov'cry  take  place,  only  the  skin  being  destroyerl,  or  the  process  may 
become  so  deep  that  the  entire  part  may  be  lost. 

This  condition  is  to  be  separated  from  senile  gangrene  liy  tiie  youth  of  tlic  j)aticnt, 
from  frost-bite  by  the  absence  of  a  history  of  exposure  to  cold,  and  from  chronic 
ergotism  by  the  absence  of  any  history  of  eating  rye  bread  contaminated  by  ergot. 

Treatment. — The  treatment  consists  in  the  use  of  tonics  and  every  possible 
measure  designed  to  re-establish  good  general  health.  Hydrotherapy  is  often  of 
value.  Locally  the  nutrition  of  the  affected  part  may  be  maintained  to  some 
extent  by  the  use  of  dry  or  moist  heat.  Great  care  should  be  taken  to  protect 
those  ]iarts  which  are  usually  affected,  from  extremes  of  heat  and  cold. 

ANGIONEUROTIC  EDEMA. 

Definition  and  Symptoms. — Angioneurotic  edema  is  a  condition  characterized 
by  the  sudden  aiiiiearaiuc,  in  a  limited  area  in  one  or  more  parts  of  the  body,  of 
well-dehned  swelling  due  to  some  j)er\ersion  of  the  normal  functional  acti\ity  of 
the  vasomotor  ner\'e  suj^ply,  so  that  the  bloodvessels  of  the  j)art  become  dilated, 
and,  in  all  probaiiility,  an  extravasation  of  fluid  takes  place.  The  condition  is  to 
be  clearly  separated  from  that  characteristic  of  inflammation.  The  temperature 
of  the  part  is  often  lower,  but  sometimes  it  is  higher  than  normal.  The  dimensions 
of  the  affected  part  vary  greatly,  but  it  is  rarely  more  than  a  few  inches  in  circum- 
ference.    The  hue  of  the  area  aif ected  may  be  a  deep  red,  as  if  suffering  from  intense 


ERYrilROMELALGIA  917 

congestion,  or  so  pallid  as  to  be  cadaveric.  It  may  be  the  seat  of  a  sense  of  tingling, 
or  heat,  or  itching,  but  actual  pain  does  not  occur,  and  pitting  on  pressure,  to  the 
extent  that  it  appears  in  ordinary  edema,  is  absent. 

Angioneurotic  edema  occurs  most  commonly  on  the  face  or  hands.  It  may 
afTect  the  body  and  quite  rarely  the  larynx  and  pharynx,  when  it  may  produce 
alarming  symptoms  by  interfering  with  respiration.  Instances  of  death  due  to  this 
cause  have  been  reported.  The  attacks  last  a  few  hours  to  several  days,  and  are 
prone  to  occur  at  irregular  intervals. 

Angioneurotic  edema  occurs  more  frequently  during  the  third  decade  of  life 
than  at  any  other  period,  and  in  the  United  States  affects  females  more  frequently 
than  males,  although  the  reverse  of  this  holds  true  in  Europe.  We  do  not  know 
what  the  causative  factor  is,  but  it  is  known  that  exposure  to  cold  and  caases 
which  diminish  nervous  tone  bring  on  an  attack  in  those  who  are  susceptible. 

In  some  cases  the  condition  is  induced  by  digestive  disorders,  or  by  the  ingestion 
of  some  food  which  is  toxic,  as  lobster,  fish,  or  other  animal  food  that  is  not  fresh. 
In  nearly  all  cases  the  patient  is  neurotic,  and  not  rarely  has  a  neurotic  family 
history,  or  even  a  direct  inheritance  of  the  disorder  from  the  parents.- 

Diagnosis. — Angioneurotic  edema  must  be  separated  from  the  local  \'asomotor 
disturbances  of  hysteria.  This  is  done  by  the  fact  that  in  hysteria  there  are  asso- 
ciated paralysis  of  motion  or  anesthesia  and,  it  may  be,  hysterical  contractures. 
Again,  the  edema  of  hysteria  is  often  persistent,  whereas  this  is  temporary.  From 
severe  attacks  of  urticaria  it  is  differentiated  by  the  fact  that  "hives"  are  usually 
scattered  widely  over  the  body,  and  if  they  appear  on  the  hands  are  characterized 
by  multiple  lesions.  In  most  cases  of  hives,  or  urticaria,  additional  lesions  can  be 
produced  by  rubbing  a  part.  Some  of  these  suffer  from  severe  attacks  of  abdomi- 
nal pain  resembling  appendicitis. 

Prognosis. — The  prospect  of  complete  ciu-e  in  the  sense  of  an  escape  from  all 
future  attacks  is  not  encouraging.  The  general  health  is  usually  good  between  the 
attacks,  and  unless  the  part  affected  be  the  larynx  the  prospect  of  any  serious  result 
is  unlikely. 

Treatment. — The  treatment  can  be  directed  only  along  those  lines  which  will 
tend  to  improve  the  general  health,  of  which  the  most  useful  are  an  out-door  life, 
hydrotherapeutics,  and  the  internal  use  of  tonics,  such  as  iron  and  arsenic  if  there 
is  anemia,  and  nux  vomica  and  quinine  if  the  nervous  system  is  atonic.  Phosphorus 
may  also  be  useful.  When  lithemic  or  gouty  conditions  are  present,  the  iodides, 
salicjdates,  and  colchicum  may  be  of  great  value.  It  is  needless  to  add  that  all 
causes  known  by  the  experience  of  the  patient  to  be  provocative  of  an  attack  should 
be  sedulously  avoided,  for  there  can  be  little  doubt  that  the  occurrence  of  one  attack 
predisposes  to  another. 

ERYTHROMELALGIA. 

Definition. — This  condition  was  first  described  by  Weir  Mitchell  in  1872.  It 
consists  of  a  hyperemia  of  the  foot  and  leg,  rarely  the  hand,  associated  with  pain 
which  maj'  vary  in  degree  from  a  sense  of  weight  and  heaviness  to  exceedingly 
severe  suffering.  The  malady  first  affects  the  neighborhood  of  the  ball  of  the  foot, 
and  thence  it  spreads  to  the  entire  plantar  surface.  In  other  cases  the  heel  is  first 
affected.  Although  exercise  greatly  increases  the  suffering,  it  is,  as  a  rule,  worse 
at  night.  The  pain  may  be  intermittent  or  continuous.  The  skin  is  often  not 
only  hyperemic,  but  is  often  marbled  or  mottled  in  appearance.  Elevation  of  the 
part,  by  decreasing  the  congestion,  diminishes  the  pain. 

Etiology. — The  causes  of  the  malady  are  several.  In  rare  instances  it  seems 
to  depend  upon  lesions  in  the  spinal  cord,  in  others  it  apparently  depends  upon 
diabetes  mellitus,  and  in  still  others  arteriocapillary  fibrosis  seems  to  be  the  under- 
lying factor. 


918  DISEASES  OF  THE  NERVOUS  SYSTEM 

Diagnosis. — Before  determining  the  diagnosis  of  erythromclalgia  it  is  essential 
that  gout  and  diseases  of  the  soft  and  hard  tissues  of  the  foot  l)e  excluded.  In 
the  vast  majority  of  cases  the  symptoms  will  jjrobably  Ijq  due  to  such  causes,  for 
true  erythromclalgia  is  a  very  rare  malady  indeed,  and  but  few  cases  have  been 
recorded. 

Treatment. — Treatment  often  fails  to  give  iiuich  relief.  The  jiart  siiould  be  kept 
in  an  elevated  posture  as  much  as  possible,  cool  lotions  may  be  applied  to  it,  and 
if  the  patient  be  lithemic  the  alkalies  and  salicylates  should  be  given. 

MIGRAINE. 

Definition. — ]Much  confusion  exists  as  to  the  exact  nature  of  the  condition  which 
is  called  migraine.  By  all  authors  it  is  used  to  describe  a  condition  of  severe  pain, 
more  or  less  limited  to  one  side  of  the  head,  often  accompanied  by  some  disturbance 
of  vision  in  one  or  both  eyes,  and  by  nausea  and  vomiting,  which  often  do  not 
develop  until  toward  the  end  of  the  attack.  Certain  clinicians  have  expressed  the 
belief  that  migraine  is  an  hereditary  affection,  and  even  go  so  far  as  to  regard  it  as 
a  manifestation  of  nervous  instability  not  far  removed  from  epilepsy.  This,  how- 
ever, is  certainly  incorrect  in  the  vast  majority  of  cases.  It  may  be  true  that  certain 
neurotic  individuals  who  are  subject  to  hysterical  or  epileptic  manifestations  often 
sufl'er  from  migraine.  But,  on  the  other  hand,  it  cannot  be  denied  that  in  the 
majority  of  instances  the  condition  is  a  toxic  neurosis  due  to  the  production  and 
retention  in  the  body  of  abnormal  jjroducts  of  metabolism.  These  products  are 
chiefly  the  result  of  a  disturbed  action  of  the  liver,  either  in  the  sense  that  the 
liver  fails  to  destroy  poisons  which  are  absorbed  from  the  intestines,  or  in  the  sense 
that  it  develops  substances  which  it  does  not  produce  when  in  health.  As  a  matter 
of  fact  migraine,  as  a  toxic  condition,  is  rarely  the  result  of  any  disorder  of  function 
in  a  single  organ,  but  is  produced  by  several  causes,  an  undue  development  of 
poison,  a  deficient  action  of  the  liver  in  destroying  these  poisons,  and  a  torpid 
condition  of  the  kidneys,  whereby  toxins  are  not  speedily  eliminated.  It  naturally 
follows  that  in  highstnmg,  nervous  individuals,  and  in  those  who  have  neurotic, 
tendencies,  these  toxic  products  can  readily  disturb  the  functions  of  the  sensory 
nerves  of  the  head  and  so  produce  a  seizure. 

Among  the  active  causes  in  provoking  an  attack  of  migraine,  aside  from  the 
effects  of  autointoxication,  there  can  be  no  doubt  that  nervous  tire,  or  exhaustion, 
aids  materially  in  causing  an  attack,  particularly  if  in  addition  to  such  stress  there 
is  added  undue  sexual  activity,  or  other  forms  of  abuse.  All  these  factors  diminish 
the  nervous  energy  which  supports  vital  processes  and  so  tend  to  cause  perversions 
of  metabolism,  and  at  the  same  time  they  diminish  the  resistance  of  the  nervous 
and  vascular  system  to  the  action  of  such  poisons. 

The  disease  occurs  most  frequently  in  women  and  rarely  develops  before  the  age 
of  puberty.  It  is  particularly  prone  to  attack  those  who  have  a  gouty  ancestry. 
Certain  schools  of  ophthalmologists  have  strongly  urged  the  view  that  all  cases 
of  migraine  are  due  to  errors  of  refraction.  There  can  be  no  doubt  that  in  many 
instances  this  cause  of  nervous  exhaustion  is  a  potent  factor.  The  important  point 
for  the  physician  to  remember  in  studying  this  malady  is  that  various  causes  may 
be  responsible  for  it;  and  if  the  jiatient  is  to  be  permanently  relieved,  one  or  more 
of  these  causes  must  be  discovered  and  removed. 

Symptoms. — The  mode  of  onset  of  an  attack  varies  greatly.  Some  patients 
state  that  for  several  days  prior  to  a  paroxysm  they  feel  generally  out-of-sorts  and 
anything  but  well.  Often  the  chief  sjTnptom  is  mental  clepressio7i.  Other  patients 
have  no  premonitory  symptoms  whatever.  Arising  in  the  morning  in  perfect 
health,  they  are  .seized  at  some  time  during  the  day  with  blurring  of  the  virion  in 
one  or  both  eyes,  soon  followed  by  a  sharp  attack  of  pain,  or  pain  may  be  the  first 


MlGttAINlE  919 

and  only  symptom,  and  its  onset  may  be  so  sudden  and  severe  as  to  eompletely 
incapacitate  the  patient.  To  this  form  of  migraine  the  terms  "fulgurating"  or 
"fulminant"  have  been  applied.  In  most  cases  the  pain  exists  chiefly  in  one  side 
of  the  head,  and  involves  the  supraorbital  region  and  the  eyeball.  When  it  is  fully 
developed  the  entire  head  may  suft'er.  The  character  of  the  ixiiti  in  ihwhhhuj  and 
the  sensation  in  the  head  is  tense.  Not  rarely  phutuphohia  is  present,  and  in  some 
cases  vision  may  be  so  much  interfered  icitli  that  actual  hemianopsia  is  described  by 
the  patient.  In  addition  to  the  pain  the  patient  not  infrequently  has  some  vertigo, 
is  mentally  heavy  and  dull,  and  not  rarely  slightly  aphasic. 

After  the  attack  has  lasted  from  one  to  several  hours  the  patient  quite  frequently 
becomes  nauseated  and  then  vomits.  As  a  rule,  the  stomach  does  not  contain 
undigested  food;  on  the  contrary,  digestion  seems  to  have  gone  on  with  undue 
rapidity.  The  material  vomited  is  usually  small  in  amount  and  excessively  acrid 
and  acid.  I  am  firmly  convinced  that  this  fluid  is  the  result  of  an  attempt  on  the 
part  of  the  stomach  to  eliminate  poisonous  materials,  just  as  this  organ  eliminates 
oxydimorphine  in  morphine  poisoning.  If  the  vomiting  persists  for  any  length 
of  time  bilious  materials  may  be  brought  up  by  reason  of  the  drawing  of  bile  through 
the  pylorus  in  the  act  of  retching.  It  is  a  question  whether  this  vomiting  is  the 
result  of  the  action  of  the  poison  which  produces  the  symptoms,  or  whether  it  is  in 
large  part  due  to  the  severity  of  the  pain  which,  when  it  affects  the  eyeball,  closely 
resembles  the  sickening  pain  produced  by  an  injury  to  the  testicle.  During  an 
attack  the  patient's  face  is  usually  pallid  and  betokens  severe  pain,  having  an 
anxious  and  hunted  expression  or  one  of  profound  depression.  Sometimes  the 
radial  indse  is  small  and  hard,  and  not  rarely  the  temporal  artery  on  the  affected 
side  stands  out  like  a  whipcord.  The  attacks  rarely  come  oftener  than  once  a  week, 
and  sometimes  much  more  rarely  than  this,  unless  the  patient  by  errors  in  diet 
and  by  various  excesses  produces  the  provoking  condition  frequently.  Sometimes 
patients  state  that  the  attack  comes  on  in  the  midst  of  perfect  health.  Thus,  I 
have  heard  a  patient  remark  that  she  felt  so  well  that  she  was  sure  she  was  going 
to  be  sick  the  next  day,  as  it  had  been  her  experience  that  a  sensation  of  well-being 
was  not  rarely  followed  by  a  nervous  explosion.  In  rare  cases  a  certain  degree 
of  paralysis  of  the  extraocular  muscles  may  be  present  during  the  attack.  In  still 
more  rare  instances  the  face  is  flushed  instead  of  being  pallid.  Not  rarely  during 
the  attack  the  urine  is  scanty  and  high  colored,  but  as  the  attack  subsides  the  urine 
is  frequently  passed  in  large  quantities  and  is  exceedingly  limpid.  Speedy  recovery 
usually  follows  the  vomiting  of  the  acrid  fluid  already  named. 

Treatment. — The  treatment  depends  upon  the  underlying  cause  of  the  malady. 
All  excesses  as  to  eating  and  sexual  activity  must  be  prevented.  If  the  patient 
is  run  down  and  neurasthenic,  a  vacation  or  a  rest  cure  is  essential.  If  the  kidneys 
fail  to  excrete  a  sufficient  quantity  of  urinary  solids  per  day,  the  various  potassium 
salts,  such  as  the  acetate,  citrate,  or  bitartrate  of  potassium,  must  be  given  in  5  or 
10  grain  doses  three  or  four  times  a  day,  in  copious  draughts  of  water  to  increase 
urinary  elimination.  If  there  are  any  evidences  that  the  liver  is  persistently  or 
occasionally  inactive,  its  function  should  be  stimulated  by  the  use  of  calomel,  blue 
mass,  or  podophyllin.  Many  of  these  cases  do  very  well  if  5  to  10  grains  of  blue, 
mass  are  taken  every  week  or  ten  days,  and  then  followed  by  a  saline  purge.  In 
those  instances  in  which  the  patient  leads  a  sedentary  life,  active  out-door  exercise 
to  ensure  perfect  oxidation  processes  in  the  body  are  essential.  In  those  patients 
who  suffer  from  gastrointestinal  catarrh,  a  dose  of  Hunyadi  or  Apenta  water,  taken 
hot  and  in  sips,  before  breakfast,  will  often  be  efficient  not  only  in  moving  the  bowels, 
but  preventing  the  attacks.  Often  diluting  one  of  these  waters  one-half  with  hot 
water  makes  it  an  efficient  purgative.  The  use  of  salol  in  the  dose  of  5  to  10  grains 
a  day  as  an  intestinal  antiseptic  is  often  advantageous. 

Of  all  forms  of  preventive  treatment,  that  which  is  devoted  to  the  increased 


920  DISEASES  OF  THE  XERVOVS  SYSTEM 

activity  of  the  intestines,  the  ii\er,  iuu!  the  kidneys  is  df  most  importance.  If 
the  patient  is  gouty,  or  suffers  from  that  coiKJition  cominonlx-  hut  erroneously  called 
"uricaciflemia,"  not  only  should  the  treatment  just  recommended  be  employed, 
but  the  use  of  other  more  active  salicylates,  such  as  the  salicylate  of  strontium 
in  5  or  10  grain  doses  three  times  a  day,  is  advisable.  If  errors  in  refraction  exist, 
carefully  fitted  glasses  should  be  provided,  and  if  the  nasal  mucous  membrane  is 
hy]«'rtroi)hied  or  other  abnormalities  e.xist  in  this  region,  they  should  be  treated. 
For  the  relief  of  the  attack  many  measures  have  been  suggested.  In  those  instances 
where  the  patient  has  prodromal  symptoms,  a  brisk  saline  cathartic,  such  as  Seidlitz 
powder,  citrate  of  magnesia,  or  Kochelle  salt,  should  be  given,  with  the  idea  of 
sweeping  out  from  the  bowels  poisonous  material.  This  may  be  followed  in  half 
an  hour  to  an  hour  by  2  grains  of  caffeine  with  10  grains  of  bromide  of  sodium. 
The  best  way  to  give  this  is  in  granular  effervescent  salts.  In  some  instances  a 
small  dose  of  phenacetin  or  acetanilid  should  be  added.  If  high  arterial  tension 
is  present,  nitroglycerin  is  valuable.  For  the  relief  of  the  pain  wlien  it  is  very 
severe  phenacetin,  antipyrin,  and  acetanilid  are  useful,  })ut  it  must  always  be  remem- 
})ered  that  the  stomach  is,  as  a  rule,  excreting  rather  than  absorbing,  and  that  the 
mere  administration  of  a  palliative  at  this  time  may  be  fruitless  for  this  reason. 
I'nder  these  circumstances  it  may  be  necessary  to  give  these  drugs  by  the  rectum, 
or  to  empty  the  stomach  by  vomiting  or  by  the  use  of  the  stomach  tube  before 
they  are  administered.  Sometimes  the  stomach  can  be  .stimulated  to  ab.sorption 
by  jV  grain  of  strychnine.  In  certain  cases  the  use  of  a  full  dose,  10,  15,  or  20  drops, 
of  the  tincture  of  gelsemium  with  a  grain  of  an  active  extract  of  cannabis  indica 
gives  the  greatest  relief.  The  use  of  cologne-water  containing  5  to  10  grains  of 
menthol  to  the  ounce  applied  over  the  course  of  the  painful  nerve  may  give  some 
relief.  In  many  instances  it  is  impossible  for  any  of  these  remedies  to  do  good 
unless  the  patient  will  rest  in  a  cjuiet  and  dark  room  for  several  hours. 


SUNSTROKE. 

Definition. — Sunstroke,  more  accurately  called  lieatstroke,  insolation,  or  thermic 
fever,  and  by  the  French  coup  de  soleil,  is  a  condition  of  the  body  produced  by 
exposure  to  great  heat.  In  rare  instances  the  temperature  of  the  patient  does 
not  rise,  l)ut  falls,  and  to  this  condition  is  given  the  name  heat  exhaustion. 

Etiology. — The  chief  factor  in  producing  heatstroke  is  the  presence  of  great 
heat  associated,  as  a  rule,  with  marked  humidity  of  the  atmosphere.  It  is  important 
to  bear  in  mind  the  fact  that  exposure  to  the  rays  of  the  sun  is  not  necessary  for  the 
development  of  heatstroke.  Cases  are  constantly  met  with  in  which  the  illness 
of  the  ])atient  is  due  to  artificial  heat,  and  heatstroke  may  occur  in  the  night  as 
well  as  in  the  day  if  the  atmosphere  is  hot  and  moist.  Dry  heat  is  better  borne 
by  all  persons  than  is  moist  heat,  probalily  because  evaporation  on  the  skin  proceeds 
ra])idly  in  dry  air,  and  so  the  body  is  cooled  by  the  function  of  perspiration,  whereas 
in  a  moist  atmosphere  the  imperfect  evaporation  results  in  an  accumulation  of 
heat  in  the  body.  For  this  rea.son  heatstroke  is  very  rare  on  the  western  ])lains 
of  the  United  States,  where  the  temperature  in  simimer  often  reaches  10.5°  in  the 
shade,  whereas  in  Philadelphia,  where  the  air  is  humid,  heatstroke  is  exceedingly 
common  when  the  thermometer  registers  a  temperature  of  90°.  In  the  one  case 
evaporation  is  so  rapid  th;it  the  heat  of  the  body  is  kept  at  a  normal  level,  whereas 
in  the  latter  case  the  jiersiiiration  lies  on  the  skin  in  great  beads.  A  second  factor 
in  producing  heatstroke  is  the  use  of  alcoholic  drinks  in  any  form.  There  can 
be  no  doubt  that  all  such  be\-erages  greatly  predispose  to  the  development  of  this 
state.  So,  too,  renal  disease  and  a  feeble  heart  may  act  as  predisposing  factors. 
I.oss  of  sleep  i\\M\  torpidit\-  of  the  bowels  are  also  possessed  of  an  evil  influence. 


SUNSTROKE  921 

Certain  French  clinicians  have  asserted,  with  notable  facts  in  support  of  their 
views,  that  sunstroke  is  really  a  form  of  infection  which  develops  under  the  atmo- 
spheric states  alreafiy  named. 

Pathology  and  Morbid  Anatomy. — While  a  very  considerable  number  of  clinicians 
in  America  and  in  the  East  Indies  described  sun.stroke  symptomatically  in  the  early 
part  of  the  last  century,  it  was  not  till  H.  C.  Wood  collated  our  knowledge  and 
enriched  it  by  further  experimentation  that  the  profession  began  to  fully  grasp  the 
facts  concerning  its  production  and  tlie  lesions  which  ensued. 

The  pathology  of  the  disorder  resides  in  the  inability  of  the  heat-regulating 
mechanism  of  the  body  to  maintain  a  normal  body  temperature.  The  primary 
difficulty  lies  in  a  decreased  power  of  the  body  to  carry  out  an  efficient  heat  dissipa- 
tion, and  this  is  followed  by  an  unrestrained  heat  production,  due,  in  ^^ood's 
opinion,  to  failure  of  the  inhibitory  heat  centres,  in  the  pons,  to  check  oxidation 
processes.  With  diminished  heat  dissipation  and  increased  heat  production  it  is 
not  difficult  to  perceive  why  the  temperature  of  the  body  rises  until  a  state  of 
hyperpyrexia  is  reached. 

The  morbid  anatomy  consists  in  changes  in  the  tissues  which  in  turn  permit 
decomposition  to  set  in  very  rapidly,  being  preceded  by  well-marked  rigor  mortis. 
The  veins  of  the  brain  and  lungs  are  found  distended  with  fluid  blood,  and  every- 
where the  blood  fails  to  clot  as  it  does  in  the  vessels  of  the  ordinary  cadaver.  If 
an  autopsy  is  made  very  soon  after  death,  the  left  ventricle  is  found  in  firm  systole, 
but  the  right  ventricle  is  distended  with  blood.  The  liver  and  kidneys  are  also 
found  to  be  intensely  engorged. 

Symptoms. — The  symptoms  of  sunstroke  consist,  in  the  preliminary  stage,  in 
oppression  and  dizziness.  If  these  evidences  of  heat  are  ignored,  the  stage  of  sudden 
unconsciousness  develops,  and  is  often  ushered  in  by  a  conndsion  which  may  be 
exceedingly  violent.  In  other  cases  no  convulsion  develops,  but  deep  stupor  with 
stertorous  breathing  comes  on.  The  face  is  at  first  litid  and  later  deeply  cyaiwtic, 
the  great  vessels  of  tlie  neck  and  upper  extremities  being  distended.  The  tempera- 
ture of  the  patient  speedily  rises  to  a  height  never  seen  in  any  other  disease,  some- 
times reaching  112°  or  more,  the  average  being  from  105°  to  110°.  The  pupils 
may  be  contracted  or  widely  dilated.  If  the  fever  cannot  be  reduced  and  the  cardiac 
and  pidmonary  congestion  are  not  relieved,  death  ensues  within  twelve  to  thirty- 
six  hours.  When  improvement  takes  place,  a  relapse  some  hours  later  often  ensues. 
A  patient  who  has  sunstroke  may  subsequently  become  very  ill  and  die  from  a 
secondary  meningitis.  Persons  who  have  had  sunstroke  are  very  susceptible  to 
high  temperatiu-es,  and  when  exposed  in  after  years  may  be  greatly  distressed  by 
an  atmospheric  temperature  as  low  as  80°,  if  the  air  is  moist. 

Diagnosis. — There  are  only  two  other  states  that  resemble  heatstroke,  namely, 
uremia  and  apoplexy.  The  first  can  be  excluded  by  the  absence  of  h^'pe^p^Texia 
and  albumin  and  casts  in  the  urine.  The  second  is  excluded  by  the  same  lack  of 
temperature,  except  in  those  cases  in  which  the  pons  is  involved,  when  the  fever 
may  be  high,  but  pontile  hemorrhage  is  usually  speedily  fatal  and  the  paralysis 
severe.  Sunstroke  and  uremia  may,  however,  exist  simultaneously.  The  history 
of  the  patient  will  exclude  epilepsy  which  is  also  excluded  by  the  high  fever. 

Prognosis. — The  prognosis  depends  on  the  height  of  the  fever  and  the  resistance 
which  it  offers  to  treatment.     Do  what  we  will  a  large  number  of  these  cases  die. 

Treatment. — The  treatment  of  sunstroke,  if  it  is  to  be  followed  by  satisfactory 
results,  must  be  bold  and  vigorous.  In  most  cases  three  things  are  essential :  First, 
that  the  temperature  must  be  reduced  until  it  is  at  a  safe  level,  by  the  application 
of  cold  water  or  ice.  This  is  best  carried  out  by  stripping  the  patient,  laying 
him  upon  a  canvas  cot,  and  then  directing  a  stream  of  cold  water  upon  his  body 
from  a  hose,  the  patient  being  actively  and  vigorously  rubbed  at  the  same  time 
by  one  or  more  attendants,  with  the  object  of  producing  reaction,  of  overcoming 


922  DISEASES  OF  THE  NERVOUS  SYSTEM 

internal  congestion,  of  bringing  the  blood  to  the  surface,  whereby  it  may  be  cooled, 
and  of  increasing  the  dissipation  of  lieat,  for  frictions  increase  the  dissipation  of  heat 
during  the  application  of  cold  nearly  fifty  per  cent.  During  this  procedure  ice 
should  be  applied  to  the  head  constantly.  In  other  instances,  the  patient  may  be 
immersed  in  a  tub  of  cold  water,  and  if  necessary  pieces  of  ice  may  be  placed  in 
this  water.  If  the  tub  is  used,  active  frictions  are  as  essential  as  in  the  case  just 
stated.  .  Care  should  be  taken  that  the  temperature,  when  it  once  begins  to  fall 
d(jes  not  drop  too  rapidly,  so  that  the  patient  passes  into  hypothermia  and  collapse. 
If  the  patient  is  robust  and  there  is  evidence  of  venous  engorgement,  free  venesection 
should  be  practised.  Many  physicians  of  large  experience  believe  that  venesection 
is  of  almost  equal  importance  with  the  use  of  cold.  Venesection  may  be  followed 
by  hypodermoclysis  or  by  the  intravenous  injection  of  normal  salt  solution.  By 
these  two  measures  engorgement  of  the  right  side  of  the  heart  is  diminished  and 
toxemia  combated.  If  the  circulation  on  the  left  side  of  the  heart  seems  failing, 
hypodermic  injections  of  Hoffmann's  anodyne  and  strychnine  may  be  administered. 
The  use  of  alcohol  should  be  avoided.  If  the  bowels  are  confined,  citrate  of  mag- 
nesia should  be  given  in  full  purgative  dose  to  relieve  them,  and  where  the  patient  is 
unconscious  and  unable  to  swallow  so  large  a  dose,  j  of  a  grain  of  elaterium  may  be 
used  not  only  to  move  the  bowels,  but  diminish  cerebral  congestion.  The  violent 
headache  which  often  follows  sunstroke  may,  in  some  instances,  yield  to  the  ordinary 
coal-tar  products  combined  with  the  use  of  bromide  of  sodium  and  caffeine.  Where 
it  does  not  do  so,  and  there  are  any  evidences  of  meningeal  or  cerebral  congestion, 
free  venesection  should  be  practised,  not  only  for  the  relief  of  pain,  but  in  order  to 
prevent  the  development  of  secondary  meningitis.  This  is  a  matter  of  very  great 
importance,  but  is  often  treated  as  of  little  moment. 

In  the  after-treatment  of  the  patient  it  is  essential  that  the  temperature  should 
be  carefully  watched,  as  it  nearly  always  has  a  tendency  to  rise  a  second  time. 
Such  a  tendency  should  be  combated  by  the  application  of  cold  to  the  head,  ami  by 
cold  bathing  if  actual  hyperpyrexia  develops.  Perfect  rest  in  bed  for  a  nimiber  of 
days  after  the  sunstroke  should  be  insisted  upon,  and  the  patient  should  be  warned 
that  any  exposure  to  heat  for  several  days  will  be  liable  to  produce  another  attack. 


HEAT  EXHAUSTION. 

•Heat  exhaustion  is  a  condition  produced  by  the  same  causes  as  heatstroke,  but 
instead  of  hyperpyrexia  developing  the  temperature  becomes  subnormal,  the 
patient's  skin  may  be  bedewed  with  a  cold  sweat,  and  all  the  evidences  of  severe 
collapse  may  be  present.  This  condition  is  to  be  treated  by  immersing  the  patient 
in  hot  water  and  by  the  application  about  his  body,  after  the  removal  from  the  bath, 
of  hot  bottles  or  hot  bricks  to  maintain  body  temperature.  A  failing  circulation 
should  be  supported  by  hypodermic  injections  of  Hoffmann's  anodyne  and  atropine. 
Care  should  be  taken  that  coldness  of  the  extremities  is  not  mistaken  for  true  heat 
exhaustion,  for  it  sometimes  happens  that  the  extremities  are  cold  in  thermic  fever, 
although  the  temperature  of  the  body  may  be  far  above  normal.  This  point 
must  be  determined  by  taking  the  rectal  temperature.  If  the  rectal  temperature  is 
found  to  be  very  high,  the  treatment  for  heatstroke  should  be  instituted  and  the 
circulation  equalized  by  active  rubbing.  A  hot  bath  in  such  a  case  is  not  advisable 
except  for  a  few  moments  to  warm  the  extremities. 


FACIAL  HEMIATROPHY. 

This  is  a  condition  in  which  one  side  of  the  face  undergoes  a  slowly  progressive 
wasting.     As  a  rule  it  begins  between  the  ages  of  ten  and  twenty  years.     The  cause 


PERIODICAL  PARALYSIS  923 

is  unknown,  although  it  is  without  doubt  due  to  some  localized  degenerative  change 
in  the  nervous  system.  In  an  autopsy  upon  a  case  of  this  character  Mindel  found 
degeneration  of  the  trifacial  nerve  in  its  efferent  fibres  and  atrophy  of  the  substantia 
nigra. 

When  the  malady  first  develops,  the  skin  of  the  affected  part  begins  to  be  thin 
and  glossy  and  seems  to  be  stretched.  The  fine  hairs  fall  out  and  the  sebaceous 
glands  atrophy,  so  that  the  part  is  unduly  dry.  After  that  the  subcutaneous  tissues 
atrophy  so  that  the  natural  fidness  of  the  face  is  diminished,  and,  in  the  later  stages 
of  the  affection,  even  the  underlying  bone  may  be  atrophied  or  absorbed.  The 
muscular  tissues  escape  the  atrophy  to  a  greater  extent,  and  do  not  undergo  degen- 
erative changes.  The  eye  may  become  sunken  from  wasting  of  the  orbital  fat, 
and  the  pupil  may  be  in  a  state  of  mydriasis.  Usually  the  condition  is  painless, 
but  local  spasm  of  the  muscles  of  the  part  may  occur.  Xo  treatment  is  of  any 
avail  in  arresting  the  progress  of  the  disease. 


PERIODICAL  PARALYSIS. 

This  term  is  applied  to  an  extraordinary  condition  of  paralysis  involving  widely 
distributed  groups  of  muscles  in  the  arms,  legs,  and  trunk,  which  develops  rapidly 
in  apparently  healthy  individuals  without  any  apparent  exciting  cause.  Not  rarelj' 
several  members  of  a  family  are  affected  by  the  malady.  The  patient  may  go  to 
bed  in  perfect  health  and  wake  to  find  himself  paralyzed,  or  the  paralysis  develops 
after  a  preliminary  sense  of  weakness  in  the  affected  parts.  As  a  rule,  the  legs 
suffer  chiefly.  Very  rarely  the  muscles  of  the  neck  are  affected,  but  the  cranial 
nerves  always  escape.  The  reflexes  are  minus,  and  the  muscles  and  nerve  trunks 
lose  their  reaction  to  faradic  stimulation.  The  paralysis  lasts  from  a  few  hours  to  a 
day,  and  speedy  and  perfect  recovery  ensues,  but  relapses  frequently  take  place. 

The  condition  is  apparently  a  form  of  auto-intoxication,  and  is  said  to  be  benefited 
by  the  use  of  alkaline  diuretics. 


INDEX 


Abdominal  facies  in  ascites,  600 
Abducens  nerve,  paralysis  of,  873 
Abscess  in  appendicitis,  574 
of  brain,  809 
in  bronchiectasis,  378 
in  erysipelas,  170 

hepatic,  602.    See  Hepatic  abscess, 
of  liver  in  dysentery,  205 
of  lung,  407 

in  croupous  pneumonia,  132,  140 
of  mediastinum,  431,  433 
in  metastatic  pneumonia,  397 
parotid,  514 
perinephritic,  672 

treatment  of,  672 
peritoneal,  594 
pulmonary,  in  septicemia,  172 

in  typhoid  fever,  39 
in  smallpox,  70 
of  spleen,  703 
Acetone  in  urine,  test  foi',  732 
Achylia-gastrica  nervosa,  559 
Acquu'ed  idiocy,  798 

syphilis,  302 
Acromegaly,  699 

definition  of,  699 
diagnosis  of,  699 

from  gigantism,  699,  701 

from  leontiasi's  ossea,  699,  701 

from  myxedema,  699,  701 

from  osteitis  deformans,  699,  701 

from   pulmonary   hypertrophic   osteo- 
arthropathy, 699,  701 
etiology  of,  699 
symptoms  of,  699 
treatment  of,  701 
types  of,  701 
Actinomycosis,  233 
cerebral,  234 
definition  of,  233 
diagnosis  of,  235 
etiology  of,  233 
morbid  anatomy  of,  233 
pathology  of,  233 
ray  fungus  in,  233 
streptothi-ix  actinomyces  in,  233 
symptoms  of,  233 
treatment  of,  234 
Acute  anterior  poliomyelitis,  111 
atrophic  paralysis.  111 
infantile  palsy.  111 
poliomyeloencephalitis.  111 
Addison's  anemia,  710 
disease,  695 

anemia  in,  697 

asthenia  in,  697 

atrophic  changes  in,  696 

definition  of,  695 

diagnosis  of,  697 


Addison's  disease,  diagnosis  of,  from  diabetes 
bronz(5,  697 
from    hypertrophic    cirrhosis    of 

liver,  697 
from  pregnancy,  697 
from  prolonged  use  of  arsenic,  697 
etiology  of,  695 
history  of,  695 
languor  in,  697 
morbid  anatomj'  of,  696 
pathology  of,  695 
pigmentation  of  skin  in,  697 
pi'ognosis  in,  698 
symptoms  of,  697 
treatment  of,  698 
tuberculosis  in,  698 
Adenitis,  cervical,  246 

tropical,  200 
Adenoma  of  kidney,  668 
of  pancreas,  637 
of  thyroid  gland,  683 
Adhesions  of  colon,  592 
Adhesive  pericarditis,  clu'onic,  440 
Adiposis  dolorosa,  764 
Adrenal  apoplexy,  696 

jEstivo-autumnal  parasite  of  malarial  fever,  319 
African  itch,  69 

lethargy,  331,  333.    See  Sleeping  sickness. 
Agglutometer  for  agglutination  test  in  typhoid 

fever,  44 
Agraphia,  800 

Ague  cake  in  malarial  fever,  321,  326 
Ainhum,  766 

treatment  of,  766 
Albuminuria,  675 

in  acute  diffuse  nephi-itis,  642 
of  adolescence,  676 
cyclic,  676 

in  diabetes  meUitus,  729 
in  diphtheria,  157 
orthostatic,  676 
in  pneumonic  plague,  198 
tests  for,  676 
in  tick  fever,  298 
in  typhoid  fever,  38 
in  ulcerative  endocarditis,  459 
in  yellow  fever,  191,  192 
Albuminuric  neuroretinitis,  653 
papillitis,  653 

retinitis  in  chronic  parenchymatous  nephri- 
tis, 646 
degenerative,  653 
hemorrhagic,  653 
typical,  653 
Albumosuria,  myelopathic,  680 
Alcoholism,  771 

acute,  symptoms  of,  771 

treatment  of,  772 
chronic,  772 

morbid  anatomy  of,  772 
symptoms  of,  773 

(925) 


926 


INDEX 


Alcoholism,  chionio,  treatment  of,  773,  774 
dietetic,  773 
definition  of,  771 
etiology  of,  771 
subacute,  772 
Aleppo  boil,  :33G 
Alexia,  800 
Algid  form  of  pernicious  malarial  fever,  325 

yellow  fever,  191 
Alimentary  canal,  tuberculosis  of,  278 
AUochiria  in  locomotor  ataxia,  827 
Alopecia,  syphilitic,  309 
Amaurosis,  uremic,  660 
Amaurotic  family  idiocy,  798 
Amblyopia  in  whooping-cough,  104 
Ameba  can-iers,  203 
Amebiasis,  intestinal,  201 
Amebic  abscess  of  liver,  604 

dysentery,  201,  202 
Amiinia,  800 
Amok,  i)U 

Amjiliiuir  l)rc;iihing,  264 
Ainvli'1,1  .hiiiiii  ration  of  heart,  449 
■  disease  of  kidney,  657 
liver,  614 
Amyotrophic  lateral  sclerosis,  838 
Anaphylactic  manifestations  in  scarlet  fever. 
Anaphylaxis  from  diphtheria  antitoxin,  163 
Anemia,  707 

Addison's,  710 

disease,  697 
aplastic,  713 
brickmakers',  338 
in  chronic  lead  poisoning,  780 
definition  of,  707 
in  diphtheria,  159 
essential,  708 
in  gastric  ulcer,  539 
infantum,  718 

blood  changes  in,  718 
definition  of,  718 
treatment  of,  718 
miners',  338 
pernicious,  710 

blood  changes  in,  711 
definition  of,  710 
diagnosis  of,  712 
etiology  of,  710 
history  of,  710 
morbid  anatomy  of,  711 
prognosis  in,  712 
symptoms  of,  712 
treatment  of,  712 
I'orto  Rican,  338 
primary,  70S 
secondary,  707 
cause  of,  707 
diagnosis  of,  708 
sj'mptoms  of,  708 
treatment  of,  708 
in  septicemia,  172 
splenic,  704 

blood  in,  704 

clinical  characteristics  of,  705 
definition  of,  704 
diagnosis  of,  704 
ctiolog>'  of,  704 
morbid  anatomy  of,  704 
pathology  of,  704 
prognosis  in,  705 
spleen  in,  704 
symptoms  of,  704 
treatment  of,  705 
in  sprue,  590 


Anemia  in  syphilis,  309 
in  typhoid  fever,  30 
tunnel,  338 
in  uncinariasis,  341 
Anesthesia  in  hj'Steria,  896 
Anesthetic  leprosy,  293 
Aneurysm,  500 

of  abdominal  aorta,  507 

cardiac,  453 

definition  of,  500 

"dissecting,"  500 

embolic,  500 

etiology  of,  500 

false,  500 

frequency  of,  501 

fusiform,  500 

hematemesis  in,  559 

of  hepatic  artery,  507 

morbid  anatomy  of,  500 

mycotic,  500 

pathology  of,  500 

of  renal  artery,  507 

sacculated,  500 

of  splenic  artery,  507 

of  superior  mesenteric  artery,  507 

of  thoracic  aorta,  501 

complications  of,  504 
diagnosis  of,  504 
prognosis  in,  505 
sequete  of,  502,  503 
symptoms  of,  502 
treatment  of,  505 
operative,  506 
Tufnell,  505 
varicose,  500 
Aneurysmal  varix,  500 
Angma,  Ludwig's,  520 
pectoris,  491 

definition  of,  491 
diagnosis  of,  492 
etiology  of,  491 
pathology  of,  491 
prognosis  in,  492 
symptoms  of,  491 
treatment  of,  492 
Vincent's,  521 
Angiomata,  cavernous,  of  fiver,  615 

of  kidney,  668 
Angioneurotic  edema,  916 
definition  of,  916 
diagnosis  of,  917 
prognosis  of,  917 
treatment  of,  917 
Angiosclerosis,  498 
Ankle  clonus  in  lateral  sclerosis,  837 
Ankylosis  in  gonorrheal  arthritis,  166 
Ankylostomiasis,  338 
Ankylostomum  duodenale,  338 
Annular  stricture  of  esophagus,  523 
Anorexia  nervosa,  558 
Anthracosis,  398 
Anthrax^  219 

bacillus  of,  219 
definition  of,  219 
diagnosis  of,  221 
etiology  of,  219 
frequency  of,  219 
history  of,  219 
lesion  of,  220 
morbid  anatomy  of,  220 
edema,  malignant,  220 
pathologj'  of,  220 
prevention  of,  219 
prognosis  in,  221 


INDEX 


927 


Anthrax,  symptoms  of,  220 

treatment  of,  222 
Anticholera  vaccine,  182 
Antigonococcic  serum,  167 
Antiplague  inoculations,  Haffkine's,'197 
Antirabic  serum,  226 

Antisepsis,  intestinal,  in  typhoid  fever,  50 
Antistreptococcic  serum  in  erysipelas,  171 
in  pulmonary  tuberculosis,  275 
in  septicemia,  173 
Antitetanic  globulin,  229 

serum,  229 
Ajititoxin,  diphtheria,  162,-163 
Antityphoid  vaccination,  20 

vaccine,  50 
Anuria,  672 

treatment  of,  673 
Aorta,  abdominal  aneurysm  of,  507 

thoracic,  aneurysm  of,  501 
Aortic  regiu-gitation,  476 

Corrigan  pulse  in,  479 
definition  of,  476 
diagnosis  of,  480 
Duroziez  sign  in,  480 
etiology  of,  477 
murmur  in,  479 
ox-heart  in,  478 
pathology  of,  477 
physical  signs  of,  478 
pistol-shot  sound  in,  480 
prognosis  in,  480 
Quincke's  pulse  in,  478 
symptoms  of,  478 
trip-hammer  pulse  in,  479 
water-hammer  pulse  in,  479 
stenosis,  474 

definition  of,  474 
diagnosis  of,  476 
etiology  of,  474 
physical  signs  of,  475 
prognosis  in,  476 
symptoms  of,  475 
Aortitis,  495 

treatment  of,  496 
Aphasia,  799 

in  apoplexy,  791 
in  brain  tumor,  802 
conduction,  800 
definition  of,  799 
symptoms  of,  799 

transitory,  in  croupous  pneumonia,  142 
Aphemia,  800 
Aphonia,  hysterical,  896 
in  smallpox,  70 
in  tuberculous  laryngitis,  369 
AphthiE  tropicae,  588 
Aphthous  stomatitis,  509 
Aplastic  anemia,  713 
Apoplectiform  attack,  785 
bulbar  paralysis,  785 
type  of  yellow  fever,  191 
Apoplexy,  785 
adrenal,  696 
aphasia  in,  791 
astereognosis  in,  791 
athetosis  in,  792 
bed-sores  in,  791 
contractures  in,  791 
definition  of,  785 
in  diabetes  mellitus,  730 
diagnosis  of,  792 

from  acute  alcoholism,  793 
from  coma  of  diabetes,  793 
of  uremia,  793 


Apoplexy,  diagnosis  of,  from  embolism  of  cere- 
bral vessels,  792,  794 
from  epilepsy,  792 

from  general  paralysis  of  insane,  793 
from  opium  poisoning,  793 
from  sunstroke,  793 
from  syncope,  792 

from   thrombosis   of   cerebral   vessels, 
792,  793 
etiology  of,  785 
frequency  of,  785 
hemianesthesia  in,  791 
hemianopsia  in,  791 
hemiplegia  in,  790 
Hutchinson's  pupil  in,  792 
ingravescent,  792 
muscular  atrophy  in,  792 
ocular  symptoms  of,  790 
paralysis  in,  790,  791 
pathology  of,  786 
prognosis  in,  794 
pulse  in,  790 
reflexes  in,  790 
sequelte  of,  791 
stertorous  breathing  in,  790 
symptoms  of,  789 

premonitory,  789 
treatment  of,  794 
unconsciousness  in,  790 
uremic,  793 
Appendicitis,  572 
abscess  in,  574 
catarrhal,  573 
definition  of,  572 
diagnosis  of,  576 

from  hepatic  coHc,  576 
from  intestinal  obstruction,  576 
from  ovarian  inflammation,  576 
from  renal  cohc,  576 
from  tuberculosis,  577 
from  typhoid  fever,  576 
etiology  of,  572 
gangrenous,  573,  574 
history  of,  572 
McBurney's  point,  575 
morbid  anatomy  of,  573 
muscular  rigidity  in,  575 
obliterative,  573 
pathology  of,  573    . 
perforative,  573 
prognosis  in,  577 
symptoms  of,  575 
treatment  of,  577 
in  typhoid  fever,  28,  36 
ulcerative,  573,  574 
vomiting  in,  576 
Apraxia,  800 

Aran-Duchenne  type  of  chronic  anterior  polio- 
myelitis, 834 
Argyll-Robertson  pupil  in  dementia  paralytica, 
818 
in  disseminated  sclerosis,  821 
in  locomotor  ataxia,  827 
Army  itch,  69 
Arrhythmia,  488 
Arsenical  poisoning,  777 

chronic,  eliiology  of,  777 
prognosis  in,  777 
pseudotabes  in,  777 
symptoms  of,  777 
treatment  of,  778 
Arteries,  diseases  of,  495 
Arteriocapillary  fibrosis,  496 
Arteriosclerosis,  496 


928 


INDEX 


ArLcriosclerosis,  dcfiiiilioii  of,  19G 
etiology  of,  496 
morbid  anatomy  of,  497 
pathology  of,  497 
symptoms  of,  499 
treatment  of,  499 
Arteritis,  syphilitic,  306 
Artery,  hemorrhage  of  cerebral,  786 
Arthritis  in  cerebrospinal  fever,  123 
in  cronpous  pneumonia,  143 
deformans,  749 

definition  of,  749 
diagnosis  of,  752 
etiology  of,  749 
Haygarth's  nodosities  in,  751 
Heberden's  nodes  in,  751 
moi'bitl  anatomy  of,  750 
prognosis  in,  753 
symptoms  of,  751 
treatment  of,  753 
gonorrheal,  165 

ankylosis  in,  166 
clironic,  165 
endocarditis  in,  166 
symptoms  of,  165 
treatment  of,  167 
serum  in,  167 
infections  in  cholera,  185 
in  mumps,  101 

in  rheumatic  fever,  acute,  176 
rheumatoid,  749 

in  bronchiectasis,  378 
septic,  in  scarlet  fever,  87 
in  smallpox,  71 
in  typhoid  fever,  40 
Articular  rheumatism,  acute,   174.     See  Rheu- 
matic fever,  acute. 
Ascariasis,  336 

symptoms  of,  336 
treatment  of,  337 
Ascaris  lumbricoides,  336 
Ascending  myelitis,  840 

paralysis,  acute,  854 
Ascites,  599 

definition  of,  599 
diagnosis  of,  600 

from  hepatic  enlargement,  601 
from  ovarian  cyst,  600 
from  splenic  enlargement,  601 
dyspnea  in,  600 
etiology  of,  600 
paracentesis  abdominis  in,  602 
physical  signs  of,  600 
symptoms  of,  600 
treatment  of,  601 
Asiatic  cholera,  181 
Aspiration  pneumonia,  387 
Astasia-abasia,  912 
definition  of,  912 
symptoms  of,  912 
Astereognosis  in  apojilexy,  791 
Asthenia  in  Addison's  disease,  697 
Asthma,  bronchial,  381 

Charcot-Lcyden  crystals  in,  383 
Curschniann's  spirals  in,  383 
ilofinilion  of,  381 
diagnosis  of,  383 

from  jiulmonary  edema,  384 
etiology  of,  381 
Harrison's  groove  in,  382 
morbid  anatomy  of,  382 
pathology  of,  382 
pigeon-breast  in,  382 
prognosis  of,  384 


Asthma,  bronchial,  sputum  in,  )jS2 
symptoms  of,  3S3 
treatment  of,  3S4 

bronchitis  tent  in,  386 

cardiac,  382 

renal,  382 
Asymmetrical  stricture  of  esophagus,  523 
Ataxia,  family,  830 

Friedreich's,  830 

hereditary,  830 

locomotor,  823 

Miirif's  cerebellar  hereditary,  833 
Alli.Toin:.,    l'.)7 
AlliciuHs  IN  :i|iuplexy,  792 
Atliyiea,  (i.s.s 
Atonic  dilatation  of  esophagus,  524 

gastrectasis,  535 
Atrophic  cin-hosis  of  liver,  606 

emphysema,  400 

enteritis  of  tropics,  588 

nasal  catarrh,  361 

paralysis,  acute.  111 

rhinitis,  361 

spinal  paralysis,  chronic,  833 
Atrophy  in  apoplexy,  792 

of  heai-t,  449 

of  liver,  red,  613 

yellow,  acute,  616 

muscular,  progi'cssive,  833 
of  peroneal  tj'pe,  886 

optic,  866 
Atypical  forms  of  typhoid  fever,  28 
Auctioneer's  sore  throat,  517 
Auditory  nerve,  disease  of,  878 
deafness  in,  878 
tinnitus  in,  878 
vertigo  in,  879 
Am-a  in  epilepsy,  902,  904 
Auricular  fibrillation,  472 
Autumnal  catarrh,  362 

fever,  17 


B 


Babinski  reflex  in  amyotrophic  lateral  sclerosis, 
839 
in  apoplexy,  790 
in  lateral  sclerosis,  837 
Bacillary  dysentery,  201 

Bacillus  aerogenes   capsulatus   in  pneumoperi- 
cardium, 443 

of  amebic  dysentery',  201 

of  anthrax,  219 

of  Asiatic  cholera,  181,  183 

coli  cdinmimis  in  typhoid,  17 

of  di])lilhcria,  152 

dysenteria;,  17,  204 

of  Eberth,  17 

lactamorbi  in  milk  sickness,  296 

lepraj,  290 

mallei  in  glanders,  231 

para-colon,  18 

paratyphosus,  21,  54 

pertussis,  102 

pestis,  194,  195 

of  Pfeiffer  in  influenza,  106,  107 

of  Shiga,  201 

of  tetanus,  227 

of  tuberculosis,  method  of  staining,  265 

typhosus,  17 

of  typhoid  fever,  17 
Bagdad  sore,  336 
Balantidium  coli,  201,  203 

dysentery,  203 


IXDliX 


92!) 


Banti's  disease,  705 
Barlow's  disease,  760 

Barrel-shaped    chest    in    chronic    hypertrophic 
tonsillitis,  S21 
in  emphysema,  400 
Basedow's  disease,  683 
Basilar  meningitis,  248 
Bath,  Brand,  in  typhoid  fever,  48 
Baths,  Nauheim,  in  myocarditis,  452 
Bean  itch,  69 

pox,  69 
Bed-sores  in  apoplexy,  791 
in  smallpox,  70 
in  typhoid  fever,  30 
Beef-worm,  350 
Benign  endocarditis,  455 

goitre,  681 
Beriberi,  766 

acute  pernicious,  769 
atrophic,  768 
blood  in,  769 
cardiac  changes  in,  769 
definition  of,  766 
diagnosis  of,  770 
distribution  of,  767 
dry,  768 
etiology  of,  767 
forms  of,  768 
frequency  of,  767 
history  of,  767 
mild,  769 

morbid  anatomy  of,  767 
paraplegic,  768 
pathology  of,  767 
prognosis  in,  770 
rudimentary,  768,  783 
symptoms  ol^,  768 
treatment  of,  770 
urine  in,  769 
Bilateral  salivary  swelling,  514 
Bile-ducts,  catarrh  of,  acute,  617 
chi'onic,  618 

treatment  of,  618 
constriction  of,  619 
inflammation  of,  suppurative,  619 
diagnosis  of,  619 
symptoms  of,  619 
treatment  of,  619 
occlusion  of,  619 
congenital,  620 
Bilharzia  disease,  353 

diagnosis  of,  355 
distribution  of,  353 
etiology  of,  353 
hematuria  in,  354 
history  of,  353 
pathology  of,  354 
prognosis  in,  355 
Schistosoma  hematobium  in,  353 
symptoms  of,  354 
treatment  of,  355 
Biliary  calculi,  621 
colic,  623 

passages,  malignant  growths  of,  627 
tract,  diseases  of,  617 
Bilious  fever,  324 

remittent  fever,  324 
Bilocular  heart,  494 

stomach,  555 
Birth  palsy,  860 
"Black"  measles,  95 
smallpox,  68 

vomit  in  yellow  fever,  191 
water  fever,  325 
59 


Bladiler,  tuberculosis  of,  282 
Blepharofacial  spasm,  878 
Blepharospasm,  878 
Blindness,  word-,  800 
Blood  in  luiilnii,  7r,!i 

in  ci'r(lii-.i-|,iii:il  I'l-vcr,  123 
chaiit;i:~  III  ;iiiriiii:i  infantum,  718 

in  pneumonic  jjlague,  198 
in  chlorosis,  709 
in  diabetes  mellitus,  728 
in  diphtheria,  156 
diseases  of,  707 
in  Hodgkin's  disease,  288 
in  malarial  fever,  changes  in,  320 
in  pernicious  anemia,  711 
in  septicemia,  172 

-spitting  in  mitral  regurgitation,  467 
in  splenic  anemia,  704 
in  splenomedullary  leukemia,  715 
in  stools,  tests  for,  541 
in  typhoid  fever,  24,  30 
in  urine,  673 

in  malarial  fever,  325 
in  yellow  fever,  190 
Blood  pressure  in  angina  pectoris,  491 
in  aortic  regurgitation,  478 
in  arteriosclerosis,  499 
in  myocardial  degeneration,  449 
Blue  line  on  gums  in  chronic  lead  poisoning,  779 
Boas'  reagent,  549 

test  meal  in  gastric  cancer,  549 
Boils  in  typhoid  fever,  30 
Bold  hives,  69 
Bone-marrow  changes  in  typhoid  fever,  25 

in  malarial  fever,  320 
Bones,  syphilis  of,  312 
Bossy  frontals  in  rickets,  757 
Bothriocephalus  cordatus,  352 
cristatus,  352 
latus,  352 
Bouquet  fever,  117 
Bouton  d 'Orient,  336 
Bovine  tuberculosis,  237 

Bowel,  hemorrhage  from,  in  typhoid  fever,  33 
treatment  of,  51 
obstruction  of,  579 

by  congenital  malformations,  579 
by  fecal  impaction,  579 
by  foreign  bodies,  579,  582 
by  internal  strangulation,  579,  581 
by  intussusception,  579 
by  strictm-e,  579 
by  tumors,  579 
by  volvulus,  581 
perforation  of,  in  typhoid  fever,  29,  34 
diagnosis  of,  35 
treatment  of,  52 
Bradycardia,  488 
Brain,  abscess  of,  809 

in  bronchiectasis,  378 
definition  of,  809 
diagnosis  of,  810 
etiology  of,  809 
morbid  anatomy  of,  809 
pathology  of,  809 
prognosis  in,  811 
symptoms  of,  810 
treatment  of,  811 
cancer  of,  801 
diseases  of,  785 
echinococcus  cyst  of,  801 
fibroma  of,  801 
ghomaof,  801,  802 
gumma  of,  801 


930 


INDEX 


Brain,  homorrhage  into,  785 
neuroma  of,  801 
sarcoma  of,  801 

softening  of,  in  croupous  pneumonia,  143 
syphilis  of,  308,  310 
tabes  of,  817 
tubercle  of,  801 
.  tuberculosis  of,  286 
tumors  of,  801 

aphasia  in,  802 
diagnosis  of,  807 

from  localized  meningitis,  807 
etiology  of,  801 
frequency  of,  801 
headache  in,  802 
liemiancsthesia  in,  804 
hemianopsia  in,  803 
hemiatoxia  in,  804 
hemiplegia  in,  804 
morbid  anatomy  of,  801 
optic  neuritis  in,  802 
paralysis  in,  803 
bilateral,  803 
crossed,  803 
pathology  of,  801 
prognosis  in,  807 
symptoms  of,  802 
table  of  cerebral  localizing  symptoms 

in,  806 
treatment  of,  808 
surgical,  808 
vasoulai-,  801 
vertigo  in,  802 
vomiting  in,  802 
^^^eber's  syndrome  in,  803 
Brand  bath  in  typhoid  fever,  48 
Breakbone  fever,  118 
Breathing,  stertorous,  in  apoplexy,  790 
Brickmakers'  anemia,  338 
Bright's  disease  acute,  641 

chronic,  643 
Bromatotoxismus,  781 
Bronchi,  diseases  of,  370 
Bronchial  asthma,  381 
Bronchiectasis,  375 

brain  abscess  in,  378 

bronchopneumonia,  septic  in,  378 

complications  of,  378 

cough  in,  376 

in  croupous  pneumonia,  141 

cyanosis  in,  378 

definition  of,  375 

diagnosis  of,  378 

from  pulmonary  tuberculosis,  378 
dyspnea  in,  378 
etiology  of,  375 
forms  of,  375 
hemoptysis  in,  378 
morbid  anatomy  of,  375 
pathology  of,  375 
physical  signs  of,  377 
prognosis  in,  378 
pulmonary  gangrene  in,  378 

oslco-arthropathy  in,  378 
rheumatoid  arthritis  in,  378 
sputum  in,  377 
symptoms  of,  376 
treatment  of,  378 
Bronchitis  actinomycotica,  chronic,  234 
capillary,  391 
catarrhal,  acute,  370 

definition  of,  370 
distribution  of,  371 
etiologj-  of,  371 


Bronchitis,  catarrhal,  acute,  history  of,  370 
morbid  anatomy  of,  372 
pathology  of,  372 
prevention  of,  372 
symptoms  of,  372 
t  reaf  ment  of,  372 
chronic,  374 

definition  of,  374 
treatment  of,  375 
in  croupous  pneumonia,  133 
fibrinous,  379 

definition  of,  379 
diagnosis  of,  381 

from  diphtheria,  381 
etiologj'  of,  379 
pathologj'  of,  380 
prognosis  of,  381 
symptoms  of,  380 
treatment  of,  381 
in  influenza,  107 
in  measles,  93,  95 
in  smallpox,  70 
tent  in  bronchial  asthma,  386 
in  whooping-cough,  105 
Bronchocele,  681 
Bronchopneumonia,  386 
complications  of,  392 
definition  of,  38(i 
diagnosis  of,  393 

from  acute  bronchitis,  393 
from  croupous  pneumonia,  393 
from  malarial  infection,  393 
from  tuberculous  infection,  393 
in  diphtheria,  156,  158,  159 
distribution  of,  387 
duration  of,  392 
e(  iologj'  of,  387 
frequency  of,  388 
in  measles,  93,  96 
morbid  anatomj'  of,  388 
pathology  of,  388 
prevention  of,  388 
prognosis  of,  394 
in  scarlet  fever,  88 
septic,  in  bronchiectasis,  378 
in  smallpox,  70 
symptoms  of,  389 
treatment  of,  394 
(ypes  of,  387 
in  whooping-cough,  103 
Bronzed  diabetes,  739 
Brown  induration  of  heart,  449 
Bubo,  climatic,  200 
parotid,  514 
tropical,  200 
Buboes  in  bubonic  plague,  198 
Bubonic  plague,  194 
Buccal  psoriasis,  513 
Bucket  fever,  117 
Bulbar  paralysis,  835 

apoplectiform,  785 
Bulimia,  558 
Bumjjs,  69 


Cachexia,  miners',  338 
in  pellagra,  783 
strumipriva,  688 
Cecum,  tuberculosis  of,  279 
Caisson  disease,  855 

treatment  of,  856 
palliative,  856 
prophylactic,  856 


INDEX 


931 


Calcareous  degeneration  of  heart,  449 
Calculi,  biliary,  621 
Calculus,  coral,  of  kidney,  669 
"hemp-seed,"  of  kidney,  670 
mulberry,  of  kidney,  670 
pancreatic,  636 
renal,  669 
Cancer  of  brain,  801 
of  kidney,  668 
of  esophagus,  525 
of  peritoneum,  599 
of  stomach,  545 
Cancrum  oris,  511 
Canker,  509 

Capillary  bronchitis,  391 
Capsular  ciri-hosis  of  liver,  612 
Carcinoma  of  biliary  ducts,  627 
of  gallbladder,  627 
of  liver,  614 
in  lung,  412 
of  mediastinum,  431 
of  thyroid  gland,  683 
Carcinosarcoma  of  thyroid  gland,  683 
Cardiac  aneurysm,  453.   See  Heart,  aneui'ysm  of. 
asthma,  382 
changes  in  beriberi,  768 

in  croupous  pneumonia,  133 
in  whooping-cough,  104 
in  yellow  fever,  190 
compUcations  in  rheumatic  fever,  177,  178 
defects,  congenital,  494 
•dilatation,  444.     See  Heart,  dilatation  of. 
disorders  not  due  to  valvular  lesions,  487 
hypertrophy,  444.    See  Heart,  hypertrophy 

of. 
neuroses,  487 

treatment  of,  490 
palpitation,  487 
valvular  anomalies,  494 
Cardiospasm,  556 

treatment  of,  557 
Caseative  nephritis,  663 
Cataract  in  diabetes  meUitus,  730 
Catarrh,  autumnal,  362 

of  bile-ducts,  acute,  617 

chronic,  618 
gastric,  acute,  525.    See  Gastric  catarrh, 
nasal,  atrophic,  361 

definition  of,  361 
etiology  of,  361 
pathology  of,  361 
prognosis  of,  362 
symptoms  of,  362 
treatment  of,  362 
chronic,  360 

definition  of,  360 
etiology  of,  360 
pathology  of,  361 
symptoms  of,  361 
treatment  of,  361 
suffocative,  acute,  389,  391 
Catarrhal  appendicitis,  573 
bronchitis,  acute,  370 

chronic,  374 
cholecystitis,  617 
dysentery,  acute,  201 
enteritis,  566 
jaundice,  617 
laryngitis,  acute,  364 

chronic,  366 
pneumonia,  386 
pyelonephritis,  664 
stomatitis,  509 
'  Cedar  itch,  69 


Celiac  disease,  702 
Cerebral  actinomycosis,  234 
embolism,  785 
hemorrhage,  785 

artery  of,  786 
meningitis,  813 
paralysis,  infantile,  795 
syphilis,  308,  310 
thrombosis,  785 
Cerebritis,  acute,  811 

definition  of,  811 
diagnosis  of,  812 
etiology  of,  811 
morbid  anatomy  of,  811 
pathology  of,  811 
prognosis  of,  812 
symptoms  of,  811 
treatment  of,  812 
Cerebrospinal  fever,  120.    See  Meningitis,  men- 
ingococcic. 
meningitis,  120 
Cervical  adenitis,  246 
Cervicobrachial  neuritis,  859 
Cestodes;  350 
Ceylon  sour  mouth,  588 
Chahcosis,  398 
Chancre,  302,  306,  308 

leprous,  292 
Charcot  joint  in  locomotor  ataxia,  828 
Charcot-Leyden  crystals,  383 

in  distomatosis  of  lung,  356 
uncinariasis,  340 
Charcot-Marie-Tooth  form  of  progressive  mus- 
cular atrophy,  886 
ChejTie-Stokes     respiration     in     cerebrospinal 

fever,  123 
Chicken-breast  in  rickets,  757 
Chicken-pox,  77.    See  Varicella. 
Chigger,  357 

treatment  of,  357 
Chloroma,  718 
Chlorosis,  708 
blood  in,  709 
complications  of,  710 
definition  of,  708 
diagnosis  of,  710 

from  pernicious  anemia,  710 
Egyptian,  338 
etiology  of,  709 
florida,  710 
pathology  of,  709 
prognosis  in,  710 
symptoms  of,  709 
tarda,  709 
treatment  of,  710 
tropical,  338 
Cholangitis,  acute,  617 

diagnosis  of,  617 
etiology  of,  617 
prognosis  in,  617 
symptoms  of,  617 
treatment  of,  617 
chi-onic,  618 

treatment  of,  618 
suppurative,  619 

diagnosis  of,  619 

from  catarrhal  cholangitis,  619 
from  hepatic  abscess,  619 
symptoms  of,  619 
treatment  of,  619 
Cholecystitis,  acute,  620 
definition  of,  620 
diagnosis  of,  621 

from  acute  appendicitis,  621 


9.32 


iM)i':x 


Cholecystitis,   acute,   diagnosis  of,   fiom   acute 

pancreatitis,  (j21 

from  Kaslrii'  ulcer,  621 

from  heinilir  CDlic,  (121 

from  iiileslinal  obstruction,  621 

etiology  of,  620 

morbid  anatomy  of,  620 

svniptoms  of,  621 

treatment  of,  621 
catarrhal,  617 
in  typhoid  fever,  37 
Cholelithiasis,  621 
colic  in,  623 
complications  of,  624 
Courvoisier's  law  in,  625 
definition  of,  621 
diagnosis  of,  625 

from  appendicitis,  625 

from  gastralgia,  625 

from  gastric  crises  of  ataxia,  625 
ulcer,  625 

from  pleurisy,  625 

from  renal  stone,  625 
enlargement  of  gallbladder  in,  624 
etiology  of,  621 
jaundice  in,  623 
pathology  of,  621 
perforation  in,  624 
sequela;  in,  624 
symptoms  of,  623 
treatment  of,  626 
in  typhoid  fever,  37 
urine  in,  623 
Cholera,  181 

arthi-itis,  infectious,  in,  185 
Asiatic,  181 
bacillus  of,  181,  183 
collapse  in,  184 
complications  of,  185 
definition  of,  181 
diagnosis  of,  185 
diarrhea  in,  183 
distribution  of,  181 
edema  of  lungs  in,  185 
etiology  of,  181 
facial  expression  in,  184 
gangrene  in,  185 
history  of,  181 
incubation  in,  183 
infantum,  569 

definition  of,  569 

etiology  of,  570 

morbid  anatomy  of,  570 

pathology  of,  570 

prognosis  in,  570 

symptoms  of,  570 

treatment  of,  570 
intestinal  changes  in,  183 
liver  in,  183 

morbid  anatomy  of,  182 
nephritis  in,  185 
parotitis  in,  185 
pathology  of,  182 
prevention  of,  181 

anticholera  inoculations  for,  182 
prognosis  in,  185 
purging  in,  184 
sequchc  of,  185 
sicca,  185 
stools  in,  183 
symptoms  of,  183 
treatment  of,  186 

irrigation  of  bowel  in,  187 
variations  in  symptoms  of,  185 


Cholera,  visceral  changes  in,  183 

vomiting  in,  183 
Cholerine,  185 
(  lioiidroma  in  lung,  412 
Clion-a,  acute,  890 

in  acute  rlicutnatic  fever,  178 
cleclrical,  Sill 
gravidarum,  MM 
hereditary,  S93 

prognosis  in,  893 
s\mptoms  of,  893 
treatment  of,  894 
Huntington's,  893 
insaniens,  892 
minor,  890 

complications  of,  892 
definition  of,  890 
diagnosis  of,  892 

from  hysteria,  892 
from  infantile  cerebral  palsy,  892 
duration  of,  892 
endocarditis  in,  892 
etiologj'  of,  890 
excitmg  causes  of,  891 
frequency  of,  891 
hysteria  in,  892 
mental  state  in,  892 
morbid  anatomy  of,  891 
movements  in,  891 
pathology  of,  891 
prognosis  in,  892 
symptoms  of,  891 
treatment  of,  893 
paralytic,  892 
Sj-denham's,  890 
Chvostek's  sign  in  gastric  tetanv,  534 

of  tetany,  692 
Chyluria,  678 

"Cinder-sifting"  kidney,  638 
Cii'culatoi'v  disturbances  in  kidney,  640 

system,  diseases  of,  435 
Circumscribed  peritonitis,  594 
Cirrhosis  of  kidney,  650 

of  liver,  606 
Claw-hand  in  chronic  anterior  poliomyelitis,  834 
Clergj'men's  sore  throat,  517 
Climatic  bubo,  200 

definition  of,  200 
symptoms  of,  200 
treatment  of,  200 
treatment  of  pulmonary  tuberculosis,  270 
Coffee-ground  vomit,  559 
Coin  sound  in  hycbopneumothorax,  431 
Cold  bathing  in  typhoid  fever,  47 
Colic,  biliary,  623 

in  chronic  lead  poisoning,  780 
painters',  780 
renal,  671 
Colica  pictonum,  780 
Colitis,  586 
acute,  586 

sj'mptoms  of,  586 
treatment  of,  586 
croupous,  587 

treatment  of,  588 
follicular,  587 
mucous,  586 

definition  of,  586 
treatment  of,  587 

counter-irritation  in,  587 
diet  in,  587 
rest  in,  587 
nodular,  587 
pseudomembranous,  588 


INDEX 


933 


Collapse  in  cholera,  184 
"Collar  of  brawn"  in  scarlet  fever,  84 
Colloid  goitre,  681 
Colon,  adhesions  of,  592 
dilatation  of,  591 

by  foreign  bodies,  591 
by  gas,  591 

treatment  of,  591 
idiopathic,  592 
by  obstruction,  591 
displacements  of,  592 
redundancy  of,  592 
Coma  in  chronic  parenchymatous  nephritis,  646 
diabetic,  730 
in  uremia,  659 
vigil  in  typhoid  fever,  39 
in  typhus  fever,  57 
Comatose  form  of  pernicious  malarial  fever,  325 
Comma  bacillus  of  Asiatic  cholera,  181,  183 
Compensatory  emphysema,  400,  404 
Compression  of  spinal  cord,  848 
Conduction  aphasia,  800 
Condylomata,  syphiUtic,  309 
Confluent  smallpox,  68 
Congenital  cardiac  defects,  494 
hydronephrosis,  665 
malformations  of  bowel,  579 


stenosis  of  pylorus,  553,  554 
wryneck,  882 
Congestion  of  lungs,  409 
definition  of,  409 
diagnosis  of,  411 

from  catarrhal  pneumonia,  411 
from  croupous  pneumonia,  411 
from  pleural  effusion,  411 
dyspnea  of,  411 
etiology  of,  410 
h3T)0static,  410 
pathology  of,  410 
prognosis  of,  411 
symptoms  of,  411 
treatment  of,  411 
Conjunctiva,  diphtheria  of,  168 
Conjunctival  hemorrhages  in  whooping-cough, 

104 
Conjunctivitis  in  measles,  96 
Constitutio  lymphatica,  694 
Contracted  kidney,  650 
Contractures  in  apoplexy,  791 
Convulsions  in  acute  anterior  poliomyeUtis,  115 
in  chronic  lead  poisoning,  779 
in  croupous  pneumonia,  138 
in  epilepsy,  903 
in  hysteria,  895 

in  infantile  cerebral  paralysis,  796 
in  mumps,  101 
in  typhoid  fever,  40 
in  uremia,  659 
in  yellow  fever,  190 
Cor  bovinum  in  aortic  regurgitation,  478 
Cordylobia  anthropophagia,  358 
Corrigan  puLse  in  aortic  regurgitation,  479 
Corynebacterium  granulomatis  mahgni  in  Hodg- 
kin's  disease,  287 
Hodgkini,  287 
Coryza,  acute,  359 
definition  of,  359 
diagnosis  of,  360 
diplococcus  corj'za;  in,  359 
etiology  of,  359 
in  measles,  94 

micrococcus  catarrhalis  in,  359 
morbid  anatomy  of,  359 


Coryza,  pathology  of,  359 

symptoms  of,  359 

transmission  of,  359 

treatment  of,  360 
Coup  de  soleil,  920 
Courvoisier's  law,  625 
Cracked-pot  sound,  263 
Cramp,  flute-players',  914 

pianists',  914 

telegraphers',  914 

violinists',  914 

writers',  914 
Cranial  nerves,  diseases  of,  865 
Craniotabes,  757 
Craw-craw,  344 
Cretinism,  689 

definition  of,  689 

diagnosis  of,  690 

prognosis  in,  690 

symptoms  of,  689 

treatment  of,  690 

thjToid  gland  in,  690 
Crises  in  croupous  pneumonia,  139 

in  locomotor  ataxia,  826 
Croup,  false,  368 

spasmodic,  368 
Croupous  coUtis,  587 

pharjmgitis,  517 

pneumonia,   128.     See  Pneumonia,   croup- 
ous. 
Cuban  itch,  69 
Curschmann's  spii'als,  383 
Cj'anosis  in  croupous  pneumonia,  136 

in  edematous  larj-ngitis,  367 

in  mitral  regurgitation,  467 
Cj'clic  albuminuria,  676 

vomiting,  560 
Cylindrical  stricture  of  esophagus,  523 
Cynache  gangrenosa,  520 
Cyst,  hydatid,  of  spleen,  703 
Cystadenoma  of  pancreas,  636 
Cystic  adenoma  of  peritoneum,  599 

disease  of  kidney,  667 
of  liver,  615 

epitheUoma  of  pancreas,  636 

goitre,  681 
Cysticercus  mediocanellata,  351 
Cystitis  in  tjTjhoid  fever,  38 
Cysts  of  mediastinum,  431 

of  pancreas,  636 
Cytoryctes  vaccinee  as  a  cause  of  smallpox,  61 
Cytoscopy  in  pleurisy  with  effusion,  421 


Dactylitis,  syphUitic,  312 
Dandy  fever,  117 
Deafness,  878 

word-,  800 
Delhi  boil,  335 

Delirium  in  acute  rheumatic  fever,  178 
in  cerebrospinal  fever,  123 
cordis  in  diphtheria,  158 
in  croupous  pneumonia,  134,  136,  138 
ferox  in  tj^jhus  fever,  57 
in  relapsing  fever,  331 
in  smallpox,  67 
in  typhoid  fever,  27,  39 
Dementia  paralytica,  816 

ArgyU-Robertson  pupil  in,  818 
definition  of,  816 
diagnosis  of,  819 
etiology  of,  816 


934 


INDEX 


Dementia  paralytica,  morbid  anatomy  of,  817 
pathology  of,  817 
prognosis  in,  819 
symptoms  of,  818 
treatment  of,  819 
Dengue,  117 
chill  in,  118 
crisis  in,  118 
definition  of,  117 
desquamation  in,  118 
diagnosis  of,  119 

from  influenza,  119 
from  rotheln,  119 
from  scarlet  fever,  119 
from  syphilitic  roseola,  119 
distribution  of,  117 
eruption  in,  118 
erythema  in,  118 
etiology  of,  117 
fever  in,  US 
history  of,  117 
prognosis  in,  119 
relapse  in,  118 
symptoms  of,  118 
treatment  of,  119 
Dentition  in  rickets,  757 
Dermatobia  cyaniventris,  358 
Dermoid  cyst  in  lung,  412 

of  mediastinum,  431 
Descending  myelitis,  840 
Desquamation  in  dengue,  118 

in  scarlet  fever,  89,  92 
Desquamative  nephritis,  chronic,  645 
Dhobie  itch,  69 
Diabetes,  bronzed,  739 

definition  of,  739 
insipidus,  739 

definitiou  of,  739 
diagnosis  of,  740 
etiology  of,  739 
morbid  anatomy  of,  739 
prognosis  in,  740 
symptoms  of,  739 
treatment  of,  740 
urine  in,  740 
mellitus,  723 

albuminuria  in,  729 
blood  changes  in,  728 
carbuncles  in,  729 
coma  in,  730 
complications  of,  729 
dyspeptic,  730 
nervous,  730 
ocular,  730 
pulmonary,  730 
definition  of,  723 
diagnosis  of,  730 

blood  tests  m,  731 
urinary  tests  in,  732,  733 
distribution  of,  723 
dyspeptic  symptoms  in,  730 
emaciation  in,  728 
etiology  of,  724 
frequency  of,  723 
gangrene  in,  729 
glycosuria  in,  725,  728,  729 
history  of,  723 
kidney  changes  in,  727 
Kussmaul's  coma  in,  730 
morbid  anatomy  of,  727 
nervous  system  in,  changes  in,  727 
pathology  of,  725 
pnignosis  in,  732 
swiucUo  of,  729 


Diabetes  mellitus,  symptoms  of,  728 

treatment  of,  734 
did  die,  734,  730 
Miedicirial,  737 

urine  in,  729 
"phosphatic,"  679 
Diaphragm,  spasm  of,  in  tetanus,  228 
Diarrhea,  565 
alba,  588 
in  cholera,  183 
hill,  214 

definition  of,  214 

etiology  of,  214 

patholog)'  of,  214 

symptoms  of,  214 

treatment  of,  214 
in  influenza,  108 
in  measles,  96 
serous,  565 

causes  of,  565 

treatment  of,  565 
Simla,  214 
in  sprue,  590 

in  typhoid  fever,  26,  27,  28 
Diazo  reaction  of  urine  in  typhoid  fever,  45 
Dibothriocephalus  latus,  350,  352 
Diet  in  tsTshoid  fever,  48 
Dietl's  crises  in  movable  kidney,  639 
Digestive  tract,  diseases  of,  509 
Dilatation  of  colon,  591 
of  heart,  446 
of  esophagus,  523 
of  stomach,  531 

acute,  535 

paralytic,  535 
Diphtheria,  151 

albuminuria  in,  157 
anemia  in,  159 
antitoxin,  162,  163 

administration  of,  163 

anaphylaxis  after,  163 

disagreeable  effects  of,  163 

results  of  administration,  163 
bacillus  of,  152 
blood  in,  156 

bronchopneumonia  in,  156,  158,  159 
circulation  in,  157 
complications  of,  158 
of  conjunctiva,  158 
definition  of,  151 
"delirium  cordis"  in,  158 
diagnosis  of,  159 

bacteriological,  160 

from  tonsillitis,  160 
distribution  of,  152 
emphysema  in,  156 
etiology  of,  152 
glandular  enlargement  in,  157 
heart  failiu-c  in,  158 

lesions  in,  155 
hemorrhage  in,  159 
history  of,  152 
kidney  lesions  in,  156 
laryngeal,  157 
local  lesion  of,  154,  156 
lymphatic  enlargements  in,  157 
in  measles,  96 
morbid  anatomy  of,  154 
myositis,  acute,  in,  155 
nasal,  157 
nephritis  in,  156 

nervous  manifestations  of,  156,  157 
j         neuritis  in,  156 

paralysis,  facial,  in,  159 


INDEX 


93; 


Diphtheria,   paralysis,   local  or  \vidcs])rpad,   in, 
159 
of  phrenic  nerve  in,  159 
pathology  of,  154 

]ioliomyelit,is,  anterior,  acute  in,  15G 
prognosis  of,  161 
prophylaxis  of,  161 
renal  disease  in,  159 
Schick  test  of  natural  immunity  to,  Uil 
sequelae  of,  158 
sore  throat  in,  156 
spleen  in,  156 
symptoms  of,  156 
systemic  lesions  in,  155 
transmission,  mode  of,  152 
treatment  of,  162 
local,  164 
serum,  162,  163 
visceral  lesions  of,  155 
Diphtheritic  dysentery,  201 

gastritis,  527 
Diplegia,  spastic,  795,  797 
Diplococcus  coryza;,  359 

of  Weichselbaum  in  cerebrospinal  fever,  120 
Diplopia,  in  locomotor  ataxia,  827 
Diptera,  infection  by  larvse  of,  357 
Dipylidium  oanmum,  350 
Displacements  of  colon,  592 
"Dissecting  anem'ysm,"  500 
Disseminated  myelitis,  840 

sclerosis,  820 
Distomatosis,  353 
of  liver,  356 

symptoms  of,  356 
treatment  of,  357 
of  lung,  353,  355 

pathology  of,  356 
prognosis  of,  356 
symptoms  of,  356 
treatment  of,  356 
Diverticula  of  esophagus,  pressure,  523 

traction,  523 
Dracontiasis,  346 
Dracunculus  medineusis,  346 
Drop-foot  in  clxronic  anterior  poliomyelitis,  834 
Dropsy  in  mediastinal  tumor,  432 
Dry  mouth,  514 

pleurisy,  413,  414,  415 
Dubini's  disease,  894 

Ducheime's  type  of  ascending  paralysis,  834 
Ductless  glands,  diseases  of,  681 
Ductus  arteriosis,  patent,  494 
Dum  dum  fever,  335 
Dumb  rabies,  224 

Duodenal  ulcer,  561.    See  Ulcer,  duodenal. 
Dura  mater,  hematoma  of,  814 
Duroziez  sign  in  aortic  regurgitation,  480 
Dwarf  tapeworm,  350 
Dysbasia,  912 
Dysentery,  200 
bacillary,  201 

pathology  of,  203 
Shiga's  bacillus  in,  201 
specific  treatment  of,  210 
catarrhal,  201 

pathology  of,  205 
symptoms  of,  206,  207 
complications  of,  207 
definition  of,  200 
diagnosis  of,  207. 
diphtheritic,  201 

pathology  of,  205 
symptoms  of,  207 
entaraebic,  201,  202 


Dysentery,  entaraebic,  diagno.sis  of,  204,  208 

hepatic  absce.ss  in,  205 
changes  in,  205 

intestinal  perforation  in,  207 

pathology  of,  204 

peritonitis  in,  207 

symptoms  of,  207 
etiology  of,  201 
frequency  of,  20)5 
morbid  anatomy  of,  203 
pathology  of,  203 
prevention  of,  203 
prognosis  in,  208 
scquelte  in,  207 
serum  in,  203,  210 
stools  in,  206 
symptoms  of,  206 
treatment  of,  209 

diet  in,  209 

local,  212 
Dysphagia  in  dilatation  of  esophagus,  524 

in  tuberculous  laiyngitis,  369 
Dyspituitari,sm,  699 

Dyspnea  in  acute  pernicious  beriberi,  769 
in  ascites,  600 
in  congestion  of  lungs,  411 
in  croupous  pneumonia,  136 
in  emphysema  of  lung,  403 
in  exophthalmic  goitre,  686 
in  Hodgkin's  disease,  288 
in  mitral  regm-gitation,  467 
in  plem-isy  with  eiTusion,  418 
in  pneumothorax,  430 
in  puhnonaiy  tuberculosis,  261 
in  tumors  of  mediastinum,  432 
in  uremia,  660 
Dystrophy,  muscular,  884 

definition  of,  884 

Erb's  juvenile,  885 

etiology  of,  884 

Lan'.ouzy-Dejerine  tj-pe  of,  885 

morbid  anatomy  of,  884 

pathology  of,  884 

treatment  of,  886 


E 


Ear.\che  in  smallpox,  70 
Echinococcic  strumitis,  681 
Echinococcus  cyst  of  brain,  801 

exogena,  351 

multilocularis,  351 
Eclampsia,  909 

infantile,  909 

diagnosis  of,  910 
prognosis  in,  9)0 
treatment  of,  910 

puerperal,  910 

treatment  of,  910 
Ectopia  cordis,  495 
Eczema  of  tongue,  512 
Edema  in  acute  diffuse  nephritis,  642 

angioneurotic,  916 

in  Hodgkin's  disease,  288 

of  larynx,  386 

of  lungs  in  cholera,  185 

mahgnant  anthrax,  220 

in  mitral  regurgitation,  467 
Edematous  laryngitis,  366 
Effusion,  pericir.dial,  438 

pleural,  417 

bloody,  429 
Egyptian  chlorosis,  338 


936 


IXDEX 


Ehrlidh's  reaction  in  typiioid  fever,  45 
Electrical  chorea,  894 
Kleph:uil  itch,  69 
lOleplKuiliMsis,  344,  345 
lOlepluLiitdiil  fever  in  filariiwis,  345 
JOnilioIio  aneurysm,  500 
Embolism,  cerebral,  785 

in  croupous  pneumonia,  143 
ill  metastatic  pneumonia,  397 
in  typhoiil  fever,  32 
lMnbryt)eanlia  in  ly|>lioiil  fever,  32 
Jiimpliysenia  in  (lii)htlieria,  156 
of  lungs,  400 

acute,  400,  404 
atropine,  400 

barrel-shaped  chest  in,  400 
chronic,  400 
compensatoi-y,  400,  404 
definition  of,  400 
diagnosis  of,  403 
dyspnea  in,  403 
etiology  of,  400 
frequency  of,  400 
hvpertrophie,  400 
irilerstilial,  400,  405 
morbid  aiiatoniv  of,  401 
))alliiiloKy  of,  4()1 
physical  signs  of,  401 
pi-ognosis  in,  403 
senile,  400 
small-lunged,  405 

treatment  of,  405 
subjective  signs  of,  402 
surgical,  400 
symptoms  of,  401 
treatment  of,  403 
venesection  in,  404 
in  whooping-cough,  103 
Emprosthotonos  in  tetanus,  229 
Empyema,  413,  423 

complications  of,  426 

in  croupous  pneumonia,  139 

definition  of,  423 

diagnosis  of,  426 

from  serous  effusion,  426 
etiology  of,  423 
micro-organisms  in,  423 
ni'frssitntis,  426 
piTN.riMi.in  m,  426 
pli\-lr:,l  -i^ilis  of,  426 
prn.,,,,.,,  ,M,  427 

in   >,';illrl    irvrv,  88 


i-j(; 


in  s.'plicrniia,  172 
syniplomsof,  425 
in  typhoiil  fever,  39 
treatment  of,  427 

aspiration  in,  427 
Encephalitis,  acute,  811 
Encephalomyelitis,  840 
Encephalopathia  saturuina,  779 
Enchirleritis,  (il)litera(ive,  498 

in  ly|)hoid  fever,  25 
I'^ndeniii-  hematuria.  353 
hemoptysis,  353,  355 
multiple  neurit  is,  7S4 
Endocarditis,  454 
acute,  455 

complications  of,  457 
diagnosis  of,  457 
etiology  of,  455 
malignant,  455 
morbid  anatomy  of,  456 
pathology  of,  456 


Endocarditis,  acute,  prognosis  in,  457 
symjjtoms  of,  457 
in  tonsillitis,  519 
tri'al  merit  of,  458 
benign,   155 
chronic,  41)0 

valvular  disease  as  result  of,  461 
ill  croupous  pneumonia,  133,  141 
definition  of,  454 
in  erysipelas,  170 
gonorrheal,  166 
Icnt-a,  459 
mural,  454 
papillary,  455 

in  rheumatic  fever,  acute,  177,  178 
simple,  455 
in  smallpox,  70 
tuberculous  vegetative,  285 
ulcerative,  458 

albuminuria,  459 
cerebral  type  of,  459 
complications  of,  460 
definition  of,  458 
diagnosis  of,  460 
in  erysipelas,  170 
etiology  of,  458 
hematm-ia  in,  459 
malarial  type  of,  459 
morbid  anatomy  of,  458 
pathology  of,  4.58 
prognosis  in,  460 
septic  form  of,  459 
splenic  enlargement  in,  459 
symptoms  of,  459 
treatment  of,  460 
serum  in,  460 
typhoid  type  of,  459 
valvular,  454 
verrucous,  456 
Endothelioma  of  kidney,  668 
in  lung,  412 
of  thjToid  gland,  683 
Entameba  histolytica,  202 
EntamebiE  dysenteriie  in  hepatic  abscess,  602 
Entamebic  dysentery,  201 
Enteric  fever,  17.    Sec  Typhoid  fever. 

intussusception  of  bowel,  579 
Enteritis,  atrophic,  of  tropics,  588 
catarrhal,  566 

sj'mptoms  of,  566 
treatment  of,  566 
Enteroptosis,  582 

definition  of,  582 
diet,  585 
etiologj'  of,  582 
symptoms  of,  584 
treatment  of,  585 
surgical,  585 
Ephemeral  fever,  295 
Epidemic  gangrenous  proctitis,  213 
definition  of,  213 
etiology  of,  213 
pathology  of,  213 
symptoms  of,  213 
treatment  of,  214 
parotitis,  99 
poliomyelitis,  113 
roseola,  98 
sore  tlu'oat,  518 

definition  of,  518 
etiologj'  of,  518 
symjitoms  of,  518 
treatment  of,  518 
Epididymitis  in  typhoid  fever,  38 


INDEX 


937 


Epilepsy,  901 

apoplexy,  905 

aura  in,  902,  904 

complications  of,  905 

convulsions  in,  903 

cry  in,  902 

definition  of,  901 

diagnosis  of,  906 

from  alcoholic  epilepsy,  900 
hysteria,  906 
from  petit  mal,  906 
from  syncope,  906 
from  tetanus,  906 
from  uremia,  906 

etiology  of,  901 

Jacksonian,  902,  909 

localized,  909 

minor,  909 

motor  paralysis  in,  905 

pathology  of,  902 

prognosis  in,  908 

risus  sardonicus  in,  903 

spinal,  887.    See  Paramyoclonus  multiplex. 

symptoms  of,  902 

traumatisms  in,  905 

treatment  of,  908 
Epiphysitis,  syphihtic,  312 
Epistaxis,  364 

etiology  of,  364 

in  leprosy,  292 

in  tick  fever,  298 

treatment  of,  364 
serum  in,  364 
Epithelioma,  cystic,  of  pancreas,  636 
Erb's  juvenile  muscular  dystrophy,  885 

sign  in  gastric  tetany,  534 
of  tetany,  692 
Ergotism,  781 
Erosive,  529 

Eructation,  nervous,  558 
Eruption  in  cerebrospinal  fever,  123 

in  dengue,  118 

in  frambesia,  235 

in  leprosy,  293 

in  measles,  94,  95 

in  miliary  fever,  300 

in  pellagra,  783 

in  rubella,  99 

in  scarlet  fever,  85 

in  smallpo.x,  64,  65 

in  tick  fever,  298 

in  typhus  fever,  57 

in  varicella,  78 

in  verruga,  301 
Eruptive  itch,  69 
Erysipelas,  168 

abscess  in,  170 

complications  of,  170 

definition  of,  168 

endocarditis  in,  170 

etiology  of,  168 

facial,  169 

frequency  of,  168 

incubation  of,  169 

migrans,  170 

morbid  anatomy  of,  169 

pathology  of,  169 

pericarditis  in,  170 

pleuritis,  purulent  in,  170 

prognosis  in,  170 

sequelae  of,  170 

in  smallpox,  70 

symptoms  of,  169 

treatment  of,  170 


Erysipelas,     treatment     of,     antistreptococcic 
serum  in,  171 
local,  171 
in  typhoid  fever,  30 
in  varicella,  78 
Erythema  in  acute  rheumatic  fever,  178 
in  dengue,  118 
endemicum,  783 
scarlatiniform,  89 
Erythremia,  713 
Erythromelalgia,  917 
definition  of,  917 
diagnosis  of,  918 
etiology  of,  917 
treatment  of,  918 
Esbach's  method  for  quantitative  estimation  of 

albumin  in  urine,  676 
Esophagismus,  524 
Esophagitis,  522 
chronic,  523 
membranous,  522 
in  typhoid  fever,  33 
Esophagus,  cancer  of,  525 
prognosis  in,  525 
symptoms  of,  525 
treatment  of,  525 
dilatation  of,  523 
atonic,  524 
diagnosis  of,  524 
diffuse,  523 
dysphagia  in,  524 
etiology  of,  523 
locaUzed,  523 
symptoms  of,  524 
treatment  of,  524 
diseases  of,  522 
spasms  of,  524 

treatment  of,  524 
stricture  of,  organic,  523 
annular,  523 
asymmetrical,  523 
cylindrical,  623 
multiple,  523 
single,  523 
symmetrical,  523 
symptoms  of,  523 
treatment  of,  523 
tuberculosis  of,  278 
ulceration  of,  in  typhoid  fever,  33 
Essential  emphysema,  400 
Ewart's  sign  of  pericardial  effusion,  438 
Exercise  in  treatment  of  pulmonary  tubercu- 
losis, 270 
Exhaustion,  heat,  922 
Exophthalmic  goitre,  683 
Exophthalmos  in  exophthalmic  goitre,  684 
Exudative  nephritis,  642 
Eyeballs,  protrusion  of,  in  exophthalmic  goitre. 


Face,  lion-like  in  leprosy,  293 
Facial  erysipelas,  169 

expression  in  cholera,  184 

in  typhoid,  26 
hemiatrophy,  922 
nerve,  paralysis  of,  875 

diagnosis  of,  876 
etiology  of,  876 
prognosis  m,  877 
symptoms  of,  876 
treatment  of,  877 
spasm,  878 


938 


INDEX 


Facial  spasm,  prognosis  in,  878 

treatment  of,  878 
Fallopian  tubes,  tuberculosis  of,  285 
False  aneurysm,  500 

croup,  368 
Family  ataxia,  830 
Famine  fever,  329 
Farcy,  231 

buds,  232 

chronic,  232 
Fat  necrosis  in  acute  pancreatitis,  631 
Fattj^  degeneration  of  heart,  448 

liver,  614 
Febricula,  295 

definition  of,  295 

diagnosis  of,  295 

etiology  of,  295 

symptoms  of,  295 

treatment  of,  295 
Febris  recurrens,  329 

Fecal  impaction  as  cause  of  intestinal  obstruc- 
tion, 579 
Feliling's  solution,  732 
Fetid  stomatitis,  510 
Fibrillation,  auricular,  472 
Fibrinous  bronchitis,  379 

pericarditis,  437 

plem-isy,  413 

pneumonia,  128 
Fibroma  of  brain,  801 

in  lung,  412 

of  mediastinum,  431 
Fibromata  of  kidney,  668 
Filaria  dim-na,  344 

loa,  344 

nocturna,  343 

perstans,  344 

sanguinis  hominis,  343 
Filariasis,  343 

definition  of,  343 

elephantiasis  in,  344,  345 

elephantoid  fever  in,  345 

filaria  dermarquaii  in,  343 
diui'na  in,  343 
loa  in,  343 
magalhesi  in,  343 
noctm-na  in,  343 

microscopic  demonstration  of,  344 
ozzardi  in,  343 
perstans  in,  343 

hcmatochj'luria  in,  345 

history  of,  343 

lymph  scrotum  in,  346 

morbid  anatomy  of,  344 

pathology  of,  344 

symptoms  of,  345 

treatment  of,  346 

varicose  groin  glands  in,  346 
Fihpino  itch,  69 

Fingers,  club-shaped,  in  mitral  regurgitation,  467 
Flatulence  in  sprue,  590 
Flea,  sand,  357 
Floating  kidney,  638 
Fluke,  genito-minary,  353 

liver,  353,  356 

lung,  355 
Flukes,  353 

Flute-players'  cramp,  914 
Follicular  colitis,  587 

pharyngitis,  517 

stomatitis,  509 

tonsillitis,  518 
Food  poisoning,  781 
Foot-and-nioulh  disease,  299 


Foot-and-mouth  disease,  definition  of,  299 
Foramen  ovale,  persistence  of,  494 
Forohheimcr's  spots  in  rubella,  99 
Foreign  bodies  in  bowel,  579,  582 
Frambesia,  235 

definition  of,  235 
diagnosis  of,  236 

from  syphilis,  230 
from  verruga,  236 
eruption  in,  235,  236 
etiology  of,  235 
history  of,  235 
incubation  of,  235 
prognosis  of,  236 
symptoms,  235 
treatment  of,  236 
tropica,  235 
Friedreich's  ataxia,  830 

definition  of,  830 
diagnosis  of,  832 

from  hereditary  cerebellar  ataxia, 
833 
etiology  of,  831 
gait  in,  832 
history  of,  830 
inco-ordination  in,  832 
morbid  anatomy  of,  831 
pathology  of,  831 
prognosis  in,  833 
speech  in,  832 
symptoms  of,  832 
treatment  of,  833 
disease,    830,     887.      See    Paramyoclonus 
multiplex. 
Fulminant  migi-aine,  919 
Fulminating  purpura,  720 
Fungus  foot  of  India,  234 

ray,  233 
Funnel  chest  in  chronic  hvpertrophic  tonsillitis, 

521 
Fusiform  aneurysm,  500 


Gait  in  Fi-iedreich's  ataxia,  832 

in  locomotor  ataxia,  825 
Galactotoxismus,  782 
Gallbladder,  carcinoma  of,  627 
diagnosis  of,  629 
etiology  of,  627 
jaundice  in,  628 
morbid  anatomy  of,  627 
pathology  of,  627 
prognosis  in,  629 
symptoms  of,  628 
treatment  of,  629 
inflammation  of,  acute,  620 
malignant  growths  of,  627 
perforation  of,  624 
Gallstone  crepitus,  624 
Gallstones,  621 
:  Gangosa,  302 
Gangrene  in  cholera,  185 
diabetic,  729 
of  lung,  405 

cougli  in,  407 

in  croupous  pneumonia,  1.32,  140,  144 

diagnosis  of,  407 

etiology  of,  405 

frequency  of,  406 

morbid  anatomy  of,  400 

odor  of  breath  in,  406 

pathology  of,  406 

septic  diarrhea  in,  407 


INDEX 


939 


Gangrene  of  lung,  sputum  in,  406 
symptoms  of,  406 
treatment  of,  407 
surgical,  407 
pulmonary,  in  bronchiectasis,  378 
in  Raynaud's  disease,  916 
of  skin  in  smallpox,  70 
in  tick  fever,  298 
in  typhoid  fever,  30 
Gangrenous  appendicitis,  573,  574 
pancreatitis,  632 
proctitis,  epidemic,  213 
pyelonephritis,  664 
stomatitis,  511 
Gastralgia,  558 
Gastrectasis,  531 
acute,  535 

diagnosis  of,  536 

from  acute  indigestion,  536 
from  volvulus,  536 
etiology  of,  535 
lavage  in,  536 
morbid  anatomy  of,  535 
prognosis  in,  536 
symptoms  of,  535 
treatment  of,  536 
atonic,  535 
toxic,  535 
Gastric  cancer,  545 

diagnosis  of,  548 

from  gastric  ulcer,  548 
from  pernicious  anemia,  548 
microscopic,  551 
test  meal  in,  549 
duration  of,  551 
etiology  of,  546 
hematemesis  in,  548,  559 
mode  of  spreading,  546 
morbid  anatomy  of,  545 
Oppler-Boas  bacillus  in,  551 
prognosis  in,  551 
symptoms  of,  547 
treatment  of,  551 
vomiting  in,  548 
catarrh,  acute,  525 

definition  of,  525 
diagnosis  of,  526 
etiology  of,  526 
symptoms  of,  526 
treatment  of,  526 
chronic,  528 
changes  in  yellow  fever,  190 
crises  in  locomotor  ataxia,  826 
dilatation,  531 
acute,  535 
definition  of,  531 
diagnosis  of,  534 
etiology  of,  531 
morbid  anatomy  of,  532 
pathology  of,  532 
physical  signs  of,  532 
symptoms  of,  532 
treatment  of,  534 
vomiting  in,  532 
fever,  17 
ectasy,  531' 
hyperperistalsis,  557 

treatment  of,  557 
juice,  h3rpersecretion  of,  558 

hyposeoretion  of,  559 
neuralgia,  558 
neuroses,  556 
tetany,  533 

Chvostek's  sign  in,  534 


Gastric  tetany,  Erb's  sign  in,  534 
Trousseau's  sign  in,  534 
ulcer,  536 

anemia  in,  539 
classes  of,  537 
chronic,  539 
definition  of,  536 
diagnosis  of,  540 

from  duodenal  ulcer,  541 

tests  for  blood  in  stools,  541 
from  gallstone  coUc,  540 
from  gastric  cancer,  541 
from  gastric  crises  of  locomotor 

ataxia,  541 
from  gastric  neuralgia,  541 
x-rays  in,  540 
etiology  of,  536 
frequency  of,  536 
gastro-enterostomy  in,  542 
hematemesis  in,  539,  559 
hemorrhage  in,  treatment  of,  544 
hour-glass  contraction  in,  538 
morbid  anatomy  of,  537 
pathology  of,  537 
perforation  in,  539 
prognosis  in,  541 
symptoms  of,  538 
treatment  of,  542 
dietetic,  543,  544 
sm-gical,  542,  545 
in  typhoid  fever,  33 
Gastritis,  catarrhal,  acute,  525 
chronic,  528 

definition  of,  528 
diagnosis  of,  529 

from  gastric  cancer,  529 
diet  in,  531 
etiology  of,  528 
lavage  in,  530 
morbid  anatomy  of,  528 
pathology  of,  528 
prognosis  in,  530 
symptoms  of,  529 
tongue  in,  529 
treatment  of,  530 
diphtheritic,  527 
erosive,  529 
mycotic,  528 
phlegmonous,  526 
definition  of,  526 
diagnosis  of,  527 
etiology  of,  526 
symptoms  of,  527 
treatment  of,  527 
polyposa,  528 
Gastrodynia,  558 
Gastro-intestinal  paralysis,  535 
Gastroptosis,  582 
Gastrorrhagia,  559 
Gaucher's  disease,  705 
etiology  of,  706 
symptoms  of,  705 
treatment  of,  706 
Genito-urinary  complications  of  typhoid  fever, 
38 
system,  tuberculosis  of,  281 
Geogi-aphical  tongue,  512 
Gerhard's  test  for  acetone  in  urine,  732 
German  measles,  98.    See  Rubella. 
Gibraltar  fever,  215 

Girdle  sensations  in  locomotor  ataxia,  826 
Gland,  thymus,  diseases  of,  693 
Glanders,  231 

bacillus  mallei  in,  231 


940 


INDEX 


Glanders,  chronic,  232 
definition  of,  231 
diagnosis  of,  232 

from  carbuncles,  232 
from  multiple  abscesses,  232 
etiology  of,  231 
morbid  anatomy  of,  231 
pathology  of,  231 
svni|)tnnis  of,  232 
rn'Mliii.'iil  or,  233 
(;iaiMl<,  (liirilr>s,  diseases  of,  681 
saliviuy,  diseases  of,  513 
suprarenal,  diseases  of,  69.5 
Glandular  enlargement  in  bubonic  plague,  198 
in  di|)htheria,  157 
in  rubella,  99 
in  scarlet  fever,  84,  88 
in  whooping-cough,  104 
fever,  296 

definition  of,  296 
diagnosis  of,  297 
etiology  of,  297 

glandular  enlargements  in,  297 
history  of,  296 
nephi'itis  in,  297 
prognosis  in,  297 
treatment  of,  297 
tuberculosis,  245 
Glaucoma,  hemorrhagic,  in  chronic  interstitial 

nephritis,  653 
Glenard's  disease,  582 
Glioma,  of  brain,  801,  802 
Globulin,  antitetanic,  229 
Globus  in  hysteria,  897 
Glomerular  nephritis,  641 

chronic,  645 
Glosso-labio-laryngeal  paralysis,  835 
Glossopharyngeal  nerve,  paralysis  of,  880 
Glottis,  spasm  of,  in  tetanus,  229 
Glycosuria,  725,  728,  729 
Goitre,  681 

benign,  681 
colloid,  681 
cystic,  681 
definition  of,  681 
etiology  of,  681 
exophthalmic,  683 
definition  of,  683 
dj^spnea  in,  686 
etiology  of,  683 
exophthalmus  in,  684 
frequency  of,  683 
Mobius'  sign  in,  685 
morbid  anatomy  of,  684 
nervous  symptoms  of,  686 
operative,  687 
pathology  of,  684 
prognosis  in,  686 
serum  in,  687 
Stelwag's  sign  in,  685 
symptoms  of,  684 
tachycardia  in,  685 
treatment  of,  686 
tremor  in,  686 
von  Graefe's  sign  in,  685 
a;-rays  in,  686 
hyperplastic,  681 
lingual,  681 
malignant,  681 
mixed,  681 
neoplastic,  681 
parenchymatous,  681 
simple,  681 
symptoms  of,  682 


Goitre,  treatment  of,  682 

vascular,  681 
Gold-dust  complaint,  399 
Gonorrheal  arthritis,  ankylosis  in,  166 
chronic,  165 
symptoms  of,  165 
tcnipiirarv,  186 
Iri'alniciit  of,  167 
antigonococcic  serum  in,  167 
endocarditis,  166 
infection,  165 

diagnosis  of,  166 
fascia  in,  166 
prognosis  of,  167 
symptoms  of,  165 
pyemia,  165 
rheumatism,  167 
Gout,  740 

acute,  745 

sj'mptoms  of,  745 
cardiovascular  changes  in,  744 
chronic,  746 

symptoms  of,  746 
definition  of,  740 
diagnosis  of,  747 

from  arthritis  deformans,  747 
etiology  of,  741 
frequency  of,  741 
irregular,  sj'mptoms  of,  740 
joint  changes  in,  743 
morbid  anatomy  of,  743 
pathology  of,  741 
prognosis  in,  747 
retrocedent,  747 
symptoms  of,  745 
treatment  of,  748 
dietetic,  748 
Gouty  lesions  in  chronic  lead  poisoning,  779 
Grain  shovellers'  disease,  398 
Grand  mal,  901 
Granular  kidney,  650 

meningitis,  247 
Graves'  disease,  683 
Green  sickness,  709 
Grindstone  consumption,  399 
Ground  itch,  339 
Guinea-worm,  346 
disease,  346 

definition  of,  346 
distribution  of,  346 
symptoms  of,  347 
treatment  of,  347 
GuU's  disease,  688 
Gumma,  801 

of  pancreas,  637 
Gummata,  syphilitic,  306,  309 
Gunzburg's  reagent,  549 


H 


Haffkine's  antiplague  inoculation,  197 
Hammerer's  palsy,  914 
Hanoi's  cirrhosis  of  liver,  61 1 
Harrison's  groove  in  bronchial  asthma,  382 

in  rickets,  757 
Haut  mal,  901 
Hay  fever,  362 

definition  of,  362 

distribution  of,  362 

etiologj-  of,  362 

morbid  anatomy  of,  362 

jjalhology  of,  362 

prognosis  of,  363 


INDEX 


941 


Hay  fever,  symptoms  of,  303 

treatment  of,  363 
Haygarth's  nodosities  in  arthritis  deformans,  751 
Head  tetanus,  231 
Heart,  aneurysm  of,  453 
causes  of,  453 
forms  of,  453 
symptoms  of,  454 
atrophy  of,  449 
bilocular,  494 
-block,  450 

brown  induration  of,  449 
congenital  defects  of,  494 
degeneration  of,  amyloid,  449 
calcareous,  449 
fatty,  448 
hyaline,  449 
parenchymatous,  448 
dilatation  of,  444,  446 
causes  of,  446 
definition  of,  444 
physical  signs  of,  447 
prognosis  in,  447 
symptoms  of,  447 
treatment  of,  447 
diseases  of,  444 
failure  in  diphtheria,  158 
fragmentation  of,  449 
hypertrophy  of,  444 
definition  of,  444 
diagnosis  of,  445 

from  cardiac  dilatation,  445 
from  pericardial  effusion,  445 
from  tobacco  heart,  446 
physical  signs  of,  445 
prognosis  in,  446 
symptoms  of,  445 
treatment  of,  446 
-muscle,  changes  in,  in  typhoid  fever,  25 
neuroses  of,  487 

definition  of,  4S7 
treatment  of,  490 
palpitation  of,  487 
pulinonary  valves  of,  disease  of,  482 
segmentation  of,  449 
-sounds  in  typhoid  fever,  32 
trilocular,  494 
tuberculosis  of,  285 
in  tjTjhoid  fever,  32 
valves  of,  mechanism  of,  462 
valvular  anomahes  of,  494 
disease  of,  chronic,  461 
causes  of,  461 
treatment  of,  483 
valves  affected  in,  461 
wounds  of,  454. 
Heat  exhaustion,  922 
Heatstroke,  920 

Heat  test  for  albumin  in  urine,  676 
Heberden's  nodes  in  arthritis  deformans,  751 
Hemameba  malariae,  316 
in  man,  318 
in  mosquito,  319 
Hematemesis,  559 
in  aneurysm,  559 

diagnosis  of;  from  hemoptysis,  560 
in  gastric  cancer,  548,  559 

ulcer,  539,  559 
in  hemophilia,  559 
in  hepatic  cirrhosis,  559 
in  purpura,  559 
in  smallpox,  559 
in  yellow  fever,  191,  559 
Hematinuria,  674 


Hematinuiia,  treatment  of,  675 
Hematitis,  suppurative,  714 
Hematochyluria  in  filariasis,  345 
Hematoma  of  dura  mater,  814 
Hematura,  673 

in  bilharzia  disease,  354 

causes  of,  673 

endemic,  353 

in  malarial  fever,  325 

in  movable  kidney,  639 

treatment  of,  674 

in  ulcerative  endocarditis,  459 
Hemianesthesia  in  apoplexy,  791 

in  hysteria,  896 
Hemianopsia,  867 

in  apoplexj',  791 

binasal,  867 

bitemporal,  867 

in  brain  tumor,  803 

homonymous,  867 
Hemiatrophy,  facial,  922 
Hemiplegia  in  apoplexy,  790 

in  croupous  pneumonia,  142 

in  malarial  fever,  326 

pneumonique,  142 

spastic,  795 

in  tj'phoid  fever,  40 

in  uremia,  660 
Hemoglobinuria,  674 

in  croupous  pneumonia,  138 

in  malarial  fever,  325 
Hemolytic  splenomegaly,  706 
Hemopericardiimi,  443 
Hemophilia,  721 

definition  of,  721 

epistaxis  in,  721 

etiology  of,  721 

hematemesis  in,  559 

morbid  anatomy  of,  721 

pathologj'  of,  721 

prognosis  in,  721 

symptoms  of,  721 

treatment  of,  721 
Hemoptysis,  560 

in  bronchiectasis,  378 

endemic,  353,  355 

parasitic,  353,  355 

in  pulmonary  tuberculosis,  261 
Hemorrhage,  cerebral,  785 

in  diphtheria,  159 

in  duodenal  ulcer,  563 

from  lungs,  560 

into  pancreas,  637 

in  pneumonic  plague,  198 

in  pulmonary  tuberculosis,  261 

retinal,  in  malarial  fever,  326 

into  spinal  cord,  846 
definition  of,  846 
diagnosis  of,  847 
etiology  of,  846 
prognosis  of,  847 
symptoms  of,  846 
treatment  of,  847 
membranes,  847 

from  stomach,  559 
symptoms  of,  559 

subconjunctival  in  whooping-cough,  104 

in  typhoid  fever,  29,  33,  34 
diagnosis  of,  34 
symptoms  of,  34 
treatment  of,  51 
Hemon'hagic  affections  of  newborn,  720 

albuminuric  retinitis,  653 

cysts  of  pancreas,  636 


942 


INDEX 


Iloiiiorrhagic    glaucoma  in  chronic    interstitial 
nephritis,  653 
inleniul  pachymeningitis,  814 
measles,  95 
neplu'ilis,  642 
pancreatitis,  acute,  637 
peritonitis,  594 
smallpox,  (iS 
Henoch's  purpm-a,  720 
Hepatic  abscess,  6tJ2 
amebic,  602 

entamebffi  dysenteric  in,  602 
diagnosis  of,  605 

from  empyema,  606 
from  infection  all  gall-ducts,  605 
from  malarial  infection,  605 
in  dysentery,  205 
etiology  of,  602 
fever  in,  605 
morbid  anatomy  of,  603 
multiple,  603 
pathology  of,  603 
prognosis  in,  606 
pyemic,  602 
single  large,  603 
symptoms  of,  605 
traumatic,  602 
treatment  of,  606 
tropical,  602 
artery,  aneurysm  of,  507 
bloodvessels,  affections  of,  612 
changes  in  croupous  pneumonia,  133 
in  malarial  fever,  37 
in  yellow  fever,  191 
cirrhosis,  606.    See  Liver,  cirrhosis  of. 

heraatemesis  in,  559 
complications  in  typhoid  fever,  320 
congestion,  612 

fever  of  Charcot,  intermittent,  624 
tuberculosis,  281 
Hepatitis,  acute,  602 

definition  of,  602 
etiology  of,  602 
Hepatization  of  lung,  410 

in  croupous  pneumonia,  132 
Hereditary  ataxia,  830 

Marie's  cerebellar,  833 
ataxic  paraplegia,  830 
chorea,  893 
syphiUs,  302,  304,  312 
Herpes  in  cerebro.spinal  fever,  123 
in  croupous  pneumonia,  136 
in  typhoid  fever,  30 
Hill  diarrhea,  214 

definition  of,  214 
etiology  of,  214 
pathology  of,  214 
symptoms  of,  214 
treatment  of,  214 
Hiji-joint,  dislocation  of,  in  scarlet  fever,  87 
Hip,    spontaneous    dislocation    of,    in   typhoid 

fever,  40 
Hippocratic  facies  in  acute  peritonitis,  595 
in  cholera,  184 
in  yellow  fever,  191 
Hob-nail  liver,  607 
Hodgkin's  disease,  286 

blood  changes  in,  288 
bronzing  of  skin  in,  289 
definition  of,  286 
diagnosis  of,  289 

from  true  leukemia,  289 
from   tuberculous   Ij'mph   glands, 
289 


Hodgkin's  disease,  dyspnea  in,  288 

etiology  of,  corynebacterium  granulo- 
matis  maligni  in,  287 
hodgkini  in,  287 
history  of,  286 
morbid  anatomy  of,  287 
edema  in,  288 
pathology  of,  287 
prognosis  in,  289 
symptoms  of,  288 
treatment  of,  289 
Hoffman's  sign  of  tetany,  692 
Hookworm  disease,  338 
Horseshoe  kidney,  638 

Hour-glass  stomach,  555.    See  Stomach,  hour- 
glass. 
Human  trypanosomiasis,  333 
Hungarian  itch,  69 
Hunger  typhus,  55 
Huntington's  disease,  893 
Hutchinson's  pupil  in  apoplexy,  792 

teeth  in  syphilis,  312 
HyaUne  degeneration  of  heart,  449 
Hybrid  scarlet  fever,  98 
Hydatid  cysts  of  liver,  351 

of  mediastinum,  431 
of  pancreas,  636 
of  peritoneum,  599 
of  spleen,  703 
Hydrocephalus,  927 
Hydronephrosis,  665 
acquired,  665 
congenital,  665 
definition  of,  665 
diagnosis  of,  666 
etiology  of,  665 
pathology  of,  665 
prognosis  of,  666 
in  tuberculosis  of  kidney,  284 
symptoms  of,  666 
treatment  of,  666 
Hydropericardium,  442 
prognosis  of,  443 
symptoms  of,  443 
treatment  of,  443 
Hydrophobia,  222 
definition  of,  222 
diagnosis  of,  225 

from  pseudohyihophobia,  225 
from  tetanus,  225 
distribution  of,  222 
etiology  of,  223 
frequency  of,  223 
history  of,  222 
incubation  of,  223 
morbid  anatomy  of,  223 
Negi'i  bodies  in,  223 
pathology  of,  223 
prevention  of,  223 
prognosis  of,  225 
symptoms  of,  in  animals,  224 

in  man,  225 
treatment  of,  225 

antirabic  vaccine  in,  226 
by  serum,  226 
Hydropneumothorax,  429 
coin  sound  in,  431 
in  croupous  pneumonia,  140 
metallic  tinkling  in,  431 
physical  signs  of,  431 
Skodaic  resonance  in,  431 
Hydrotherapy  in  typhoid  fever,  47 
Hydrothorax,  428  " 
Hymenolipsis  nana,  350 


INDEX 


943 


Hyperemia  of  kidney,  acute,  040 
chi'onic,  640 

of  liver,  612 
Hyperesthesia  of  stomach,  558 
Hyperleukooytosis  in  scarlet  fever,  84 
Hypernepliromata  of  kidney,  668 
Hyporperistalsis,  gastric,  557 
Hyperplastic  goitre,  681 

tuberculosis,  chronic,  243 
Hypertrophic  cirrhosis  of  liver,  610 

emphysema,  400 

pulmonary  osteo-arthropathy,  765 

rhinitis,  361 

stenosis  of  pylorus,  552 

tonsillitis,  chronic,  521 
Hypertrophy,  pseudomuscular,  884 
Hypodermoclysis  in  cholera  infantum,  570 
Hypoglossal  nerve,  disease  of,  883 
Hypostatic  pneumonia,  410 
Hysteria,  894 

anesthesia,  896 

aphonia  in,  896 

convulsion  in,  895 

in  chorea  minor,  892 

definition  of,  894 

diagnosis  of,  897 

from  organic  nervous  disease,  897 

distm-bances  of  special  sense  in,  896 

etiojogy  of,  894 

globus  in,  897 

hemianesthesia  in,  896 

major,  895 

merycismus  in,  897 

ovarian  tenderness  in,  896 

paralysis  of  motion  in,  896 

pathology  of,  895 

prognosis  in,  898 

pseudo-angina  in,  897 

symptoms  of,  895 
sensory,  896 

tachycardia  in,  897 

treatment  of,  898 
Hysteroepilepsy,  897 


Ice,  infection  by,  in  typhoid  fever,  18 
"  Iced  liver,"  440 
Ichthyosis  lingualis,  513 
Ichthyotoxismus,  782 
Icterus  neonatorum,  630 
Idiocy,  acquired,  798 

amaurotic  family,  798 
Idiopathic  dilatation  of  colon,  592 

muscular  spasm,  691 
Ileocecal  intussusception  of  bowel,  580 
Ileocolic  intussusception  of  bowel,  580 
Ileocolitis  of  childhood,  566 

definition  of,  566 

diagnosis  of,  569 

from  typhoid  fever,  569 

etiology  of,  566 

morbid  anatomy  of,  567 

pathology  of,  567 

prognosis  in,  569 

symptoms  of,  568 

treatment  of,  569 
Ileotyphus,  55 
Immunity,  natural,  to  diphtheria,  Schick 

for,  161 
Impetigo,  69 
Incarcerated  kidney,  638 
Inclusion  bodies  in  scarlet  fever,  89 


Inco-ordination  in  Fricclreicli's  ataxia,  832 

in  locomotor  ataxia,  825 
"India-rubber  bottle  stomach,"  546 
Indicanuria,  679 
test  for,  679 
Indurative  mediastinopericarditis,  440 

parotitis,  chronic,  514 
Infantile  cerebral  paralysis,  795 

eclampsia,  909.    See  Eclampsia,  infantile. 
palsy,  acute.  111 
spinal  paralysis,  111 
scurvy,  760 
Infantilism,  702 
Infarct  of  spleen,  702 

in  septicemia,  172 
Infarction  of  lung  in  typhoid  fever,  39 
Infection,  diseases  due  to  specific,  17 
gonorrheal,  165 
of  larvae  of  diptera,  357 
latent  malarial,  328 
Infectious  jaundice,  296 
Inflammation  of  bUe-ducts,  suppurative,  619 
of  liver,  602 
of  salivary  glands,  514 
Influenza,  106 

bacillus  of  Pfeiffer  in,  106,  107 
bronchitis  in,  107 
chill  in,  107 
compUcations  of,  109 
cardiac,  108,  109 
definition  of,  106 
diagnosis  of,  109 
diarrhea  in,  108 
endemic-epidemic,  106 
etiology  of,  106 
fever  in,  107 
history  of,  106 
incubation  in,  107 
jaundice  in,  108 
kidnej's  in,  109 
meningitis,  108 
mental  disturbances  in,  108 
nervous  manifestations  of,  108 
pleurisy  in,  108 
pneumonia  in,  108 
prophylaxis  of,  111 
pulmonary  congestion  in,  108 
sequelae  of,  109 
symptoms  of,  107 
toxic  neuritis  in,  109 
treatment  of,  110 
vera,  107 
vomiting  in,  108 
Infusoria,  parasitic,  357 
Ingravescent  apoplexy,  792 
Inoculation  preventive  in  plague,  197 
Insolation,  920 

Insomnia  in  croupous  pneumonia,  138 
in  tjrphoid  fever,  26 
treatment  of,  52 
in  uremia,  660 
Insular  sclerosis,  820 
Intermittent  fever,  diagnosis  of,  323 
from  septicemia,  323 
from  tuberculosis,  323 
from  ulcerative  endocarditis,  323 
prognosis  of,  323 
treatment  of,  323 
hepatic  fever  of  Charcot,  624 
malarial  fever,  316 
Interstitial  emphysema,  400,  405 
myocarditis,  acute,  450 

chronic,  450 
nephritis,  chronic,  644 


944 


IXDHX 


Interstitial  neuritis,  857 

pai'otitis,  suppurative,  514 
Intrrvontrii-ul:ir  septum,  perforated,  494 
Ililcsliii.il  ;iinrl,i:isis,  201 

am  isip.si.s  in  lyplioid  fever,  50 
(■liaiij;cs  ill  yellow  fever,  191 
hemorrhage  in  typhoid  fever,  34 

treatment  of,  51 
perforation  in  typhoid  fever,  34 

treatment  of,  52 
myiasis,  358 
obstruction,  579 
acute,  579 
causes  of,  579 
chronic,  579 

by  congenital  malformations,  579 
diagnosis  of,  579 
prognosis  of,  579 
symptoms  of,  579 
treatment  of,  579 
definition  of,  579 
by  f.ii-cif;n  iKi.lies,  579,  582 
by  internal  strangulation,  579,  581 

symptoms  of,  581 
by  intestinal  paralysis,  579 
by  intussusception,  579 
etiology  of,  580 
frequency  of,  580 
pathology  of,  580 
prognosis  in,  581 
symptoms  of,  580 
treatment  of,  581 
by  volvulus,  581 

prognosis  in,  582 
s\'Tnptoms  of,  581 
treatment  of,  582 
ulcers  in  jiaial yiilmid  fever,  53 
Intestines,  diseases  of,  .'itjl 
tuberculosis  of,  278 

clu-onic  hyperplastic,  279 
Intoxications,  771 

Intubation  in  edematous  laryngitis,  367 
Intussusception,  579 
acute,  579 
enteric,  580 
et  ioloKv  of,  580 
frc(|ueiiev  of,  580 
ileoecM'al,'  5S0 
ileocolic,  .580 
pathology  of,  580 
prognosis  in,  581 
retrograde,  580 
subacute,  579 
symptoms  of,  580 
treatment  of,  5S1 
ultra-acute,  579 
Iritis  in  acute  rheumatic  fever,  178 

svphilitic,  309 
Italian  itch,  69 
Itch,  Dhobie,  69 


Jacksonian  epilepsy,  909 

Japanese  measles,  69 

Jaundice  in  acute  pancreatitis,  632 
in  cancer  of  gall-bladder,  628 
catarrhal,  617 
in  cholelithiasis,  623 
In  crou|)i)Us  piH'umonia,  138 
infectious,  296 
in  inllueiiita,  108 
in  new  born,  630,  720 
in  relapsing  fever,  330 


Jaundice  in  typhoid  fever,  37 

in  yellow  fever,  191 
Jaw,  lum|)y,  233 

Joint  complications  in  typhoid  fever,  40 
Joints  in  gonorrheal  infection,  165 

in  gout,  changes  in,  743 

inflammation  of,  in  acute  rheumatic  fever, 
176 

in  verruga,  301 

K 

Kakke,  861 
Kala-azar,  335 

definition  of,  335 
etiology  of,  335 
morbid  anatomy  of,  335 
mortality  of,  335 
pathology  of,  335 
symptoms  of,  335 
treatment  of,  336 
Kangaroo  itch,  69 
Keratitis  in  measles,  96 

syphilitic,  312 
Kernig's  sign  in  meningococcic  meningitis,  123 
Kidnev,  adenoma  of,  668 
alveolar,  668 
IKiiiillary,  66S 
amyloid  disease  of,  057 

definition  of,  657 
etiology  of,  657 
pathology  of,  657 
prognosis  in,  658 
symptoms  of,  657 
treatment  of,  658 
urine  in,  (557 
angiomata  of,  668 
cancer  of,  668 
chronic  contracted,  650 
"cinder-sifting,"  638 
circulatory  distiu-banccs  in,  640 
cirrhosis  of,  650 
contracted,  650 
in  croupous  pneumonia,  133 
cystic  disease  of,  667 
cysts  of,  congenital,  667 
eehinococcus,  668 
multiple,  667 
in  diabetes  mellitus,  changes  in,  727 
diseases  of,  638 
endothelioma  of,  60S 
fibromata  of,  668 
floating,  638 
gi-anvdar,  650 
lioi'seshoe,  638 
hyperemia  of,  acute,  640 
treatment  of,  640 
chronic,  640 

albinninuria  in,  640 
diagnosis  of,  641 
symptoms  of,  640 
treatment  of,  641 
hypernephroniata  of,  668 
incarcerateil,  638 
in  influenza,  109 
large  white,  ()4() 
lesions  in  tliphtheria,  156 
lipomata  of,  668 

in  malarial  fever,  changes  in,  320,  321 
malformations  of,  638 
movable,  638 

definition  of,  638 
diagnosis  of,  638 
Dictl's  crises  in,  639 


INDEX 


945 


Kidney,  etiology  of,  638 

hematuria  in,  639 
symptoms  of,  639 
treatment  of,  640 

papilloma  of,  668 

sarcoma  of,  668 

in  scarlet  fever,  84,  87 

sclerotic,  650 

small  white,  646 

stone  in,  669    • 

suppuration  of,  in  septicemia,  172 

tuberculosis  of,  283 

tumors  of,  668 

malignant,  hematuria  in,  669 
symptoms  of,  669 

in  typhoid  fever,  changes  in,  25 

in  typhus  fever,  57 
Klebs-Loeffler  bacillus  of  diphtheria,  152 
Knee-jerks  in  locomotor  ataxia,  826 
Knife-grinders'  rot,  399 
Kopf-tetanus,  231 
Koplik's  spots  in  measles,  94 
Korssakoff's  disease,  862 
Kreotoxismus,  782 
Kussmaul's  coma  in  diabetes  mellitus,  730 


La  Grippe,  106.    See  Influenza. 
Landouzy-Dejerine  type  of  muscular  dystrophy, 

885 
Landry's  paralysis,  854 
Lane's  kink,  579 
Large-lunged  emphysema,  400 
Larval  plague,  symptoms  of,  199 
Lar3mgeal  diphtheria,  157 
tuberculosis,  259 
ulceration  in  typhoid  fever,  38 
Laryngitis,  catarrhal,  acute,  364 
definition  of,  364 
diagnosis  of,  365 
etiology  of,  364 
intubation  in,  367 
pathology  of,  364 
prognosis  of,  365 
symptoms  of,  365 
treatment  of,  365 
chronic,  366 
diagnosis  of,  366 
patliology  of,  366 
symptoms  of,  366 
treatment  of,  366 
edematous,  366 

cyanosis  in,  367 
definition  of,  366 
diagnosis  of,  367 

from  foreign  body,  367 
from  laryngeal  crises  in  locomotor 
ataxia,  367 
etiology  of,  366 
intubation  in,  367 
pathology  of,  367 
prognosis  in,  367 
symptoms  of,  367 
tracheotomy  in,  367 
treatment  of,  367 
in  smallpox,  70 
spasmodic,  368 

definition  of,  368 
etiology  of,  368 
treatment  of,  368 
syphilitic,  370 

60 


Laryngitis,  syphilitic,  diagnosis  of,  370 

from    tuberculous    ulceration, 
370 
etiology  of,  370 
prognosis  of,  370 
symptoms  of,  370 
trt^atment  of,  370 
tuberculous,  368 
aphonia  in,  369 
cough  in,  369 
definition  of,  368 
diagnosis  of,  369 

from  carcinoma  of  larynx,  369 
from  syphilitic  lar3'ngit)s,  369 
dysphagia  in,  369 
etiology  of,  368 
lesion  in,  369 
pathology  of,  368 
prognosis  of,  369 
symptoms  of,  369 
treatment  of,  369 
Larynx,  diseases  of,  364 
Latah,  911 
Lateral  sclerosis,  836 

amyotrophic,  838 
Lavage  in  chronic  gastritis,  530 
Lead  poisoning,  778 
acute,  778 
chronic,  778 

anemia  in,  780 
blue  line  on  gums  in,  779 
colic  in,  780 
convulsions  in,  779 
diagnosis  of,  780 

from  acute  poliomyelitis,  780 
from     chronic     poUomyelitis, 

780 
from  epilepsy  palsy,  780 
from  pressure  palsy,  780 
etiology  of,  778 
gouty  lesions  in,  779 
morbid  anatomy  of,  779 
neuritis  in,  779 
optic  nem-itis  in,  779 
pathology  of,  779 
prevention  of,  778 
prognosis  in,  780 
squint  in,  779 
sjrmptoms  of,  779 
treatment  of,  780 
wrist-drop  in,  779 
Leathery  stomach,  546 
Leontiasis,  293 
ossea,  765 
Leprosy,  289 

anesthetic,  293 
bacillus  of,  290 
clinical  forms  of,  292 
definition  of,  289 
diagnosis  of,  294 
distribution  of,  290 
epistaxis  in,  292 
eruptions  in,  293 
etiology  of,  290 
history  of,  289 
incubation  period  in,  292 
leontiasis  in,  293 
leprous  chancre  in,  292 
manner  of  infection  in,  290 
mixed,  293 

morbid  anatomy  of,  292 
nodular,  293 
prognosis  in,  294 
prophylaxis  of,  295 


946 


1X1)  EX 


Leprosy,  symptoms  of,  292 
treatment  of,  294 
tubercular,  293 
Leprous  chancre,  292 
Leptomeningitis,  814 
diagnosis  of,  815 
morbifl  anatomy  of,  815 
pathology  of,  815 
symptoms  of,  815 
Ircntinent  of,  816 
L.tJKirnv,  African,  331,  333 
Leukemia,,  714 

definition  of,  714 
diagnosis  of,  717 
etiology  of,  714 
history  of,  714 
lymphatic,  714,  716 

symptoms  of,  716 
morbid  anatomy  of,  715 
myelogenous,  714 
pathology  of,  715 
prognosis  in,  717 
splenomedullary,  714,  715 
blood  changes  in,  715 
spleen  in,  716 
symptoms  of,  716 
treatment  of,  717 
Leukocythemia,  714 
Leukocytosis  in  typhoid  fever,  31 

in  whooping-cough,  103 
Leukoplakia  buccalis,  513 
Lingual  goitre,  681 
Lipomata  of  kidney,  668 
Lithiasis,  398 
Lithuria,  680 
Little's  disease,  799 
Liver,  abscess  of,  602 

diagnosis  of,  605 
in  dysentery,  205 
etiology  of,  602 
multiple,  603 
pathology  of,  603 
prognosis  of,  606 
pyemic,  602 
single  large,  603 
symptoms  of,  605 
traumatic,  602 
treatment  of,  606 
tropical,  602 
amyloid,  614 

symptoms  of,  614 
treatment  of,  614 
angiomata,  cavernous  of,  615 
carcinoma  of,  614 

secondary,  615 
changes  in,  in  typhoid  fever,  25,  37 
in  cholera,  183 
cirrhosis  of,  606 
atrophic,  607 

etiology  of,  607 
hepatic  coma  in,  609 
morbifl  anatomy  of,  607 
pathologj-  of,  607 
physical  signs  of,  609 
prognosis  in,  609 
S3Tnptoms  of,  609 
treatment  of,  610 
capsular,  612 
definition  of,  606 
hypertrophic,  606,  610 
definition  of,  610 
diagnosis  of,  611 
etiology  of,  610 
Hanot's  type,  61 1 


Liver,      cirrhosis     of,     hypertrophic,     morbid 

analomj-  of,  (ilO 
pathology  of,  610 
prognosis  in,  61 1 
symptoms  of,  611 
treatment  of,  61 1 
syphilitic,  611 

treatment  of,  612 
congest  ion  of.  (112 

iiiiliiii-  .■i|.|H';iraiice  in,  613 
s\ni|.l.iMi-  u(.  613 
IrraUiieiil  of,  613 
cystic  disease  of,  615 
diseases  of,  602 
distomatosis  of,  356 
hyperemia  of,  612 
fatty,  614 
flukes,  356 

varieties  of,  356 
hydatid  cysts  of,  351 
"iced,"  440 
inflammation  of,  602 
in  malarial  fever,  changes  in,  320 
pericarditic  pseudocirrhosis  of,  440 
red  atrophy  of,  613 
sarcoma  of,  615 
syphilis  of,  307 
tuberculosis  of,  281 
tumors  of,  614 

diagnosis  of,  615 

from  echinococcus  cyst,  615 
from  gumma,  615 
from  hypertrophic  cirrhosis,  615 
prognosis  in,  615 
symptoms  of,  615 
treatment  of,  616 
in  typhoid  fever,  changes  in,  25 
yellow  atrophy  of,  acute,  616 
definition  of,  616 
diagnosis  of,  616 
etiologj'  of,  616 
morbid  anatomy  of,  616 
pathologj'  of,  616 
prognosis  in,  616 
symptoms  of,  616 
treatment  of,  616 
Lobar  pneumonia,  128 
Lobular  pneumonia,  386 
Localized  epilepsy,  909 

peritonitis,  594 
"Lock-jaw"  in  tetanus,  228 
Locomotor  ataxia,  823 

allochiria  in,  827 
Argj'U-Robertson  pupil  m,  827 
Charcot  joint  in,  828 
crises  in,  826 
cystitis  in,  828 
definition  of,  823 
diagnosis  of,  828 

from  caries  of  vertcbrre,  828 

from  cerebellar  tumor,  828 

from  general  paralysis  of  insane, 

828 
from  paraplegia,  828 
from  peripheral  neuritis,  828 
diplopia  in,  827 
etiologj'  of,  823 
gait  in,  825 

girdle  sensations  in,  826 
history  of,  823 
inco-ordination  in,  825 
knee-jerk  in,  826 
lightning  pains  in,  826 
morbid  anatomy  of,  823 


INDEX 


947 


Locomotor  ataxia,  ocular  symptoms  of,  827 
optic  atrophy  in,  827 
pathology  of,  823 
perforating  ulcer  of  foot  in,  828 
prognosis  in,  828 
Romberg's  symptom  in,  826 
symptoms  of,  825 
treatment  of,  829 
baths  in,  830 
electrical,  830 
Westphal's  symptom  in,  826 
Loculated  peritonitis,  594 
Lombardian  leprosy,  782 
Lucilia  macellaria,  357 
Ludwig's  angina,  520 

symptoms  of,  520 
treatment  of,  521 
Lues,  302 

venerea,  302 
Lumbar  puncture  as  aid  to  diagnosis  of  cerebro- 
spinal fever,  125 
"Lumpy  jaw,"  233 
Lung,  abscess  of,  407 

in  croupous  pneumonia,  132,  140 
congestion  of,  409 
diseases  of,  386 
distomatosis  of,  353,  355 
edema  of,  in  cholera,  185 
emphysema  of,  400 
fever,  128 
flukes,  355 
gangrene  of,  405 

in  croupous  pneumonia,  132,  140,  144 
hemorrhage  from,  560 

hypostatic  congestion  of,  in  tj-phoid  fever, 
38 
in  typhus  fever,  57 
infarction  of,  in  tj-phoid  fever,  39 
syphilis  of,  307 
tumors  in,  412 
Lungs,  diseases  of,  386 
Lymph  nodes,  syphilitic,  308 
scrotum  in  filariasis,  346 
Lymphadenoma  of  mediastinum,  431 
Lymphatic  areas  of  stomach,  546 
constitution,  694 
glands,  tuberculosis  of,  245 
involvement  in  diphtheria,  157 
leukemia,  714,  716 
system,  diseases  of,  681 
Lymphocytosis  in  whooping-cough,  103 
Lymphoma  of  mediastinum,  431 
Lvssa,  222 


M 


McBurney's  point,  575 
Macular  syphilide,  309 
Madura  foot,  234 
Mai  de  sole,  782 
Malarial  fever,  316 

estivo-autumnal,  diagnosis  of,  327 

parasite  of,  319 

symptoms  of,  324 

treatment  of,  327 

ague  cake  in,  321,  326 

blood  changes  in,  320 

examination  in,  320 
bone-marrow  in,  320 
chill  in,  321 
chronic,  316 

changes  in,  320 
comphcations  of,  325 
nervous,  326 


Malarial  fever,  dcfinilimi  of,  316 
distribution  (jf,  317 
etiology  of,  317 

mosquito  as,  317 
hemiplegia,  326 
hepatic  changes  in,  320 
history  of,  316 
intermittent,  316 
morbid  anatomy  of,  320 
nephritic  changes  in,  320,  321 
pathology  of,  320 
pernicious,  316,  325 
algid  form  of,  325 
comatose  form  of,  325 
symptoms  of,  325 
Plasmodium,  316 
prevention  of,  319 
quartan,  parasite  of,  318 

symptoms  of,  321 
relapse  in,  328 
remittent,  316 

sjTiiptoms  of,  324 
retinal  hemorrhages  in,  326 
sequelae  of,  325 
splenic  changes  in,  320,  321 

enlargement  in,  322,  326 
symptoms  of,  321 
tertian,  parasite  of,  318 
sjTnptoms  of,  321 
infection,  latent,  328 
Malformations,  congenital,  of  bowel,  579 

of  kidney,  638 
Malignant  anthi-ax  edema,  220 
goitre,  681 

growths  of  gallbladder  and   biliaiy  ducts, 
627 
of  spleen,  703 
of  vertebrfe,  850 
Mah-maU,  911 
Malta  fever,  215 

comphcations  of,  218 
definition  of,  215 
diagnosis  of,  217 
distribution  of,  215 
duration  of,  217 
etiology  of,  215 
fever  in,  2l6 
history  of,  215 
incubation  of,  216 
micrococcus  melitensis  in,  215 
pathology  of,  216 
prognosis  of,  217 
spleen  in,  216 
symptoms  of,  216 
treatment  of,  218 
Mania  in  uremia,  660 
Manila  itch,  69 

scab,  69 
Marie's  cerebellar  hereditary  ataxia,  833 

disease,  699 
Measles,  92 

bacteriology  of,  92 
"black,"  95 
bronchitis  in,  93,  95 
bronchopneumonia  in,  93,  96 
chill  in,  94 
comphcations  of,  96 

nervous,  96 
conjunctivitis  in,  96 
coryza  in,  94 
diagnosis  of,  97 
diarrhea  in,  96 
diphtheria  in,  96 
distribution  of,  92 


948 


INDEX 


Mciislcs,  eruption  of,  94,  95 
etiology  of,  93 
fever  in,  94 
freciucncy  of,  93 
Gorman,  98.    See  Rubella. 
hcniorrhuKif,  95 
iiiculi.'ition  of,  93 
Ucnititis  in,  96 
"Koplik's  spots"  in,  94 
■leukocytosis  in,  96 
leukopenia  in,  95 
meningitis  in,  96 
morbid  anatomy  of,  93 
noma  in,  96 
pathology  of,  93 
prevention  of,  93 
prognosis  in,  97 
respiratory  form  of,  95 
scquete  of,  96 
stomatitis  in,  96 
symptoms  of,  94 
transmission  of,  mode  of,  93 
treatment  of,  98 
tuberculosis  after,  96 
ulcerations  in,  96 
variations  of,  95 
vomiting  in,  95,  96 
whooping-cough  in,  96 
Mediastinal  glands,  tuberculosis  of,  246 
Mediastinopericarditis,  indurative,  440 
Mediastinum,  abscess  of,  431,  433 
carcinoma  of,  431 
dermoid  cyst  of,  431 
diseases  of,  431 
fibroma  of,  431 
hydatid  cyst  of,  431 
lymphadenoma  of,  431 
lymphoma  of,  431 
sarcoma  of,  431 
teratoma  of,  431 
tumors  of,  431 

abdominal  effusion  in,  432 

dropsy  in,  432 

dyspnea  in,  432 

pain  in,  433 

symptoms  of,  432 
Medina  worm,  346 
Mediterranean  fever,  215 
Molanuria,  680 
Membranous  esophagitis,  522 

pericolitis,  592 
Meniere's  disease,  879 

treatment  of,  879 
Meningeal  tuberculosis,  acute,  247 
Mciiiiiniiis  in  acute  rheumatic  fever,  178 
hasilar,  248 
cerebral,  813 

definition  of,  813 

etiology  of,  813 
cci'i-hrospinal,  120 
ill  crdiipiius  pneumonia,  133,  142 
granular,  247 
in  influenza,  108 
in  measles,  96 
mcningoeoccic,  120 

arthritis  in,  123 

blood  in,  123 

lirudzinski's  contralateral  reflex  in, 

complications  m,  124 

croupous  pneumonia  in,  124 

deafness  from  124 

definition  of,  120 

delirium  in,  123 

diagnosis  of,  124 


Meningitis,  mcningoeoccic,  diagno.sis   of,  from 
acute  poliomyelitis,  125 
from  croupous  pneumonia,  125 
fniin  influenza,  125 
luruliar  puneUire  as  aid  to,  125 
from  tuberrulnus  meningitis,  125 
from  typhoid  fever,  121 
diplococcus  of  Wi'iehselbauni  in,  120 
eruption  in,  123 
etiology  of,  120 
fever  in,  122 
forms  of,  123 
chronic,  123 
intermittent,  123 
malignant,  123 
moderate,  123 
typhoid,  123 
frequency  of,  121 
headache  in,  122 
herpes  in,  123 
history  of,  120 
incubation  of,  122 
Keruig's  sign  in,  123 
morbid  anatomy  of,  122 
nervous  complications,  124 
otitis  media  in,  124 
pathology  of,  122 
prevention  of,  121 
prognosis  of,  127 
respiration  in,  123 

Cheyne-Stokes,  123 
sequelae  of,  124 
symptoms  of,  123 
treatment  of,  127 
serum  in,  127 
vaccine  in,  121 
in  mumps,  101 
spinal,  851 

chronic,  853 

diagnosis  of,  853 
etiology  of,  853 
symptoms  of,  853 
treatment  of,  854 
definition  of,  851 
diagnosis  of,  852 
etiology  of,  851 
morbid  anatomy  of,  852 
pathology  of,  852 
prognosis  in,  853 
symptoms  of,  852 
treatment  of,  853 
in  typhoid  fever,  39,  40 
Meningoencephalitis,  816 
Mental  disturbances  in  influenza,  108 

§tate  in  chorea  minor,  892 
Merycismus,  557 

in  hj'stcria,  897 
Mesenteric  artery,  superior,  aneurysm  of,  507 
glands,  tuberculosis  of,  247 
nodes  in  typhoid  fever,  24 
Mesentery,  cysts  of,  599 
Metallic  tinkling  in  hydropncumothorax,  431 

in  pulmonarj'  tuberculosis,  2(14 
Metastatic  pneumonia,  396 
Micrococcus  catarrhalis  in  acute  coryza,  359 
lanceolatus  in  pneumonia,  128,  131 
melitenhis  in  Malta  fever,  215 
rheumaticu.s  in  acute  rheumatic  fever,  175 
Migraine,  918 

definition  of,  918 
fulgurating,  919 
fulminant,  919 
symptoms  of,  918 
treatment  of,  919 


INDEX 


949 


Mikulicz's  disease,  514 
Miliary  fever,  299 

definition  of,  299 
eruption  in,  300 
etiology  of,  299 
history  of,  299 
prognosis  in,  300 
symptoms  of,  300 
treatment  of,  300 
tubercle,  242 
tuberculosis,  acute,  243 
Milk,  infection  by,  in  typhoid  fever,  18 
sickness,  295 

bacillus  lactamorbi  in,  296 
definition  of,  295 
mortality  in,  296 
symptoms  of,  296 
treatment  of,  296 
Miners'  anemia,  338 
cachexia,  338 
disease,  338 
phthisis,  399 
Minor  epilepsy,  909 
Mitral  regurgitation,  464 

blood-spitting  in,  467 
club-shaped  fingers  in,  467 
cyanosis  in,  467 
diagnosis  of,  468 
dyspnea  in,  467 
edema  in,  467 
pathology  of,  465 
physical  signs  of,  467,  468 
prognosis  in,  468 
symptoms  of,  467 
objective,  467 
subjective,  467 
stenosis,  469 

definition  of,  469 
diagnosis  of,  472 

from  adhesive  pericarditis,  473 
from  Flint's  murmur,  473 
from  tricuspid  stenosis,  473 
etiology  of,  469 
pathology  of,  469 
physical  signs  of,  470 
prognosis  m,  473 
symptoms  of,  470 
Mobius'  sign  in  exophthalmic  goitre,  685 
Monoplegia  in  croupous  pneumonia,  142 

in  uremia,  660 
Morbilh,  92.    See  Measles. 
Morbus  maculosus  neonatorum,  720 
Moro  test  in  acute  meningeal  tuberculosis,  249 
Morphinism,  775 
chronic,  775 

symptoms  of,  775 
treatment  of,  775 
Morvan's  disease,  845 
Motor  neuritis,  861 
Mountain  fever,  297 

Mouth  breathing  in  chronic  hypertrophic  ton- 
siUitis,  521 
diseases  of,  509 
dry,  514 

lesions  in  sprue,  589 
putrid  sore,  510 
Movable  kidney,  638 

spleen,  703 
Movements  in  chorea  minor,  891 

in  paralysis  agitans,  889 
Mucomembrauous  enteritis,  586 
Mucous  colitis,  586 
patches,  513 

in  syphilis,  .309 


Muguet,  511 
Multiple  neuritis,  860 
endemic,  784 
myoclonus,  887 
sclerosis,  820 
serositis,  440 
Mumps,  99 

arthritis  in,  101 
complications  of,  100 
convulsions  in,  101 
definition  of,  99 
etiology  of,  100 
fever  in,  100 
incubation  of,  100 
meningitis  in,  101 
orchitis  in,  100 
pancreatitis  in,  101 
pathology  of,  100 
sequela;  of,  100 
symptoms  of,  100 
treatment  of,  101 
Mural  endocarditis,  454 
Muscle  changes  in  croupous  pneumonia,  133 
Muscles,  diseases  of,  884 
Muscular  atrophy,  peroneal  type  of,  886 
definition  of,  886 
etiology  of,  886 
morbid  anatomy  of,  886 
pathology  of,  886 
prognosis  in,  886 
symptoms  of,  886 
treatment  of,  886 
in  apoplexy,  792 
progressive,  833,  886 

Charcot-ISIarie-Tooth  form  of,  886 
neural,  of  Hoffman,  886 
contractions  in  paramyoclonus   multiplex, 

887 
dystrophies,  884 

definition  of,  884 
Erb's  juvenile,  885 
etiology  of,  884 

Landouzy-Dejerine  type  of,  885 
morbid  anatomy  of,  884 
pathology  of,  884 
treatment  of,  886 
rheumatism,  754 
rigidity  in  paralysis  agitans,  889 

in  tetanus,  228 
spasm,  idiopathic,  691 
tremors  in  typhoid  fever,  26 
Mycetoma,  234 

treatment  of,  235 
Mycotic  aneurysm,  500 

gastritis,  528 
Myelitis,  840 
acute,  840 

etiology  of,  840 
morbid  anatomy  of,  840 
paraplegia  in,  841 
pathology  of,  840 
prognosis  in,  842 
symptoms  of,  841 
treatment  of,  842 
ascending,  840 
central,  840 
chronic,  842 

definition  of,  842 
diagnosis  of,  843 
etiology  of,  842 
morbid  anatomy  of,  843 
pathology  of,  843 
prognosis  in,  843 
symptoms  of,  843 


950 


INDEX 


Myelitis,  chronic,  treatment  of,  843 
flefiiiition  of,  840 
clcscc'iKliiifi;,  S40 

clisSCMlilKllcil,   840 

sul):iriilc,  MO 
trill:SV(TSC,  SIO 
Myel(if;<'iHius  lciikcmi;i,  714 
MyeUmiiilacia,  S44 
Myelopathic  albumosuria,  680 
Myiasis,  358 

intestinal,  358 
Myocarditis,  450 
acute,  450 
chronic,  450 
definition  of,  450 
interstitial,  acute,  450 

chronic,  450 
Nauheim  baths  in,  452 
physical  signs  of,  451 
prognosis  in,  451 
in  rheumatic  fever,  acute,  178 
in  smallpox,  70 
symptoms  of,  451 
treatment  of,  451 
in  typhoid  fever,  32 
in  typhus  fever,  57 
Myocardium,  (I(nini'r:ition  of,  448 
anulohl,   1  I'.i 
cal("iiv..iis,  44!) 
falty,  44S 
hj-aiine,  449 
parenchymatous,  448 
prognosis  of,  449 
symptoms  of,  449 
disease  of,  448 
tuberculosis  of,  285 
Myoclonus,  887.    Sec  Paramyoclonus  multiplex, 
epilejiticus,  887 
multiple,  887 
Myomalacia  cordis  in  syphihs,  306 
Myositi.s,  acute,  in  diphtheria,  155 

in  typhoid  fever,  40 
Myotonia  congenita,  886 
definition  of,  886 
symptoms  of,  887 
Myriachit,  911 
Mytilotoxismus,  781 

InviUiirut  of,  782 
Mvx'''i''ni:i,  (iss 

(■oiiu:riiil:il,  tiSS 
defiuitiDii  of,  688 
etiology  of,  688 
frequency  of,  688 
morbid  anatomy  of,  688 
pathology  of,  688 
prognosis  in,  688 
treatment  of,  688 

thyroid  gland  in,  689 


N 


Nasal  catarrh,  atrophic,  361 
chronic,  361 

diphtheria,  157 
Nauheim  bulhs  in  myocarditis,  452 
NeapnliiiLii  feviT,  215 
Negri  bullies  in  hydrophobia,  223 
Nematodes,  336 
Neoplastic  goitre,  681 
Nephritic  changes  in  yellow  fever,  190 
Nephritis,  acute,  641 

in  glandular  fever,  296 

caseative,  063 


Nephritis  in  cholera,  185 

desquamative,  chronic,  645 
ilKTuse,  acute,  611 

(lelinilion  iif.  li  1 1 
diaKiiusis  of,  (ilM 
i-liolnny  of,  641 
incirbiii  anatomy  of,  641 
edeiiia  in,  642 
liathdlogy  of,  641 
l)rognosis  of,  643 
symptoms  of,  642 
treatment  of,  643 
urine  in,  642 
chronic,  645 
in  diphtheria,  1.56 
exudative,  642 
glomerular,  641 
hemorrhagic,  642 
interstitial,  chronic,  644,  650 

hemorrhagic  glaucoma  in,  653 
Hirschberg's  vessels  in,  653 
pathology  of,  650 
prognosis  in,  655 
retinal  detachment  in,  653 

lesions  in,  653 
sj'mptoms  of,  652 
cerebral,  653 
circulatory,  652 
respiratory,  653 
treatment  of,  655 
climatic,  657 
dietetic,  656 
medicinal,  656 
urme  in,  652 
parenchj'matous,  chronic,  643,  644,  645 
coma,  646 
definition  of,  643 
diagnosis  of,  647 
dropsy  in,  646 
etiology  of,  644 
frequency  of,  644 
morbid  anatomy  of,  645 
pathology  of,  645 
prognosis  in,  647 
retinitis  in,  646 
symptoms  of,  646 
treatment  of,  648 
dietetic,  648 
lu-ine  in,  646 
in  scarlet  fever,  84,  87 
syphilitic,  306 
tubular,  chi-onic,  645 
in  typhoid  fever,  28,  38 
in  varicella,  78 
Nephrolithiasis,  669 
colic  in,  671 
definition  of,  669 
diagnosis  of,  671 

from  acute  appendicitis,  671 
from  gallstone  colic,  671 
from  hydronepltfosis,  671 
from  neui'algia,  671 
from  twist  of  ureter,  671 
etiologj'  of,  669 
frequency  of,  670 
pathology  of,  669 
prognosis  in,  670 
symptoms  of,  671 
treatment  of,  671 
urine  in,  671 
Nerve,  abducens,  paralysis  of,  873 
auditory,  diseases  of,  878 
facial,  diseases  of,  875 
glossopharyngeal,  paralysis  of,  880 


INDEX 


951 


Nerve,  hypoglossal,  diseases  of,  883 
oculomotor,  disoaMes  of,  870 
olfactory,  diseases  of,  865 
optic,  diseases  of,  865 

paralysis  of,  867 
pathetic,  paralysis  of,  871 
trifacial,  paralysis  of,  871 
vagus,  diseases  of,  880 
Nerves,  cranial,  diseases  of,  865 
diseases  of,  857 
inflammation  of,  857 
Nervous  complications  of  acute  rheumatic  fever, 
178 

of  malarial  fever,  326 

of  scarlet  fever,  88 

of  typhoid  fever,  39 
diseases,  functional,  886 
disorders  of  gastric  secretion,  558 
eructation,  558 
exhaustion,  899 
manifestations  in  diphtheria,  156,  157 

in  influenza,  108 
system  in  diabetes  mellitus,  changes  in,  727 

diseases  of,  785 

syphilis  of,  308,  310 
Neuralgia,  gastric,  558 
Neurasthenia,  899 
definition  of,  899 
diagnosis  of,  900 
etiology  of,  899 
prognosis  of,  900 
symptoms  of,  899  ' 

treatment  of,  900 
Neuritis,  857 

cervicobrachial,  859 

prognosis  in,  860 

treatment  of,  860 
in  croupous  pneumonia,  143 
definition  of,  857 
diagnosis  of,  858 
in  diphtheria,  156 
endemic  multiple,  780 
etiology  of,  857 
interstitial,  857 
morbid  anatomy  of,  857 
motor,  861 
multiple,  860 

definition  of,  860 

diagnosis  of,  863 

etiology  of,  860 

prognosis  in,  863 

symptoms  of,  861 

treatment  of,  864 
obstetrical,  860 
optic,  865 

in  brain  tumor,  802 

in  oiu'onic  lead  poisoning,  779 

symptoms  of,  865 

treatment  of,  866 
parenchymatous,  857 
pathology  of,  857 
periaxial,  of  Gombault  in  lead  poisoning, 

779 
peripheral,  860 

in  chronic  arsenical  poisoning,  862 
lead  poisoning,  779,  862 
prognosis  in,  858 
retrobulbar,  866 
sciatic,  860 
symptoms  of,  857 
toxic,  in  influenza,  109 
treatment  of,  858 
in  typhoid  fever,  40 
Neuroma  of  bi'ain,  801 


Neuroretinitis,  albuminuric,  653 

in  syphilis,  310 
Neuroses,  gastric,  550 
of  heart,  487,  490 
occupation,  914 
traumatic,  912 

definition  of,  912 
etiology  of,  913 
paralyses  in,  913 
symptoms  of,  913 
treatment  of,  914 
Neurotic  atrophy,  886 
Newborn,  hemorrhagic  affections  of,  720 

jaundice  in,  630,  720 
Nitric  acid  test  for  albumin  in  urine,  676 
Nodding  spasm,  883 
Nodular  colitis,  587 
Nodules,  leprous,  293 
Noma,  511 

in  measles,  96 
Nose,  diseases  of,  359 
Nummular  sputum  in  tuberculosis,  261 
Nutrition,  diseases  of,  723 
Nystagmus  in  disseminated  sclerosis,  821 


Obesity,  762 

definition  of,  762 
etiology  of,  762 
symptoms  of,  762 
treatment  of,  762 
dietetic,  763 
ObUterative  appendicitis,  573 
Obstetrical  neuritis,  860 
Obstruction,  intestinal,  579 
Occupation  neuroses,  914 
Ochronosis,  766 

Ocular  compUcations  of  diabetes  mellitus,  730 
muscles,  disturbances  of  motility  of,  873 
symptoms  in  apoplexj',  790 

in  disseminated  sclerosis,  821 
in  locomotor  ataxia,  827 
Oculomotor  nerve,  diseases  of,  870 
paralysis  of,  870 

diagnosis  of,  871 
prognosis  in,  871 
symptoms  of,  870 
Ogo,  302 

Oidium  albicans  in  thrush,  511 
Olfactory  nerve,  diseases  of,  865 
Ophthalmoplegia,  874 
etiology  of,  874 
externa,  874 
interna,  874 
pathology  of,  874 
symptoms  of,  875 
treatment  of,  875 
Opisthotonos  in  tetanus,  229 
Oppler-Boas  bacillus  in  gastric  cancer,  551 
Optic  atrophy,  866 

in  diabetes  mellitus,  730 
diagnosis  of,  867 
etiology  of,  866 
in  locomotor  ataxia,  827 
pathology  of,  866 
prognosis  in,  867 
symptoms  of,  866 
treatment  of,  867 
nerve,  inflammation  of,  865 
neuritis  in  brain  tumor,  802 

in  chronic  lead  poisoning,  779 
Orchitis  in  malarial  fever,  326 


952 


INDEX 


Orchitis  in  mumps,  100 
in  typlioid  fevor,  38 
Oriental  sore,  335,  336 
Oroya  fever,  300,  301 
Orthostatie  albuminuria,  676 
Osteitis  (Icriiruians,  765 
Osteo-arllirili.s,  7  19 

Osteo-artliroijathy,  pulmonary,  in  bronchiectasis, 
378 

hypertrophic,  765 

in  pulmonary  tuberculosis,  262 
Osteoma  in  lung,  412 
Osteomyelitis  in  typhoid  fever,  4(1 
Otitis  media,  acute,  in  typhoid  fever,  40 

in  croupous  pneumonia,  144 

in  scarlet  fever,  84,  87 
Ovaries,  tuberculosis  of,  285 
Ox-heart  in  aortic  regurgitation,  478 
Oxaluria,  679 
Oxyuris  vermicularis,  337 
Oysters,  infection  by,  in  tvphoitl  fever,  18 
Ozena,  361,  362 


Pachymeningitis,  813 

cervical,  hypertrophic,  851 
diganosis  of,  814 
externa,  813 
interna,  813,  814 

morbid  anatomy  of,  814 

pathology  of,  814 

symptoms  of,  814 
morbid  anatomy  of,  813 
pathology  of,  813 
prognosis  in,  814 
symptoms  of,  813 
treatment  of,  814 
Paget's  disease,  765 
Painters'  colic,  780 
Palpitation  of  heart,  487 
Palsy,  acute  infantile.  111 
birth,  860 
hammerers',  914 
scriveners',  914 

shaking,  888.    See  Paralysis  agitans. 
Pancreas,  adenoma,  637 
carcinoma  of,  637 
cystadenoma,  636 
cystic  epithelioma  of,  636 
cysts  of,  636 

hemorrhagic,  636 

hydatid,  636 

proliferation,  636 

pscudo-,  636 

retention,  636 
diseases  of,  630 
gumma  of,  637 
hemorrhages  into,  637 
sarcoma  of,  637 
tumors  of,  637 
Pancreatic  calculus,  636 

symptoms  of,  636 

treatment  of,  636 
cysts,  636 

diagnosis  of,  637 

prognosis  in,  637 

symptoms  of,  637 

treatment  of,  637 
tumors,  637 
Pancreatitis,  630 
acute,  630 

constipation  in,  632 

diagnosis  of,  632 


Pancreatitis,  acute,  diagnosis  of,  from  fulmina- 
ting appendicitis,  633 
from  intestinal  obstruction,  632 
fj-om  perforation  of  duodenum,  632 

of  gastric  ulcer,  632 
from  rupture  of  gallbladder,  633 
from  suppurative  cholecystitis,  633 
ctiologj'  of,  630 
fat-necrosis  in,  631 
history  of,  630 
jaundice  in,  632 
inorljid  anatomy  of,  631 
liatlicilogy  of,  631 
pmunosis  in,  633 
.s\iiili(omsof,  632 
ticalnient  of,  633 
chronic,  630,  634 
diagnosis  of,  634 

from  cancer  of  head  of  j-ancreas, 

634,  635 
from  gallstones   in  common  duct, 

634,  635 
from  subphrenic  abscess,  634 
interacinar,  634 
interlobular,  634 
interstitial,  634 
intralobular,  634 
prognosis  in,  635 
symptoms  of,  634 
treatment  of,  635 
definition  of,  630 
gangrenous,  632 
hemorrhagic,  acute,  637 
in  mumps,  101 
subacute,  632 

symptoms  of,  632 
treatment  of,  634 
suppurative,  632 
Papillary  endocarditis,  455 
PapiUitis,  865 

albuminuric,  653 
Papilloma  of  kidney,  668 
Paracentesis  abdominis  in  ascites,  602 

thoracic  in  pleurisy  with  effusion,  421,  422 
Paracholecystitis,  620 
Paragonimus   westermaimi    in    distomatosis    of 

lung,  355 
Paralysis  of  abducens  nerve,  873 
agitans,  888 

definition  of,  888 
diagnosis  of,  889 

from  multiple  sclerosis,  889 
from  senile  tremor,  890 
etiology  of,  888 
movements  in,  889 
muscular  rigidity  in,  889 
pathology  of,  889 
prognosis  in,  890 
symptoms  of,  889 
treatment  of,  890 
tremor  in,  889 
ascending,  acute,  854 

definition  of,  854 
diagnosis  of,  855 
etiology  of,  854 
morbid  anatomy  of,  854 
pathology  of,  854 
prognosis  in,  855 
symptoms  of,  854 
treatment  of,  855 
atrophic,  acute,  111 
of  bowel,  591 
in  brain  tumor,  803 
bulbar,  835 


INDEX 


953 


Paralysis,  bulbar,  apoplectiform,  785 
diagnosis  of,  836 
etiology  of,  835 
morbid  anatomy  of,  835 
pathology  of,  835 
prognosis  in,  836 
symptoms  of,  835 
treatment  of,  836 
cerebral,  infantile,  795 

convulsions, in,  796 
definition  of,  795 
deformities  in,  796,  797,  798 
diagnosis  of,  798 

from  amaurotic  family  idiocy, 

798 
from  hereditary  spastic  spinal 
paralysis,  798 
etiology  of,  796 
lesions  in,  796 
morbid  anatomy  of,  796 
paralysis  in,  797 
pathology  of,  796 
prognosis  in,  798 
symptoms  of,  796 
in  diphtheria,  156,  158,  159 
of  facial  nerve,  875 
gastro-intestinal,  535 
general,  of  insane,  816 
glosso-labio-laryngeal,  835 
glossopharyngeal  nerve,  880 
of  internal  and  external  muscles  of  eyeball, 

874 
Landry's,  854 

monoplegic,  in  croupous  pneumonia,  142 
of  oculomotor  nerve,  870 
of  pathetic  nerve,  871 
periodical,  923 

of  spinal  accessory  nerve,  883 
atrophic,  chronic,  833 
infantile.  111 
spastic,  syphilitic,  838 
of  trifacial  nerve,  871 
in  whooping-cough,  104 
Paralytic  chorea,  892 

dilatation  of  stomach,  535 
Paramyoclonus  multiplex,  887 
definition  of,  887 
diagnosis  of,  888 

from  chorea,  888 
from  electrical  chorea,  888 
from  h}'sterical  spasm,  888 
from  "maladie  des  tics  convulsifs,'' 
888 
etiology  of,  887 
muscular  contractions  in,  887 
prognosis  in,  888 
treatment  of,  888 
Paraphasia,  800 

Paraplegia  in  acute  myeUtis,  841 
ataxic,  hereditary,  830 
senile,  844 

symptoms  of,  844 
treatment  of,  844 
spastic,  836 
Parasites,  animal,  diseases  due  to,  316 
Parasitic  hemoptysis,  353,  355 
infusoria,  357 
stomatitis,  511 
strumitis,  681 
Parasyphilitic  affections,  308 
Parathyroid  gland,  diseases  of,  691 
Paratyphoid  fever,  53 
bacillus,  21 
bacteriology  of,  53 


Paratyphoid  fever,  complications  of,  54 
diagnosis  of,  54 
intestinal  ulcers  in,  53 
pathology  of,  53 
prevention  of,  53 
prognosis  of,  54 
splenic  enlargement  in,  53 
symptoms  of,  54 
treatment  of,  54 
Parenchymatous  degeneration  of  heart,  448 
goitre,  081 

nephritis,  acute,  643,  644 
neuritis,  857 
Paresis,  816 

Parkinson's  disease,  888.     See  Paralysis  agitans. 
Parotid  abscess,  514 

bubo,  514 
Parotitis,  epidemic,  99.    See  Mumps, 
in  cholera,  185 
chronic  indurative,  514 
in  croupous  pneumonia,  144 
in  scarlet  fever,  88 
suppurative  interstitial,  514 
in  t3rphoid  fever,  33 
Parry's  disease,  683 
Pathetic  nerve,  paralysis  of,  871 
symptoms  of,  871 
Pectoriloquy,  264 
"Peg"  teeth  in  syphilis,  312 
Peliomata  in  tj^ahoid  fever,  30 
Peliosis  rheumatica,  719 
Pellag:-a,  782 

blood  in,  784 
diarrhea  in,  783,  784 
eruption  in,  783 
etiology  of,  783 
history  of,  782 
prognosis  of,  784 
symptoms  of,  783 
nervous,  783 
synonyms  of,  782 
treatment  of,  784 
Pemphigus  neonatorum  in  syphilis,  312 
Peptic  ulcer,  536 

Perforation  of  bowel  in  typhoid  fever,  34,  35 
in  duodenal  ulcer,  563 

S3rmptoms  of,  563 
in  empyema,  426 
of  gaUbladder,  624 
in  gastric  ulcer,  539 
Perforative  appendicitis,  573 
Pericardial  effusion  in  croupous  pneumonia,  137 
diagnosis  of,  438 

from  aortic  aneurysm,  439 
from  cardiac  dilatation,  439 

hypertrophy,  439 
from  pleural  effusion,  439 
physical  signs  of,  438 
tuberculosis,  250 
"Pericarditic  pseudocirrhosis  of  hver,"  440 
Pericarditis,  acute,  435 

definition  of,  435 
diagnosis  of,  438 

from  phthisis.  438 
etiology  of,  435 
forms  of,  436 
frequency  of,  435 
pathology  of,  436 
physical  signs  of,  437 
prognosis  in,  439 
saddle-leather  sound  in,  438 
symptoms  of,  437 
treatment  of,  439 
chronic,  440 


954 


INDEX 


Pericarditis,  chronic  adhesive,  440 
definition  of,  440 
diagnosis  of,  442 
patliology  of,  440 
physical  signs  of,  442 
prognosis  in,  442 
])ulsus  paradoxus  in,  442 
symptoms  of,  441 
treatment  of,  442 
in  croupous  pneumonia,  133,  141 
in  erysipelas,  170 
externa  et  interna,  440 
in  rheumatic  fever,  acute,  177,  178 
serofibrinous,  acute,  436 

symptoms  of,  438 
in  smallpox,  70 
in  typhoid  fever,  32 
PericarcUuxn,  diseases  of,  435 

tuberculosis  of,  251 
Pericholecystitis,  620 
Pericohtis,  membranous,  592 
Perihepatitis,  612 
Perinephritic  abscess,  672 
Perineuritis,  857 

Period  of  steep  curves  in  typhoid  fever,  28 
Periodic  rhinitis,  362 
Periodical  paralysis,  923 
Peripheral  neuritis,  860 
Peristaltic  unrest,  557 
Peritoneal  abscess,  594 

tuberculosis,  251 
Peritoneum,  cancer  of,  599 
cystic  adenoma  of,  599 
diseases  of,  592 
hydatid  cyst  of,  599 
morbid  growth  of,  599 
sarcoma  of,  599 
tuberculosis  of,  251 
Peritonitis,  acute,  592 

complications  of,  595 
definition  of,  592 
diagnosis  of,  596 

from  acute  hemorrhagic  pancreati- 
tis, 596 
from  gallstone  colic,  596 
from  hysteria,  596 
from  intestinal  obstruction,  596 
from  perforation  of  stomach,  596 
from  tyjihoid  fever,  596 
etiology  of,  592 
Hippocratic  facies  in,  595 
micro-organisms  in,  593 
morbid  anatomy  of,  594 
pathology  of,  594 
prognosis  in,  596 
sequela  of,  595 
symptoms  of,  594 
treatment  of,  596 

counter-irritation  in,  597 
tympany  in,  595 
adhesive,  sclerotic,  chronic,  598 
in  amebic  dysentery,  207 
chronic,  598 
chronic  forms  of,  598 
circumscribed,  594 
hemorrhagic,  594 
localized,  594 
loculated,  594 
putrid,  594 
in  scarlet  fever,  88 
septic,  594 
tuberculous,  251 
in  typlioid  fever,  35 

diagnosis  of,  35 


Pernicious  anemia,  710 

malarial  fever,  316,  325 
Pertussis,  101.    .SVe  Whooping-cough. 
Pestis  minor,  199 
Petechia;  in  relapsing  fever,  330 
in  smallpox,  ()7 
in  typhoid  fever,  30 
in  tj'phus  fever,  56,  57 
Petechial  fever,  120 
Petit  mal,  909 

Peyer's  patches  in  typhoid  fever,  23 
Pharyngitis,  acute,  515 

definition  of,  515 
etiology  of,  515 
pathology  of,  515 
prognosis  in,  516 
symptoms  of,  515 
treatment  of,  516 
local,  510 
chronic,  517 

etiology  of,  517 
pathology  of,  517 
symptoms  of,  517 
treatment  of,  517 
croupous,  517 

etiology  of,  517 
treatment  of,  517 
follicular,  517 

etiology  of,  517 
treatment  of,  518 
phlegmonous,  516 
in  typhoid  fever,  33 
ulcerative,  516 

etiology  of,  516 
sjTiiptoms  of,  516 
treatment  of,  516 
Pharynx,  diseases  of,  515 
tuberculosis  of,  278 
Phlebitis  in  typhoid  fever,  32 
Phlebosclerosis,  598 
Phlebotomous  fever,  218 
Phlegmonous  gastritis,  526 

pharjmgitis,  516 
"Phosphatic  diabetes,"  679 
Phosphaturia,  679 
Phthisis,  syphiUtic,  308 

ventriculi,  529 
Pianists'  cramp,  914 
Pigeon-breast,  382 

in  chronic  hypertrophic  tonsillitis,  521 
Pin-worm,  337 

Pistol-shot  sound  in  aortic  regurgitation,  480 
Pituitary  body,  diseases  of,  699 
Plagiomonas  urinaria,  357 
Plague,  194 

bacillus  of,  195 
bubonic,  194,  197 
buboes  in,  198 
fever  in,  197,  198 
glandular  enlargomonts  in,  198 
sj'mptoms  of,  198 
vomiting  in,  198 
definition  of,  194 
diagnosis  of,  199 
distribution  of,  194 
etiology  of,  195 
frequency  of,  196 
historv  of.  194 


larval,  ^yri 

l.tnnis  of.  199 

mode  I'l  1  r 

iM-iiii--iun  of,  195 

patholoMic 

1  •iMMlomy  of,  197 

llllclUIIUIlil 

:ilburiiiiiuria  in,  198 

blc.nil 

•hangcs  in.  198 

hemiirrhagc  in,  198 


INDEX 


955 


Plague,  pneumonic,  relapses  in,  199 
sputum  in,  198 
symptoms  of,  198 
prognosis  in,  199 
prophylaxis  of,  196 
protective  inoculation  in,  197 
septicemic,  symptoms  of,  198 
symptoms  of,  197 
treatment  of,  199 
Plasmodium  falciparum,  319 
malarife,  316,  318 
of  malarial  fever,  316 
vivax,  318 
Pleura,  diseases  of,  413 
Pleural  effusion,  417 
bloody,  429 
purulent,  423 
Pleurisy,  413 
chronic,  427 

definition  of,  427 
primitive  dry,  428 
in  croupous  pneumonia,  133,  139 
definition  of,  413 
dry,  413,  414 

cough  in,  416 
diagnosis  of,  416 

from  intercostal  neuralgia,  416 
from  muscular  rheumatism,  416 
soreness,  416 
fever  in,  415,  416 
friction  somid  in,  415 

pleuropericardial,  415 
pain  in,  415 
physical  signs  of,  415 
prognosis  in,  416 
symptoms  of,  415 
treatment  of,  416 
etiology  of,  413 
fibrinous,  413 
forms  of,  413 
frequency  of,  414 
influenza,  108 
purulent,  413 

in  erysipelas,  170 
serofibrinous,  413 
in  smallpox,  70 
tuberculous,  250,  413 
in  typhoid  fever,  39 
with  effusion,  417 

cytoscopy  in,  421 
diagnosis  of,  420 

from  hydatid  cyst  of  liver,  420 
from    hypostatic    congestion, 

420 
from  new  growths  in  lung,  420 
from  pleurisy  with  thickening, 

420 
from  pneumonia,  420 
from  pneumothorax,  421 
from  pulmonary  edema,  420 
from  subphrenic  abscess,  421 
from     tubercular     consolida- 
tion, 420 
duration  of,  420 
dyspnea  in,  418 

paracentesis  thoracis  in,  421,  422 
physical  signs  of,  418 
posture  in,  418 
prognosis  in,  421 
symptoms  of,  418 
treatment  of,  421 
blisters  in,  423 
diaphoretics  in,  422 
diuretics  in,  422 


Pleurisy  with  effusion,  treatment  of,  purges  in, 
422 
tapping  in,  422 
Pleuritis,  413.    Sec  Pleurisy. 
Plumbism,  774.    See  Lead  poisoning. 
Pneumogastric  nerve,  disea.se  of,  SSO 
symptoms  of,  881 
treatment  of,  881 
Pneumonia,  aspiration,  387 
catarrhal,  386 
croupous,  128 

abscess  in,  132,  140 

aphasia,  transitorj',  in,  142 

arthritis  in,  143 

blood  in  diagnosis  of,  145 

brain  softening  in,  143 

bronchiectasis  in,  141 

bronchitis  in,  133 

cardiac  changes  in,  133 

in  cerebrospinal  fever,  125 

chill  in,  134 

compHcations  of,  139 

congestion  of  lung  in,  131 

convulsions  in,  138 

cough  in,  135 

crisis  in,  139 

protracted,  139 

cyanosis  in,  136 

definition  of,  128 

delirium  in,  134,  136,  138 

diagnosis  of,  144 

from   acute   pulmonarj'   tubercu- 
losis, 145 
from  appendicitis,  145 
from  catarrhal  pneumonia,  145 
from     hjTDOstatic     congestion     of 

lung,  145 
leukocjiiosis  in,  145 
from  pleurisy  with  effusion,  145 
from  pulmonary  infai'ction,  145 

distribution  of,  130 

dyspnea  in,  136 

embolism  in,  143 

empyema  in,  139 

endocarditis  in,  133,  141 

engorgement  of  lung  in,  131 

etiology  of,  129 

fever  in,  134 

frequency  of,  140 

gangrene  in,  132,  140,  144 

gi'ay  hepatization  in,  132 

headache  in,  134 

hemiplegia  in,  142 

hemiplegie  pneumonique,  142 

hemoglobiuuria  in,  138 

hepatic  changes  in,  133 

hepatization  in,  gray,  132 
red,  131 

herpes  in,  136 

hydi-opneumothorax  in,  140 

incubation  of,  134 

insomnia  in,  138 

jaundice  in,  138 

meningitis  in,  133,  142 

micrococcus    lanceolatus    in,    128, 
131 

monoplegia  va.,  142 

morbid  anatomy  of,  131 

muscle  changes  in,  133 

nephritic  changes  in,  133 

nervous  symptoms  of,  138 

neuritis  in,  143 

otitis  media  in,  144 

pain  in,  134 


956 


INDEX 


Pneumonia,  froupous,  paralysis  in,  mono])Iogic, 
142 
parotitis  in,  144 
pathology  of,  131 
pericardial  effusion  in,  137 
pericarditis  in,  133,  141 
physical  signs  of,  in  first  stage,  135 

in  well-developed  stage,  136 
pleui-isy  in,  133,  139 
pneurnoeoecus  of  Fraenkel,  128 
prevention  of,  131 
prognosis  in,  145 

ratio   of   blood-pressure   to   i)ulse 
rate  in,  147 
pseudoerisis  in,  139 
pulse  in,  134,  135,  136 
rilles  redux  in,  139 
red  hepatization  in,  131 
relapse  in,  144 
renal  changes  in,  133 
respirations  in,  134,  135 
skin  in,  138 
sputum  in,  135 
sweating  in,  138 
symptoms  of,  134 

in  developed  stage,  135 
in  stage  of  onset,  134 
of  resolution,  139 
temperature  in,  134 
tongue  in,  138 
treatment  of,  147 
tympanites  in,  138 
unusual  changes  in  lung  in,  132 
urine  in,  137,  145 
varieties  of,  144 
venous  thrombosis  in,  143 
fibrinous,  128 
hypostatic,  410 
in  influenza,  108 
lobar,  128 
lobular,  386 
metastatic,  396 
abscess  in,  397 
definition  of,  396 
embolism  in,  397 
etiology  of,  396 
pathology  of,  396 
prognosis  in,  398 
sputum  in,  397 
symptoms  of,  397 
treatment  of,  398 
pyemic,  397 
in  typhoid  fever,  28,  38 
Pneumonic  plague,  symptoms  of,  19S 
Pneumonitis,  128 
Pneumonoconiosis,  398 
definition  of,  398 
etiology  of,  398 
pathologj'  of,  399 
prognosis  in,  399 
symi)toms  of,  399 
treatment  of,  399 
Pneuino])ericardium,  443 

baei'.illus  aerogenes  capsulatus  in,  443 
jirognosis  of,  444 
s}'in])toms  of,  443 
treatment  of,  444 
Pneumothorax,  429 
definition  of,  429 
diagnosis  of,  430 

from  diaphragmatic  hernia,  430 
from  emphysema,  430 
from  pyopneumothorax  subphrenieus, 
430 


Pneumothorax,  dyspnea  in,  430 
etiology  of,  429 
history  of,  429 
physical  signs  of,  430 
prognosis  in,  430 
in  puliTionnrv  tuberculosis,  262 
syinplniiis  of,  429 
syni'(il)e  in,  430 
treatment  of,  430 
in  whooping-cough,  104 
Podagra,  740 
Poisoning,  alcoholic,  767 
acute,  767 
chronic,  768 
arsenical,  777 
by  cheese,  782 
by  ergot,  781 
by  fermented  maize,  783 
by  fish,  782 
food,  781 

by  impure  milk,  782 
lead,  acute,  778 

clu-onic,  778 
by  meat,  782 
morphine,  chronic,  775 
by  mussels.  781 
Poker  back,  752 

Polioencephalitis  superior  of  Wernirke,  S12 
Pohomyelitis,  840 

anterior,  acute,  111 

convulsions  in,  115 
definition  of.  111 
diagnosis  of,  115,  116 
in  diphtheria,  156 
etiology  of.  111 
morbid  anatomy  of,  113 
paralysis  in,  114 
pathology  of,  113 
prognosis  in,  116 
symptoms  of,  114 
treatment  of,  116 
chronic,  833 

Aran-Duchenne  type  of,  834 
claw-hand  in,  834 
definition  of,  833 
diagnosis  of,  834 

from  amyotrophic  lateral  scle- 
rosis, 834 
from  muscular  dystrophy,  834 
from  neuritis,  835 
from  syringomyelia,  835 
drop-foot  in,  834 
etiology  of,  833 
morbid  anatomy  of,  833 
pathology  of,  833 
prognosis  in,  835 
symptoms  of,  834 
treatment  of,  835 
Poliomyeloencephalitis,  acute.  111 
definition  of.  111 
diagnosis  of,  115,  116 
etiolog>-  of,  111 
morbiii  anatomy  of,  113 
pathology  of,  113 
prevention  of,  113 
|)rognosis  of,  116 
symptoms  of,  114 
treatment  of,  116 
Polycythemia,  splenomegalic,  chronic,  713 
definition  of,  713 
etiology  of,  713 
moibid  anatomy  of,  713 
pathology  of,  713 
symptoms  of,  714 


INDEX 


9o7 


Polycythemia,    splenomcgalic,    chronic,    treat- 
ment of,  714 
Polyneuritis,  860 
Polyuria  in  typhoid  fever,  38 
Porencephaly,  796 
Pork-worm,  350 
Portal  vein,  thrombosis  of,  613 
Porto  Rican  anemia,  338 
Porto  Rico  itch,  69 

scratches,  69 
Postui'e  in  plem'isy  with  effusion,  418 
Potassium    ferrooyanide    test   for    albumin    in 

urine,  676 
Potters'  rot,  398 
Pox,  302 
Pregnancy,  smallpox  complicating,  71 

typhoid  fever  complicating,  41 
Prevention  of  smallpox,  62 

of  tetanus,  228 
Primitive  dry  pleurisy,  428 
Proctitis,  epidemic  gangrenous,  213 
Progressive  muscular  atrophy,  833 
Proliferation  cysts  of  pancreas,  636 
Prophylaxis  of  acute  poliomyeloencephalitis,  113 
against  diphtheria,  161 
influenza,  111 
plague,  196 
scarlet  fever,  83 
smallpox,  72 
tetanus,  228 
yellow  fever,  189 
Pseudoangina  in  hysteria,  897 
Pseudocrisis  in  croupous  pneumonia,  139 
Pseudocysts  of  pancreas,  636 
Pseudohydrophobia,  225 
Pseudoleukemia,  286 
Pseudolyssaphobia,  225 
Pseudomembranous  colitis,  588 

pyelonephritis,  664 
Pseudomuscular  hypertrophy,  884 

prognosis  in,  885 
Pseudotabes  arsenical,  777 
Psilosis,  588 
Psoriasis,  buccal,  513 
Psorospermiasis,  331 
Psychoneurosis  maidica,  782 
Ptyahsm,  513 
Puerperal  eclampsia,  910 
"Puking  fever,"  295 
Pulex  penetrans,  357 
Pulmonary  abscess,  407 
diagnosis  of,  409 
etiology  of,  407 
multiple,  408 
prognosis  m,  409 
in  septicemia,  172 
symptoms  of,  409 
treatment  of,  409 
in  typhoid  fever,  39 
compUcations  of    rheumatic    fever,    acute, 

178 
congestion,  409 

in  influenza,  108 
emphysema,  400 
gangrene,  405 

in  bronchiectasis,  378 
edema  in  cholera,  185 
osteo-arthropathy  in  bronchiectasis,  378 
hypertrophic,  765 
in  pulmonary  tuberculosis,  262 
regurgitation,  483 
stenosis,  483 
tuberculosis,  255 
valves  of  heart,  diseases  of,  482 


Pulsus  paradoxus  in  chronic  adhesive  pericardi- 
tis, 442 
Purpura,  719 

causes  of,  719 
fulminating,  720 
hematemesis  in,  559 
hemorrhagica,  720 
Henoch's,  720 
micro-organisms  in,  719 
in  rheumatic  fever,  acute,  178 
rheumatica,  719 
treatment  of,  720 
Purulent  pericarditis,  436 
pleural  effusion,  423 
pleurisy,  413 
Pus  in  urine,  678 
Putrid  fever,  55 
peritonitis,  594 
sore  mouth,  510 
PyeUtis,  662 
Pyelonephritis,  662 
catarrhal,  664 
definition  of,  662 
diagnosis  of,  664 

from  aneurysm,  665 
from  malarial  fever,  664 
from  perinephritis  abscess,  664 
from  suppm-ative  cystitis,  664 
from  typhoid  fever,  664 
etiologj'  of,  663 
gangrenous,  664 
micro-organisms  m,  663 
morbid  anatomy  of,  664 
patholog}'  of,  664 
prognosis  in,  665 
pseudomembranous,  664 
suppurative,  663,  664 
symptoms  of,  664 
treatment  of,  665 
Pyemia,  171.    See  Septicemia. 

gonorrheal,  165 
Pyemic  abscess  of  Kver,  602 

pneumonia,  397 
Pylephlebitis,  suppurative,  613 
Pylorospasm,  557 

Pylorus,  stenosis  of,  congenital,  553,  554 
hypertrophic,  552 

definition  of,  552 
diagnosis  of,  553 

from    cicatricial    contraction, 

553 
from  gastric  cancer,  553 
etiology  of,  552 
morbid  anatomy  of,  552 
prognosis  of,  554 
symptoms  of,  553 
treatment  of,  554 
Pym's  fever,  218 
Pyonephritis,  663 
Pyonephi-osis,  663 

in  tuberculosis  of  kidney,  284 
Pyopericardium,  438 
Pyopneumothorax,  429 
Pyuria,  678 

treatment  of,  678 
in  tjrphoid  fever,  38 


Quartan  parasite  of  malarial  fever,  318 
Quincke's   pulse   in   aortic   regurgitation, 
478 


958 


INDEX 


Rabies,  222 

flumb,  224 
K;icliilic  rosiiry,  757 
Hacliitis,  7.55 
HaKWCcd  fever,  362 

Hales  reiliix  in  ernuijous  pneumonia,  139 
Haslies,  inill:,l,  in  Miiiillp.ix,  07 
Ray  riiie^ii-  III  :,rii,iMiiivr(,,sis,  233 
Kaynaii.lV  diM-ise,  IMii 

definition  of,  916 

etiology  of,  916 

gangrene  in,  916 

treatment  of,  916 
Recrudescence  in  typhoid  fever,  29 
Rectal  crises  in  locomotor  ataxia,  S26 
Rectum,  tuberculosis  of,  279 
Ked-lislit  treatment  of  smallpox,  74 
Redundancy  of  colon,  592 
Reflexes  in  apoplexy,  790 
Regurgitation,  aortic,  476 
mitral,  464 
puliiinn.-irv,   IN3 

tl-irll~|ihl.     ISd 

Relapsi-  ill  cioiipdiis  pneumonia,  144 
Relapsing  fever,  329 

chill  in,  330 

crisis  in,  331 

definition  of,  329 

delirium  in,  331 

distribution  of,  329 

etiologj'  of,  329 

fever  in,  330 

history  of,  329 

incubation  in,  330 

jaundice  in,  330 

morbid  anatomy  of,  330 

pathology  of,  330 

petechias  in,  330 

prognosis  of,  331 

relapse  in,  331 

spirillum  in,  329 

spirocheta  novyi  in,  329 
recurrentis  in,  329 

spleen  in,  330 

symjjtonis  of,  330 

treatment  of,  331 

vomiting  in,  330 
Remittent  fever,  bilious,  324 

complications  of,  325 

diagnosis  of,  327 

hemoglobinuria  in,  325 

prognosis  of,  327 

sequela;  of,  325 

symptoms  of,  324 

treatment  of,  327 
Renal  arterj',  aneurysm  of,  508 
asthma,  382 
calculus,  069 

changes  in  croujious  pneumonia,  133 
colic,  671 
disease,  acute,  in  typhoid  fever,  28 

in  diphtheria,  159 
tuberculosis,  283 
Respira(()i\'  lesimis  in  typhoid  fever,  25 

SyMrlM.    illM-;lsesof,"359 

Retenlion  (■\>i  ni'  pancreas,  636 

Retinal  hemorrhages  in  malarial  fever,  326 

lesions  in  chronic  interstitial  nephritis,  653 
Retinitis,  albmninuric,  in  chronic  parenchyma- 
tous nephritis,  646 
degenerative,  653 
hemorrhagic,  653 


Retinitis,  albuminuric,  in  puerperal  eclampsia 
910 
typical,  653 
diabetic,  730 
Retrobulbar  neuritis,  866 
Retrocedr-iit  gout,  747 
Retnigra.le  intus.-iisreption  of  bowel,  580 
Relropeiiluneal  glands,  tuberculosis  of,  247 
Rheumatic  fever,  acute,  174 
arthritis  in,  176 
bacteriology  of,  175 
chorea  in,  178 
complications  of,  177 
definition  of,  174 
delirium  in,  178 
diagnosis  of,  179 

from  arthritis,  acute,   179 

septic,  179 
from  gonorrheal  rheumatism, 

179 
from    mono-articular  inflam- 
mation, 179 
from  osteomyelitis,  acute,  179 
distribution  of,  174 
duration  of,  177 
endocarditis  in,  177,  178 
erythema  in,  178 
etiology  of,  175 
iritis  in,  178 
joints  in,  176 
meningitis  in,  178 
micrococcus  rhcumaticus,  175 
morbid  anatomy  of,  176 
myocarditis  in,  178 
nervous  complications  in,  178 
pericarditis  in,  177,  178 
prognosis  of,  179 
puhnonarj'  complications  in,  178 
purpura  rheumatica  in,  178 
rheumatic  nodules  in,  178 
sweating  in,  176 
symptoms  of,  176 
tongue  in,  176 
treatment  of,  179 
urine  in,  177 
urticaria  in,  178 
Rheumatism,  acute  articular,  174.     See  Rheu- 
matic fever,  acute, 
chronic,  753 

definition  of,  753 
etiology  of,  753 
morbid  anatomy  of,  753 
symptoms  of,  753 
treatment  of,  753 
gonorrheal,  167 
muscular,  754 

treatment  of,  754 
Rheumatoid  arthritis,  749 

in  bronchiectasis,  378 
Rhinitis,  atrophic,  361 
hjTJertrophic,  361 
periodic,  362 
syphilitic,  312 
Rhinopharj'ngitis  mutilans,  302 
Rice-water  stools  in  Asiatic  cholera,  183 
Rickets,  755 

bossy  frontals  in,  757 
chicken-breast  in,  757 
definition  of,  755 
dentition  in,  757 
diagnosis  of,  758 
etiology  of,  755 
Harrison's  groove  in,  757 
morbid  anatomy  of,  756 


INDEX 


r).')f) 


Rickets,  |)niijnnsis  in,  75S 
.SVIIl|llnl,ls..r,  757 

truiiliiii'Ml  of,  75S 
Risus  siirdoiiicus  in  epilepsy,  903 

in  tetanus,  228 
Rook  fever,  215 

Rooky  mountain  spotted  fever,  297 
Romberg's  symptom  in  looomotor  ataxia,  826 
Rose  cold,  362 

rash  in  rubella,  99 

spots  in  typhoid  fever,  27 
Roseola,  epidemic,  98 

in  syphilis,  309 
Rotch's  sign  of  pericardial  effusion,  438 
Rotheln,  98.    See  Rubella. 
Round-worm,  336 
Rubella,  98 

definition  of,  98 

diagnosis  of,  99 

from  measles,  99 
from  scarlet  fever,  99 

eruption  in,  99 

etiology  of,  99 

Forchheimer's  spots  in,  99 

glandular  enlargements  in,  99 

incubation  of,  99 

prognosis  in,  99 

"rose  rash"  of,  99 

symptoms  of,  99 

treatment  of,  99 
Rubeola  notha,  98 

Rumpel-Leede  test  for  scarlet  fever,  89 
Running  amok,  911 
Rupture  of  spleen,  326,  703 
Russian  tapeworm,  350 


Saccharomyces  albicans  in  thrush,  511 
Sacculated  aneurysm,  500 
Saddle-leather  sound  in  acute  pericarditis,  438 
Salivary  glands,  diseases  of,  513 

functional  disorders  of,  513 
mflammation  of,  514 
swelling,  bilateral,  514 
Salivation,  513 
Sand  flea,  357 
Sanduhrmagen,  555 

Sansom's  sign  of  pericardial  effusion,  438 
Sarcoma  of  brain,  801 
of  kidney,  668 
of  liver,  615 
in  .lung,  412 
of  mediastinum,  431 
of  pancreas,  637 
of  peritoneum,  599 
of  thyroid  gland,  683 
Saturnine  epilepsy,  779 
Scarlatina,  79 
Scarlet  fever,  79 

anaphylactic  manifestations  in,  84 
bacillus  diphtheria3  in,  87 
bacteriology  of,  82 
bronchopneumonia  in,  88 
"collar  of  brawn"  in,  84 
compUcations  of,  87 
definition  of,  79 
desquamation  in,  85,  89,  92 
diagnosis  of,  88 

from  erythema  soarlatiniform,  89 
from  German  measles,  88 
from  nephritic  eruption,  89 
from  rash  of  sepsis,  89 


Scarlet  fever,  diugno.sis  of,  from  rose  ru-sh  of 
indigestion,  88 
from  syphilitic  rash,  88 
dislor.'ition  of  hip-joint  in,  87 

di.s(rilMili.,ii  ,,!,  79 

(Tllpl  Mill    III,    S.'l 

|j(iuli:irilius  of,  85 
etiology  of,  79 
fever  in,  85 
fulminant  form  of,  86 
glandular  enlai'gemcnts  in,  84,  88 
history  of,  79 
hybrid,  98 

hyperleukocj'tosis  in,  84 
"inclusion  bodies"  in,  89 
incubation  period  of,  84 
kidneys  in,  84,  87 
malignant,  86 
morbid  anatomy  of,  S3 
mortality  of,  90 
nephritis  in,  84,  87 
nervous  complications  in,  88 
otitis  in,  84,  87 
parotitis  in,  88 
pathology  of,  83 
peritonitis  in,  88 
prognosis  of,  90 
prophjdaxis  of,  83 
Rumpel-Leede  test  for,  89 
septic  arthritis  in,  87 
infections  in,  84 
sequela}  of,  87 
sore  throat  in,  84,  85,  86 
"strawberry  tongue"  in,  89 
streptococcus  conglomerans  in,  82 
suppression  of  urine  in,  86 
surgical,  86 
symptoms  of,  84 
temperature  in,  85 
treatment  of,  90 

antiscarlatinal  serum  in,  92 
hygienic,  90 
valvular  disease  of  heart  in,  88 
vomiting  in,  85 
Schick  test  of  natural  immunity  against  diph- 
theria, 161 
Schistosoma  hematobium  in  bilharzia  disease, 

353 
"Sohluok-pneumonie,"  387 
Schonlein's  disease,  719 
Sciatica,  860 

treatment  of,  860 
Scleroderma,  765 

treatment  of,  766 
Sclerosis,  disseminated,  820 

Argyll-Robertson  pupil  in,  821 
definition  of,  820 
diagnosis  of,  822 

from  general  paralysis  of  insane, 

822 
from  hysteria,  822 
from  locomotor  ataxia,  822 
from  paralysis  agitans,  822 
from  spastic  paraplegia,  822 
etiology  of,  820 
morbid  anatomy  of,  820 
nystagmus  in,  821 
pathology  of,  820 
prognosis  in,  822 
symptoms  of,  821 
treatment  of,  822 
insular,  820 
lateral,  836 

amyotrophic,  838 


960 


INDEX 


Sclerosis,  lateral,   amyotrophia,  Ual)inski  reflex 
in,  839 
definition  of,  838  I 

diagnosis  of,  839  . 

from  bulbar  paralysis,  839 
from  syringomyelia,  839 
etiology  of,  838 
pathology  of,  838 
prognosis  in,  840 
symptoms  of,  839 
treatment  of,  840 
ankle  clonus  in,  837 
Babinski  reflex  in,  837 
definition  of,  836 
diagnosis  of,  837 
etiology  of,  836 
history  of,  836 
morbid  anatomy  of,  836 
pathology  of,  836 
prognosis  in,  837 
StriimpoU's  family  type  of,  836 
symptoms  of,  836 
treatment  of,  837 
multiple,  820 
spinal,  posterior,  823 
Sclerotic  kidney,  650 

peritonitis,  chronic  adhesive,  5J» 
Scorbutus,  759 
Screw-worm,  357 

treatment  of  infection  by,  358 
Scriveners'  palsy,  914 
Scrofula,  245 
Scurvy,  759 

definition  of,  759 
diagnosis  of,  761 
etiology  of,  759 
infantile,  760  __^ 

morbid  anatomy  of,  loJ 
pathology  of,  759 
symptoms  of,  760 
treatment  of,  761 
Scat-worm,  337  _ 
Secondary  anemia,  707 
Secretion,  gastric,  nervous  disor.lers  of,  5o8 

treatment  ot,  ouS 
Segmentation  of  heart  muscle,  449 
Senile  emphysema,  400 

paraplegia,  844 
Sepsis  in  empyema,  426 
Septic  arthritis  in  scarlet  fever,  8/ 
in  smallpox,  71 
diarrhea  in  pulmonary  gangrene,  407 
peritonitis,  594 
pneumonia,  397 
Septicemia,  171 
anemia  in,  172 
blood  in,  172 
chill  in,  172 
chronic,  173 
definition  of,  171 
diagnosis  of,  173 
empyema  in,  172 
etiology  of,  171        , 
infarction  of  spleen  m,  li^ 
morbid  anatomy  ot,  171 
pathology  of,  171 
pulmonary  abscess  m,  1  /^ 
subacute,  173  ■      ,--, 

suppm-ation  oMvidney  m,  1(2 
sweating  in,  172 
symptoms  of,  172 
treatment  of,  173  . 

antistreptococcic  serum  m,  17^ 
Septicemic  plague,  symptoms  of,  198 


Septum,  interventricular,  pprf™"i^c(l,  494 
Serofibrinous  pericarditis,  acute,  436,  438 

pleurisy,  413 
Serositis,  nmltiple,  440 
Serous  diarrhea,  565 

membranes,  tuberculosis  of,  247 
Serum  antitlii>hthenli(;^162,  103 
antigonococric,  16* 
antimeningococcic,  127 
antirabic,  226 
antiscarlatinal,  92 
antistreptococcic,  m_erysipelas,  in 

in  septicemia,  173 
antitetanic,  229 
antitubercle,  275 
treatment  of  dysentery,  210 
of  exophthalmic  goitre,  68 < 
of  pulmonary  tuberculosis,  Iio 
of  ulcerative  endocarditis,  40U 
Seven  days'  fever,  329 
ISgKlsl    .SeeParab-sisagitans. 
Shiga's  baciUus  in  dysentery,  201 
Ship  fever,  55 
Siderosis,  398 
Simla  diarrhea,  214 
Sitotoxismus,  781 
Skin  changes  in  typhoid  fever,  30 
in  verruga,  301 
eruptions,  s>'phil»t''=',  308,  309 
gangrene  of,  in  smallpox,  <0 
in  Hodgkin's  disease,  289 

i^^S-enu'tiof of,  in  Addison's  disease,  697 
Skodaic  resonance  in  hydropneumothorax,  431 
Sleeping  sickness,  331,  333 
diagnosis  of,  334 
etiology  of,  333 
pathology  of,  334 
prognosis  in,  334 
symptoms  of,  334 
treatment  of,  334 
"Slows"  in  cattle,  295 
I  Smallpox,  60  .,    ,   ,.  .   rq 

I         aberrant  manifestations  ol,  69 
abscesses  in  ,^70 
aphonia  in,  70 
backache  in,  65 
bed-sores  in,  70 
black,  68 
bronchitis  in,  "0  _ 
bronchopneumonia  m,  lO 
complications  of,  70 
confluent,  68  .      „, 

cytoryctes  vaccmx  m,  61 
definition  of,  60 
delirium  in,  6J 
diagnosis  of,  71  _ 

from  chicken-pox,  i  i 
from  measles,  71     __ 
from  scarlet  fever,  / 1 
from  syphilides,  71 
distribution  of,  61 
earache  in,  70 
endocarditis  in,  70 
eruption  in,  64,  65 

development  of,  65 
forms  of,  65  K 
on  mucous  membrane,  b( 
stages  of,  65 
variations  in,  67 
erysipelas  in,  70 
etiology  of,  61_ 
fever  in,  65,  67 


INDEX 


961 


Smallpox,  forms  of,  69 
frequency  of,  64 
gangrene  of  skin  in,  70 
hematemesis  in,  559 
lieailachc  in,  65 
hemorrhagic,  68 
history  of,  60 
incubation  of,  61 
laryngitis  in,  70 

mode  of  spreading  contagion,  61 
morbid  anatomy  of,  64 
mj'ocarditis  in,  70 
pathology  of,  64 
pericarditis  in,  70 
plem'isy  in,  70 
in  pregnancy,  71 
prevention  of,  62 
prognosis  of,  72 
pulse  in,  65 
rashes  in,  67 
septic  arthritis  in,  71 
sequeliB  of,  70 
symptoms  of,  65 
temperature  in,  65,  67 
treatment  of,  73 
red-light,  74 
urine  in,  65 

vaccination  as  a  preventive,  62,  74 
varioloid,  69 
Smokers'  tongue,  513 
"Snuffles,"  304 
Soor,  511 

Sore  mouth,  putrid,  510 
throat,  515 

auctioneer's,  517 
clergymen's,  517 
in  diphtheria,  156 
epidemic,  518 

definition  of,  518 
etiology  of,  518 
symptoms  of,  518 
treatment  of,  518 
in  scarlet  fever,  84,  85,  86 
ulcerated,  516 
Spanish  measles,  69 
Spasm  of  diaphragm  in  tetanus,  228 
facial,  878 

of  glottis  in  tetanus,  229 
muscular,  idiopathic,  691 
nodding,  883 
of  esophagus,  524 
sewing,  914 
Spasmodic  croup,  368 
laryngitis,  368 
wryneck,  882 
Spasmus  nutans,  883 
Spastic  diplegia,  795,  797 
hemiplegia,  795 
paraplegia,  836 
Speech  in  Friedreich's  ataxia,  832 
Spinal  accessory  nerve,  disease  of,  882 
symptoms  of,  882 
paralysis  of,  883 
cord,  compression  of,  848 
by  aneurysm,  850 
definition  of,  848 
by  disease  of  vertebrae,  848 
diagnosis  of,  849 
prognosis  in,  849 
symptoms  of,  849 
treatment  of,  850 
etiology  of,  848 

by  hypertrophic   cervical    pachy- 
meningitis, 851 
61 


Spinal   cord,  compression   of,  by   hypertrophic 
cervical      pacliy- 
moningitis,  symp- 
toms of,  851 
treatment  of,  851 
by  malignant  growths,  850 
hemorrhage  into,  846 
definition  of,  846 
diagnosis  of,  847 
jjrognosis  in,  847 
symptoms  of,  846 
treatment  of,  847 
inflammation  of,  840 
syphilis  of,  308,  310 
tulDerculosis  of,  286 
epilepsy,  887.     See  Paramj'oclonus  multi- 
plex, 
membranes,  hemorrhage  into,  847 
definition  of,  847 
etiology  of,  847 
extrameningeal,  847 
intrameningeal,  847 
prognosis  in,  848 
sjonptoms  of,  84S 
treatment  of,  848 
meningitis,  851 

chronic,  853 
paralysis,  atrophic,  chronic,  833 
infantile.  111 
spastic,  syphilitic,  838 
sclerosis,  posterior,  823 
S3'philis,  308,  310 
Spine  typhoid,  40 
Spirillum  cholerae  asiaticas,  181 

of  relapsing  fever,  329 
Splanchnoptosis,  582 
Spleen,  abscess  of,  703 
diseases  of,  702 
in  diphtheria,  156 

enlargement  of,  in  paratyphoid  fever,  53 
epithelioma  of,  primary,  705 
in  hepatic  cirrhosis,  608 
hydatid  cyst  of,  703 
infarct  of,  702 

in  septicemia,  172 
in  malarial  fever,  326 

changes  in,  320,  321 
maUgnant  growths  of,  703 
in  Malta  fever,  216 
movable,  703 
in  relapsing  fever,  330 
ruptm-e  of,  326,  703 
in  splenic  anemia,  704 
in  splenomeduUary  leukemia,  705,  716 
in  typhoid  fever,  24,  26,  28,  702 
in  typhus  fever,  57 
wandering,  703 

treatment  of,  703 
Splenic  anemia,  704 

artery,  aneurysm  of,  507 
Splenization  of  lung,  410 
SplenomeduUary  leukemia,  714,  715 
Splenomegalic  polycythemia,  chronic,  713 
Splenomegaly,  hemolytic,  706 
large-celled,  705 
primary,  705 
tropical,  335 
Spondylitis  deformans,  752 

rhizomelique,  752 
Spotted  fever,  55,  120,  297 
Sprue,  588 

anemia  in,  .590 
definition  of,  588 
diagnosis  of,  590 


902 


i.\i)i':x 


Sprue,  iliarrhe.a  in,  590 
i-licilnnv  of,  589 
fhilulcMcn  in,  590 
iiKiiilli  lesions  of,  589 
|)atli(,l.]ny  of,  589 
pretlisposing  causes  of,  588 
prognosis  in,  590 
symptoms  of,  589 
tonKue  in,  5S9 
treiihiii'Ml  of,  590 
Sputum  111  hiniiehial  asthma,  382 
iu  hronel.MvlMsis,  H77 
in  croupous  pneunioiiia,  135 
in  distoiii;iio-,is  of  lung,  350 
in  motashitic  pucuuionia,  397 
in  pneumonic  plague,  198 
in  pulmonary  gangrene,  406 
tuberculosis,  261 

microscopic  examination  of,  265 
Squint  in  chronic  lead  poisoning,  779 
St.  Anthony's  fire,  168 
St.  Gothard's  tunnel  disease,  338 
St.  Vitus'  dance,  890.    See  Chorea  minor. 
Status  epilepticus,  904 

thymolymphaticus,  694 
definition  of,  694 
etiology  of,  694 
morbid  anatomy  of,  694 
.     pathology  of,  694 
symptoms  of,  695 
tetany  of,  695 
treatment  of,  695 
Stelwag's  sign  in  exophthalmic  goitre,  685 
Stenosis,  aortic,  474 
mitral,  469 
pulmonary,  483 

congenital,  494 
of  pylorus,  congenital,  5.52,  553 

hypertrophic,  552 
of  right  conns  arteriosus,  494 
tricuspid,  4X2 
Still's  di.seasc,  7.52 
Stokes-Adams  syndrome,  450 
Stomach,  bilocular,  555 
cancer  of,  545 
dilatation  of,  531.    See  Gastric  dilatation. 

paralytic,  535 
diseases  of,  525 
hemorrhage  fi'ora,  559 
hour-glass,  555 

ilefinition  of,  .555 
etiology  of,  555 
morbid  anatomy  of,  .556 
pathology  of,  5.56 
symptoms  of,  556 
treatment  of,  556 
hyperesthesia  of,  558 

symptoms  of,  558 
lymphatic  areas  of,  546 
neuroses  of,  556 
tuberculosis  of,  278 
ulcer  of,  536.    See  Gastric  ulcer. 
Stomatitis,  509 
aphthous,  509 
catarrhal,  509 

prognosis  of,  509 
symjjtoms  of,  509 
definition  of,  509 
fetid,  510 
follicular,  509 
gangrenous,  5 1 1 

symptoms  of,  512 
treatment  of,  512 
in  measles,  90 


Stomatitis,  parasitic,  511 

endomyccs  albicans  in,  oil 
oidium  albicans  in,  51 1 
prognosis  in,  511 
.saccharomyces  albicans  in,  511 
symptoms  of,  511 
li'catiTienl  of,  511 
ulccriilivc,  511) 

treatment  of,  510 
vesicular,  .509 
Stone  in  kidney,  609 
Stools  in  cholera,  1.S3 
in  dvseiilerv,  2()i; 
in  tyi>lioh!  levei,  :« 
Strangulation,  internal,  of  bowel,  579,  581 
"Strawberry  tongue"  in  scarlet  fever,  89 
Strcjitococcus  congloraerans  in  scarlet  fever,  82 

erysipelatus,  108 
Strcptothrix  actinomyces,  233 
inadura;,  234 
mycetoma;,  234 
Stricture  of  bowel,  579 

of  esophagus,  organic,  523 
Strongyloides  intestinalis,  348 
classification  of,  348 
definition  of,  348 
diarrhea  in,  348 
distribution  of,  348 
emaciation  in,  348 
treatment  of,  348 
Struma,  681 

colloid,  081 
Strumitis,  echinococcic,  681 
parasitic,  681 
.syphilitic,  681 
traumatic,  681 
tuberculous,  681 
Strtimpell's  family  type  of  lateral  sclerosis,  836 
Sudamina  in  miliary  fever,  300 

in  typhoid  fever,  30 
Suffocative  catarrh,  acute,  389,  391 
Sunstroke,  920 

definition  of,  920 
diagno.sis  of,  921 
etiology  of,  920 
morbid  anatomy  of,  921 
pathology  of,  921 
prognosis  in,  921 
symptoms  of,  921 
treatment  of,  921 

hydrothcrapeutic,  92 1 
venesection  in,  922 
Suppression  of  lu'ine,  672 
Suppuration  of  kidney  in  septicemia,  172 
Suppurative  heniatitis,  714 

inflanunation  of  liile-ducts,  619 
interstitial  parotitis,  514 
jiancreal  it  is,  liM2 
pyelonephritis,  111)3,  664 
pyleiihlelntis,  013 
Suiirarenal  glands,  diseases  of,  095 
Surgical  emphysema,  400 
kidney,  065 
scarlet  fever,  86 
Sweat,  stage  of,  in  malarial  fever,  321 
Sweating  sickness,  299 
Swelling  of  thyroid,  082 
Swine-pox,  ()9 

SycU'nham's  chorea,  890.    Sec  Chorea  minor. 
Symmetrical  stricture  of  esophagus,  523 
Syncojje  in  pneumothorax,  430 
Syphilis,  .302 

acquired,  302 
anemia  in,  309 


INDEX 


n(i3 


Syphilis,  arteritis  in,  30(3 
of  bones,  312 

of  brain  and  spinal  cord,  308,  310 
chancre  of,  302,  306,  308 
condylomata  in,  309 
definition  of,  302 
diagnosis  of,  310 

luetin  test  in,  311 

Wassei'mann  test  in,  311 
distribution  of,  302 
etiology  of,  302 
frequency  of,  305 
gummata  in,  306,  309 
headache  in,  310 
heart  changes  in,  306 
hereditary,  302,  304,  312 

epiphysitis  in,  312 

eruptions  in,  312 

Hutchinson  teeth  in,  312 

mucous  patches  in,  312 

rhinitis  in,  312 

symptoms  of,  312 
ii-itis,  309 
of  larynx,  370 
lesions  of,  primary,  306 

secondary,  306 

tertiary,  306 
of  liver,  307 
of  lungs,  307 
lymph  nodes,  308 
macular  syphilide  in,  309 
morbid  anatomy  of,  306 
mucous  patches  in,  309 
myomalacia  cordis  in,  306 
nephi-itis  in,  306 
of  nervous  system,  308,  310 
neuroretinitis  in,  310 
paralysis  in,  310 
pathology  of,  306 
prevention  of,  304 
prognosis  of,  311 
roseola  in,  309 
skin  eruptions  in,  308,  309 
spirocheta  pallida  in,  302 
stages  of,  302,  306 
symptoms  of,  308 
transmission  of,  303,  304 
treatment  of,  312 

neosalvarsan  in,  314 
f^  salvarsan  in,  313 

oontra-indications  to,  314 
Herxheimer  reaction  after,  314 
treponema  paUidum  in,  302 
Syphihtio  alopecia,  309 
arteritis,  303 
cirrhosis  of  liver,  611 
condylomata,  309 
dactylitis,312 
epiphysitis,  312 
eruptions,  308,  309 
gummata,  306,  309 
infantilism,  312 
iritis,  309 
keratitis,  312 
laryngitis,  370 
lymph  nodes,  308 
marasmus,  312 
nephritis,  306 
phthisis,  308 
rhinitis,  312 

spastic  spinal  paralysis,  838 
strumitis,  081 
Syringomyelia,  844 
definition  of,  844 


Syringomyelia,  diagnosis  of,  846 
etiology  of,  844 
hands  in,  845 
history  of,  844 
morbid  anatomy  of,  844 
pathology  of,  844 
prognosis  in,  846 
symptoms  of,  845 
treatment  of,  846 


Tabes  of  brain,  817 

dorsalis,  823 

mesenterica,  247 
Tache  blendtre  in  typhoid  fever,  30 

cerebrale  in  typhoid  fever,  30 
Tachycardia,  487 

in  exophthalmic  goitre,  685 

in  hysteria,  897 
Tapeworm,  350 

dog,  double-pored,  350 

dwarf,  350 

Russian,  350 

symptoms  of,  352 

treatment  of,  352 

varieties  of,  350 
Tapping  in  pleurisy  with  effusion,  422 
Teeth  in  syphilis,  312 
Telegraphers'  cramp,  914 
Tenia  confusa,  350 

cucumerina,  352 

echinococcus,  350,  351 

mediocaneUata,-  350 

nana,  350 

saginata,  350 

solium,  350,  351 
Teratoma  of  mediastinum,  431 
Tertian  parasite  of  malarial  fever,  318 
Testicle.tuberculosis  of,  281 
Test,  Rumpel-Leede,  for  scarlet  fever,  89 

Widal,  in  typhoid  fever,  43 
Test-meal  in  gastric  cancer,  549 
Tests  for  albumin  in  urine,  676 

blood,  in  diabetes  mellitus,  731 

for  sugar  in  urine,  732 
Tetanilla,  691 
Tetanus,  227 

baccQus  of,  227 

definition  of,  227 

diagnosis  of,  229 

from  hysteria,  229 

from  strychnine  poisoning,  229 

from  tetany,  229 

distribution  of,  227 

emprosthotonos  in,  229 

etiology  of,  227 

frequency  of,  227 

head,  231 

history  of,  227 

incubation  of,  228 

kopf-,  231 

"lock-jaw"  in,  228 

morbid  anatomy  of,  228 

muscular  rigidity  in,  228 

opisthotonos  in,  229 

pain  in,  229 

pathology  of,  228 

prevention  of,  228 

prognosis  of,  229 

risus  sardonicus  in,  228 

spasm  of  diaphi-agm  in,  228 
of  glottis  in,  229 


964 


IXDKX 


Tetanus,  sj'mptoms  of,  228 
treatment  of,  229 
antitoxin,  229 
Tetany,  691 

Chvostek's  sign  of,  692 
diagnosis  of,  692 

from  Jacksohian  epilepsy,  692 
from  hj'steria,  692 
Erb's  sign  of,  692 
etiology  of,  691 
gastric,  533 

Chvostek's  sign  in,  534 
Erb's  sign  in,  534 
Trousseau's  sign  in,  534 
Hoffmann's  sign  of,  692 
morbid  anatomy  of,  691 
pathologj'  of,  691 
prognosis  in,  692 
in  status  lymphaticus,  695 
symptoms  of,  691 
treatment  of,  692 
Trousseau's  sign  of,  692 
symptoms  of,  692 
Thermic  fever,  920 
Thomsen's  disease,  886 
Thread-worm,  337 
Three-day  fever,  218 
Thrombosis,  cerebral,  785 

in  croupous  pneumonia,  144 
of  portal  vein,  613 
in  typhoid  fever,  32 
venous,  in  croupous  pneumonia,  143 
sinuses,  812 

etiology  of,  812 
morbid  anatomy  of,  812 
pathology  of,  812 
prognosis  of,  813 
symptoms  of,  813 
treatment  of,  813 
Thrush,  511.    See  Stomatitis,  parasitic. 
Thymus,  enlarged,  694 

gland,  diseases  of,  693 
Thyreocele,  681 

Thyroid  gland,  adenoma  of,  683 
carcinoma  of,  683 
carcinosarcoma  of,  683 
diseases  of,  681 
endothelioma  of,  683 
sarcoma  of,  683 
swelling  of,  682 
tuberculosis  of,  286 
tumors  of,  683 
Tic  conviilsif,  878 
Tick  fever,  297 

albuminuria  in,  298 
definition  of,  297 
diagnosis  of,  298 
epistaxis  in,  298 
etiology  of,  298 
fever  in,  298 
gangrene  in,  298 
morbid  anatomy  of,  298 
prognosis  of,  299 
prophylaxis  in,  299 
pulse  in,  298 
rash  in,  298 
symptoms  of,  298 
treatment  of,  299 
Tinnitus,  878 

Tongue  in  croupous  pneumonia,  138 
eczema  of,  512 

treatment  of,  513 
geographical,  512 
smokers',  513 


Tongue  in  sprue,  589 

strawberry,  in  scarlet  fever,  89 
wooden,  233 
Tonsillitis,  acute,  518 

definition  of,  518 
difTuse,  518 
endocarditis  in,  519 
etiology  of,  518 
foUioular,  518 
forms  of,  518 
morbid  anatomy  of,  519 
pathology  of,  519 
symptoms  of,  519 
treatment  of,  52fJ 
hypertrophic,  chronic,  521 

barrel-shaped  chest  in,  521 
definition  of,  521 
funnel  chest  in,  521 
mouth  breathing  in,  521 
pigeon-breast  in,  521 
symptoms  of,  521 
treatment -of,  522 
Tonsils,  diseases  of,  518 
tuberculosis  of,  278 
Torticollis,  882 
Toxic  gastrectasis,  535 

gastritis,  acute,  525 
Tracheotomy  in  edematous  laryngitis,  367 
Transverse  myelitis,  840 
Traumatic  abscess  of  liver,  602 
neuroses,  912 
strumitis,  681 
Trematodes,  353 

definition  of,  353 
"Trembles"  in  cattle,  295 
Tremor  in  exophthalmic  goitre,  086 

in  paralysis  agitans,  889 
Trichina  spiralis,  337 
Trichiniasis,  337 

diagnosis  of,  338 
etiology  of,  337 
morbid  anatomy  of,  338 
pathology  of,  338 
prognosis  in,  338 
symptoms  of,  338 
treatment  of,  338 
Trichocephalus  dispar,  349 
Trichomonas  hominis,  357 

vaginalis,  357 
Tricuspid  regurgitation,  480 
definition  of,  480 
diagnosis  of,  482 
etiology  of,  481 
pathology  of,  481 
physical  signs  of,  481 
prognosis  in,  482 
symptoms  of,  481 
stenosis,  482 

diagnosis  of,  482 
Trifacial  nerve,  paralysis  of,  871 
sjTnptoms  of,  871 
Trilocular  heart,  494 

Trip-hammer  pulse  in  aortic  regurgitation,  479 
Trommer's  test  for  sugar  in  urine,  732 
Tropical  abscess  of  liver,  602 
adenitis,  200 
bubo,  200 
chlorosis,  338 
sore,  336 

splenomegaly,  335 
Trousseau's  sign  in  gastric  tetany,  534 

of  tetany,  692 
Trypanosoma  fever,  333 

treatment  of,  333 


INDEX 


965 


Trypanosomata,  varieties  of,  332 
Trypanosomiasis,  331 
definition  of,  331 
human,  333 
prevention  of,  332 
transmission  of,  332 
tsetse  fly  in,  332 
Tubercle,  242 
of  brain,  801 
miliary,  242 
Tuberculin  treatment  of  tuberculosis,  275 
Tuberculosis,  237 

in  Addison's  disease,  698 
of  alimentary  canal,  278 
bacillus  of,  237 
of  bladder,  282 

diagnosis  of,  283 
symptoms  of,  283 
treatment  of,  283 
bovine,  237 
of  brain,  286 
of  cecum,  279 
of  cervical  glands,  246 
chronic  h3'perplastic,  243 
definition  of,  237 
of  esophagus,  278 
etiology  of,  237 
of  Fallopian  tubes,  285 
frequency  of,  240 
of  genito-urinary  system,  281 
glandular,  245 
signs  of,  246 
treatment  of,  247 
of  heart,  285 
of  intestine,  278 

chi'onic  hjyerplastic,  279 
prognosis  in,  280 
symptoms  of,  279 
treatment  of,  281 
of  kidneys,  283 
acute,  284 
chronic,  284 
hydronephi'osis  in,  284 
pyonephrosis  in,  284 
symptoms  of,  284 
of  liver,  281 

of  mediastinal  glands,  246 
meningeal,  acute,  247 

diagnosis  of,  249 

from  acute  meningitis,  249 
from   cerebrospinal   meningi- 
tis, 249 
diagnosis  of,  Moro  test  in,  249 
in  children,  types  of,  249 
prognosis  of,  249 

symptoms  of,  248 
of  mesenteric  glands,  247 
miliary,  acute,  243 

bacillus  in,  243 
diagnosis  of,  245 
prognosis  of,  245 
symptoms  of,  244 
treatment  of,  245 
mode  of  infection  in,  237 
morbid  anatomy  of,  242 
mortality  of,  241 
of  myocardium,  285 
of  ovaries,  285 
pathology  of,  242 
of  pericardium,  250 

symptoms  of,  251 
of  peritoneum,  251 
acute  miliary,  251 
caseous  type  of,  252 


Tuberculosis    of    peritoneum,    chronic    fibroid, 
253 
symptoms  of,  253 
treatment  of,  254 
of  pharynx,  278 
of  pleura,  250 

lesions  in,  250 
pneumonic,  acute,  diagnosis  of,  263 

physical  signs  of,  263 
prcdisposnig  causes  of,  239 
prevention  of,  240 
pulmonary,  255 

amphoric  breathing  in,  264 
bacillus  of,  method  of  staining,  265 
caseation  in,  256 
cavities  in,  256 
complications  of,  261 
"cracked-pot  sound"  in,  263 
diagnosis  of,  263 

fluoroscope  in,  266 

microscopic,  265 

ophthalmotuberculin      test      in, 
267 

von  Pirquet  test  in,  267 

tuberculin  in,  266 
hemoptysis  in,  261 

prognosis  of,  269 

treatment  of,  276 
hemorrhage  in,  261 
infiltration  of  Laennec  in,  256 
lesions  in,  255 
metaUic  tinkling  in,  264 
mode  of  infection  in,  255 
pectorUoquj'  in,  264 
ph}'sical  signs  of,  263 
pneumothorax  in,  262 
prognosis  in,  268 

pulmonary  osteo-arthropathj',  262 
reparation  in,  257 
symptoms  of,  259 

cough,  261 

dyspnea,  261 

fever,  260 

laryngeal,  259 

loss  of  weight,  260 

sputum,  261 

sweating,  260 
treatment  of,  269 

antistreptococcic  serum  in,  275 

artificial  pneumothorax  in,  277 

bronchitis,  274 

ehmatic,  270 

cough,  274 

diet  in,  269 

drugs  in,  273 

exercise  in,  270 

fever,  274 

hemoptysis  in,  276 

laryngeal,  276 

medicinal,  273 

night-sweats,  273 

out-door  hfe  in,  270 

serum,  275 

special  symptoms,  273 

tuberculin  in,  275 
types  of,  255 

caseating,  256 

chronic,  255 

fibroid,  255,  258 

miliary,  255 

ulcerative,  255 
vascular  changes  in,  255 
vomiting  in,  treatment  of,  276 
of  rectum,  279 


966 


INDEX 


Tuberculosis  of  retroperitoneal  glands,  247 
of  serous  membranes,  247 
acute,  247 
chronic,  247 
treatment  of,  254 
of  spinal  cord,  2S6 
of  stomach,  278 
of  testic^le,  281 

diaijii'i-^is  <i(.  L'S2 
SVMiphnri,  of,  _'S2 
ti-eatiii.'iil  .,l\  L'S2 
of  thyroid  gland,  2S6 
of  tonsils,  278 
of  uterus,  285 
Tuboreulous  lar3mgitis,  368 
leprosy,  293 
pleurisy,  250,  413 
strumitis,  681 

vegetative  endocarditis,  285 
Tubular  nephritis,  clironic,  645 
Tumbu-fly  disease,  358 

Tumors  of  bowel  as  cause  of  obstruction,  579 
of  brain  and  its  membranes,  801 
of  kidney,  668 
of  liver,  614 
in  lungs,  412 
of  mediastinum,  431 
of  pancreas,  637 
of  thyroid  gland,  683 
Tungau,  357 
Tunnel  anemia,  338 
disease,  338 

St.  Gothard's,  338 
Tympanites,  591 

in  croupous  pneumonia,  138 
in  typhoid  fever,  27,  36 
treatment  of,  51 
Tympany  in  acute  peritonitis,  595 

in  typhoid  fever,  27 
Typhoid  fever,  17 

albuminuria  in,  38 
anemia  in,  30 
antisepsis  in,  50 
appendicitis  in,  28,  36 
arthritis  in,  40 
atypical  forms  of,  28 
bacillus  of,  17 

in  blood,  24 
bathing  in,  48 
bed-sores  in,  30 

treatment  of,  52 
blood  in,  30 

bloodvessels,  lesions  of,  in,  32 
boils  in,  30 

bone  comi^lications  in,  40 
bone-marrow  changes  in,  25 
Rrand  bath  in,  48 

contra-indications  to,  48 
cardiac  failure  in,  32 
carrier,  18 
in  children,  28 
chills  in,  28,  30 
cholecystitis  in,  37 
cholelithiasis  in,  37 
circulatory  complications  in,  32 
cold  in,  47 
coma  vigil  in,  39 
complicating  pregnancy,  41 
complications  of,  32,  33 
constipation  in,  26 

treatment  of,  50 
convulsions  in,  40 
cystitis  in,  38 
definition  of,  17 


Typhoid  fever,  delirium  in,  27,  28 
delusions  in,  39 
diagnosis  of,  41 
diarrhea  in,  26,  27,  28,  33 

treatment  of,  51 
diazo-reaction  of  urine  in,  45 
(li('t  in,  48 
dilTirentiation  of,  from  other  fevers,  42, 

43 
disinfection  of  discharges  in,  18 
dislocation  of  hip  in,  spontaneous,  40 
distribution  of,  17 
lihrlich's  reaction  in,  45 
embolism  in,  32 
embryocardia  in,  32 
empyema  in,  39 
endarteritis  in,  25 
epididymitis  in,  38 
erysipelas  in,  30 

migrans  in,  30 
esophagitis  in,  33 
esophagus  in  ulceration  of,  33 
etiology  of,  17 
facial  expression  in,  26 
frequency  of,  21 
gallbladder  in,  37 
gangrene  in,  30 
gastric  ulcer  in,  33 
genito-urinary  compUoations  in,  38 
headache  in,  26,  27 
heart  clot,  32 

muscle  in,  changes  in,  25 

sounds  in,  32 
hemiplegia  in,  40 
hemorrhage  in,  29,  33 

diagnosis  of,  34 

symptoms  of,  34 

treatment  of,  51 
hepatic  complications  in,  37 
herpes  in,  30 
history  of,  17 
hydrotherapy  in,  47 
hypostatic  congestion  of  lung  in,  38 
incubation  of,  25 
infarction  of  lung  in,  39 
insomnia  in,  26 

treatment  of,  52 
jaundice  in,  37 
joint  complications  in,  40 
Iddneys  in,  25 
laryngeal  ulceration  in,  38 
leukocytosis  in,  31 
liver  in,  25,  37 
medicines  in,  49 
meningitis  in,  39,  40 
mesenteric  nodes  in,  24 
iiiixc  li  infection  in,  32 
iii.mIc  (if  iiifiTtion  in,  IS 
HKirhid  anatomy  of,  21 
Miorlality  of,  21 
muscle,  comi)lications  in,  40 
m\iscular  tremors  in,  28 
myocarditis  in,  32 
myositis  in,  40 
ne])hritis  in,  3S 
nervous  complications  of,  39 
neuritis  in,  40 
nose-bleed  in,  26 
orchitis  in,  38 
osteomyehtis  in,  40 
otitis  media,  acute,  in,  40 
liarolilis  in.  33 
pathnl,,gy  of,  21 
))elioiiiata  in,  30 


INDEX 


mi 


Typhoid  fever,  pericarditis  in,  32 
perforation  in,  34 

diagnosis  of,  35 

signs  of,  34 

treatment  of,  52 
period  of  steep  curves  in,  28 
peritonitis  in,  35 

diagnosis  of,  35 
petecliiaj  in,  30 
pfiaryiigitis  in,  33 
plilebitis  in,  32 
pleurisy  in,  39 
pneumonia  in,  28,  38 
polyuria  in,  38 
prevention  of,  18 
preventive  inoculation  in,  20 
prognosis  of,  46 
pulmonary  abscess  in,  39 
pulse  in,  27 
pyuria  in,  38 
recrudescence  in,  29 
renal  disease,  acute,  in,  28 
respiratory  complications  in,  38 

lesions  in,  25 
rose  spots  in,  27 
sequela3  in,  32 
skin  changes  in,  30 
splenic  enlargement  in,  24,  26,  28 
stimulants  in,  49 
stools  in,  33 
stupor  in,  27 
sudamina  in,  30 
symptoms  of,  26 
tache  blen&tre  in,  30 

cerebrale  in,  30 
temperature  in,  26,  29 
tests  in,  43 
thirst  in,  20 
thrombosis  in,  32 
tongue  in,  26 
treatment  of,  47 

during  convalescence,  53 

medicinal,  49 
special  symptoms,  50 
tympanites  in,  27,  36 

treatment  of,  51 
typhoid  spine  in,  40 
ulcer  in,  23 

vaccination  against,  20 
vaccine  in,  50 
vomiting  in,  33 

treatment  of,  51 
Widal's  test,  43 
Typhomania,  in  typhus  fever,  57 
Tjrphus  fever,  54 

chiU  in,  57 
complications  of,  58 
definition  of,  54 
delirium  in,  57 
diagnosis  of,  58 
distribution  of,  55 
eruption  in,  56,  57 
etiology  of,  55 
fever  in,  57 
hepatic  changes  in,  57 
history  of,  55 

hypostatic  congestion  of  lungs  in,  57 
intestinal  lesions  in,  57 
■     kidneys  in,  57 

morbid  anatomy  of,  56 
myocarditis  in,  57 
pathology  of,  56 
petechia;  in,  57 
prevention  of,  56 


Typhus  fever,  pi'ognosis  of,  59 

pulse  in,  57 

pui)ils  in,  58 

relapses  in,  58 

retention  of  urine  in,  00 

spleen  in,  57 

termination  of,  58 

treatment  of,  60 
siderane,  57 
Tyrotoxicon,  782 
TjTotoxismus,  782 

U 

Ulcer,  duodenal,  561 

diagnosis  of,  563 

from  acute  fat-necrosis,  564 
from  gallstone  colic,  564 
from  gastric  ulcer,  563 
from  intestinal  obstruction,  564 
s-rays  in,  564 
etiology  of,  561 
hemorrhage  in,  563 
morbid  anatomy  of,  562 
pathology  of,  562 
perforation  in,  563 

symptoms  of,  563 
prognosis  in,  564 
symptoms  of,  563 
treatment  of,  564 
gastric,  536.    See  Gastric  ulcer, 
intestinal,  in  paratyphoid  fever,  53 

in  typhoid  fever,  34 
peptic,  536 

perforating,  of  foot,  in  locomotor  ataxia,  828 
of  stomach,  536 
Ulceration  of  esophagus  in  tj^hoid  fever,  33 
laryngeal,  in  typhoid  fever,  38 
Peyer's  patch  in  typhoid  fever,  23 
Ulcerative  appendicitis,  573,  574 
endocarditis,  458 
pharyngitis,  516 
stomatitis,  510 
Ulcus  ventricuh,  536 
Uncinaria  Americana,  340 

duodenale,  338 
Uncinariasis,  338 
anemia  in,  341 

Charcot-Leyden  crystals  in,  340 
definition  of,  338 
diagnosis  of,  341 
etiology  of,  339 
frequency  of,  338 
morbid  anatomy  of,  339 
pathology  of,  339 
prophylaxis  of,  339 
symptoms  of,  340 
treatment  of,  343 
Undulant  fever,  215 
Uremia,  658 

amaurosis  in,  660 
convulsive  type  of,  659 
definition  of,  668 
diagnosis  of,  660 

from  heatstroke,  661 
from  opium  poisoning,  661 
etiology  of,  658 
hemiplegia  in,  660 
insomnia  in,  660 
latent,  660 
mania  in,  660 
monoplegia  in,  660 
odor  in,  660 
paralytic  form  of,  660 


INDEX 


Uremia,  patliology  of,  658 

prognosis  in,  661 

symptoms  of,  659 

treatment  of,  hot  pack  in,  CG7 
Uremic  apoplexy,  793 
Uric  acid  diathesis,  6S0 
Urinary  secretion,  disorders  of,  672 
Urine  acetone  in,  tests  for,  732 

in  acute  diffuse  nephritis,  642 

albumin  in,  675 
tests  for,  676 

albumose  in,  680 

in  beriberi,  783 

blood  in,  673 

in  cholelithiasis,  623 

in  clironio  interstitial  nephritis,  652 
parenchymatous  nephritis,  646 

chyle  in,  678 

in  croupous  pneumonia,  137,  145 

in  diabetes  insipidus,  740 
mellitus,  729 

hemoglobin  in,  674 

indican  in,  679 

melanin  in,  680 

oxalates  in,  679 

phosphates  in,  679 

pus  in,  678 

in  renal  calculus,  669 

in  rheumatic  fever,  acute,  177 

in  smallpox,  65 

sugar  in,  tests  for,  732 

suppression  of,  672 

in  scarlet  fever,  86 

uric  acid  in,  680 

in  yellow  fever,  191 
Urticaria  in  acute  rheumatic  fever,  178 
Uterus,  tuberculosis  of,  285 


Vaccination,  74 

antityphoid,  20 

liistory  of,  74 

method  of,  75 

in  smallpox,  62,  74 
Vaccine,  anticholera,  182 

antii-abic,  226 

lymjih,  glycerinated,  75 

lueningococcic,  in  meningococcic  meningi- 
titis,  121 

treatment  of  whooping-cough,  105 
Vaccinia,  74 

in  man,  primary,  76 
secondary,  76 
Vagus  nerve,  disease  of,  880 
Valvular  anomalies,  congenital,  494 

endocarditis,  454 
Varicella,  77 

definition  of,  77 

diagnosis  of,  78 

from  smallpox,  71,  78 

eruption  in,  78 

erysipelas  in,  78 

etiology  of,  77 

incubation  in,  77 

nephritis  in,  78 

prognosis  in,  79 

symptoms  of,  78 

treatment  of,  79 
Vai'icose  aneurysm,  500 

groin  glands  in  filiariasis,  346 
Variola,  GO.    Sec  Smallpox. 

fulminans,  69 


Variola  pustulosa  hemorrhagica,  69 

sine  cruptione,  70 
Varioloid,  69 
Vascular  goitre,  681 

Venesection  in  pulmonary  emphysema,  404 
Venous  sinuses,  thrombosis  of,  812 

thrombosis  in  croupous  pneumonia,  143 
Verrucous  endocarditis,  456 
Verruga,  300 

definition  of,  300 

distribution  of,  300 

eruption  in,  301 

etiology  of,  300 

incubation  of,  301 

joints  in,  301 

Peruviana,  300 

prognosis  in,  301 

skin  in,  301 

symptoms  of,  301 

treatment  of,  301 
Vertebrae,  disease  of,  849 
diagnosis  of,  849 
prognosis  in,  849 
symptoms  of,  849 
treatment  of,  850 

malignant  growths  of,  850 
Vertigo,  878 

in  brain  tumor,  802 
Vesical  crises  in  locomotor  ataxia,  826 

tuberculosis,  282 
Vesicular  stomatitis,  509 
Vincent's  angina,  521 
VioUnists'  cramp,  914 
Visceral  lesions  in  diphtheria,  155 
Visceroptosis,  582 
Visual  tract,  868 
Volvulus,  581 

prognosis  of,  582 

S3anptoms  of,  581 

treatment  of,  582 
Vomiting,  cyclic,  560 
Von  Graefe's  sign  in  exophthalmic  goitre,  685 


W 


Water-hammer  pulse  in  aortic  regurgitation, 
479 

infection  by,  in  typhoid  fever,  18 
Weber's  syndrome  in  brain  tumor,  803 
Weil's  disease,  296 
Weisses  blut,  714 
Westphal's     symptom    in    locomotor     ataxia, 

826 
Wet  brain,  770 
Whipworm,  349 
White  flux,  588 
Wliooping-cough,  101 

amblyopia  in,  104 

bacillus  pertussis,  102 

bronchopneumonia  in,  103 

cardiac  changes  in,  104 

conjunctival  hemorrhages  in,  104 

comj)lications  of,  103 

definition  of,  101 

diagnosis  of,  104 

distribution  of,  101 

duration  of,  105 

emphysema  in,  103 

etiology  of,  102 

frequency  of,  101 

glandular  onlargempnt  in,  101 

liistory  of,  101 


INDEX 


909 


Whooping-cough,  incubation  in,  102 

in  measles,  96 

leukocytosis  in,  103 

lymphocytosis  in,  103 

morbid  anatomy  of,  101 

mortahty  in,  104 

paralysis  in,  104 

paroxysm  of,  102 

pathology  of,  101 

physical  signs  in,  103 

pneumothorax  in,  104 

prognosis  in,  104 

symptoms  of,  101 

treatment  of,  105 

bronchitis  tent  in,  105 
vaccine,  105 

vomiting  in,  104 
Widal  test  in  typhoid  fever,  43 
Winckel's  disease,  720 
"Wooden  tongue,"  233 
Wool-sorters'  disease,  219 
Word-blindness,  SOO 

deafness,  800 
Worm,  beef-,  350 

guinea-,  346 

hook-,  338 

Medina,  346 

pin-,  337 

pork-,  337,  350 

round-,  336 

screw-,  357 

seat-,  337 

tape,  350 

thread-,  337 

whip-,  349 
Wounds  of  heart,  454 
Wrist-drop  in  lead  poisoning,  779 
Writers'  cramp,  914 
Wryneck,  882 

congenital,  882 

spasmodic,  882 

spurious,  883 


Xerostomia,  514 

treatment  of,  514 


Yaws,  235 

Yellow  atrophy  of  liver,  acute,  616 
fever,  187 

albuminuria  in,  191,  192 
apoplectiform  type  of,  191 
blood  in,  190 
cardiac  changes  in,  190 
convulsions  in,  190 
definition  of,  187 
diagnosis  of,  192 

from  dengue,  192 

from      malarial      hemoglobinuric 
fever,  192 

from  pernicious  malarial  fever,  192 
etiology  of,  187 
gastric  changes  in,  190 
hematemesis  in,  191,  559 
headache  in,  190 
history  of,  187 
intermittent  changes  in,  191 
jaundice  in,  191 
morbid  anatomy  of,  190 
mortality  of,  192 
nephritic  changes  in,  190 
pain  in,  190 
pathology  of,  190 
prevention  of,  187 
proKnosis  of,  192 
prophylaxis  of,  189 
remission  in,  191 
respiration  in,  191 
sjTnptoms  of,  190 
temperature  in,  190 
tongue  in,  191 
treatment  of,  192 
urine  in,  191 
vomiting  in,  191 


